HealthBenefitsofIncreasedWalkingforSedentary,

GenerallyHealthyOlderAdults
Background.Olderadultsareoftenadvisedtowalkmore,butrandomizedtrialshavenotconclusively
establishedthebenefitsofwalkinginthisagegroup.Typicalanalysesbasedonobservationaldatamay
havebiasedresults.Here,weproposealimitedbias,moreinterpretableestimateofthehealthbenefits
tosedentaryhealthyolderadultsofwalkingmore,usinglongitudinaldatafromthecardiovascularhealth
study.
Methods.Thenumberofcityblockswalkedperweek,collectedannually,wasclassifiedassedentary(<7
blocksperweek),somewhatactive,oractive(28).Analysiswasrestrictedtopersonssedentaryand
healthyinthefirst2years.Inyear3,somebecamemoreactive(thetreatmentgroups).Selfratedhealth
atyear5(followup)wasregressedonwalkingatyear3,withadditionalcovariatesfromyear2,whenall
weresedentary.
Results.Atfollowup,83.5%ofthoseactiveatbaselinehadexcellent,verygood,orgoodselfrated
health,ascomparedwith63.9%ofthesedentary,anapparentbenefitof19.6percentagepoints.After
covariateadjustment,thelimitedbiasestimateofthebenefitwas11.2percentagepoints(95%
confidenceinterval3.718.6).Tendifferentoutcomemeasuresshowedabenefit,rangingfrom5to11
percentagepoints.Estimatesfromotherstudydesignsweresmaller,lessinterpretable,andpotentially
morebiased.
Conclusions.Inlongitudinalstudieswherewalkingandhealthareascertainedateverywave,limitedbias
estimatescanprovidebetterestimatesofthebenefitsofwalking.Asurprisinglysmallincreaseinwalking
wasassociatedwithmeaningfulhealthbenefits.

HealthBenefitsofIncreasedWalkingforSedentary,
GenerallyHealthyOlderAdults
BACKGROUND
Physicalactivityisrecommendedforpersonsofallages.Becausewalkingisthemostcommonlyreported
leisuretimephysicalactivityintheUnitedStatesandisrelativelycommonamongtheelderlyadults,olderadults
areoftenadvisedtowalkmore.Butthefewlongtermrandomizedtrialsofthehealthbenefitsofwalkingforolder
adultshavehadequivocalresults,andtherecommendationstowalkmorehavebeenbasedprimarilyonresults
fromobservationalstudies.Suchstudieshavefoundastrongcorrelationbetweentheamountwalkedandsurvival
andincidentcardiovasculardisease(CVD)inoldermenandaninverseassociationbetweenwalkingintensityand
cardiovasculareventsinolderwomen.Amongadultdiabetics,walkingatleast2hoursperweekwascorrelated
withlowerallcausemortality(39%)andcardiovascularmortality(34%)over8yearsoffollowup.However,
whenisolatedfromoverallphysicalactivity,walkingshowednosignificantassociationwitheithermortalityor
CVDintheShanghaiWomensHealthstudy.Asdiscussedbelow,thehealthbenefitsofwalkingestimatedfrom
observationaldatamaybebiased.Weproposetouselongitudinaldatatomaketheanalysisofobservationaldata
moreliketheanalysisofarandomizedtrial.
Supposethegoalistoestimatethebenefitofincreasedwalkingforhealthysedentarypersons.Ideally,a
randomizedcontrolledtrial(RCT)wouldbeconducted.TheRCTmightrandomizepersonswhohadbeenhealthy
andsedentary(accordingtothetrialseligibilitycriteria)forsomeamountoftimetooneofthreewalkinggroups:
sedentary,somewhatactive,oractive.Thehealthofthethreegroupsmightbecompared2yearslater.Differences
amongthegroupswouldbeunequivocalestimatesofthebenefitofthewalkingprogramforhealthysedentary
persons. Healthat randomization wouldbe unassociatedwithtreatment group because of randomization. The
analysismightcontrolformeasuresofhealthstatusatbaselineanywaytoadjustforanysmallimbalancesamong
thegroupsandperhapsincreasepower.Ifthegroupofinterestincludedolderadults,thehealthoutcomemeasure
shouldaccountfordeath(10).NotethattheRCTdesignhasfourimportantfeatures:(a)itaddressesthequestionof
interest(theeffectofwalkingonthehealthofsedentarypersons).(b)thetimewhenthewalkingprogramstartedis
known, (c) the health at the start was equivalent in the three groups because of randomization, and (d) any
covariatesusedinthemodelweremeasuredbeforeanyonestartedtoexerciseandsocannothavebeeninthecausal
pathwaybetweenexerciseandhealth.
Mostoften,however,thebenefitsofwalkinghavebeenestimatedfromobservationalcohortstudiesthat
measuredphysicalactivityonlyonce,atbaseline,andfollowedparticipantsprospectivelyforhealthevents(here
calledthetypicaldesign)(59,1114).Atypicalanalysismightclassifyparticipantswalkinglevelatthestudys
baselineandexaminetheirhealth2yearslater,controllingbyregressionforbaselinedifferencesinthehealthof
thegroups.NotethatthisanalysishasnoneofthefeaturesoftheRCTjustmentioned:(a)itdoesnoteffectively
addressthequestionofinterestbecauseanalysisisnotrestrictedtohealthysedentaryolderadults,(b)thetime
whenpersonsstartedtoexerciseisunknownandmayhavebeenlongbeforebaseline,(c)personshealthwhen
theystartedtoexerciseisunknownandcannotbeadjustedfor,and(d)allthecovariatesforthetreatmentgroup
weremeasuredafterexercisewasalreadyinitiatedandsomaybeinthecausalpathwaybetweenexerciseand
health.(Controllingforhealthvariablesthathavealreadybeenimprovedbyexerciseislikelytobiastheeffects
towardthenull.)

Figure1.Schematicdiagramofthelimitedbiasdesign(year4omitted).Analysisisrestrictedtopersonswhoweresedentaryandhealthyin
years1and2.TheprimaryanalysisregressesY(abinaryvariableindicatingwhetherthepersonishealthyatyear5)onX(walkinglevel
measuredatyear3).Thelimitedbiasanalysiscontrolsforage,sex,race,andallthehealthvariablesatyear2andalsoforselfratedhealth
atyear2.5.Sedentaryisdefinedaswalkinglessthansevenblocksperweek,andactiveiswalking28ormoreblocksperweekatyear3.
Healthy(yes/no)isabinaryvariabledenotingnotsickordeadonthevariableofinterest.(Healthatyear2.5isbasedonselfratedhealth
becausethatwastheonlyhealthvariablemeasuredsemiannually.Walkingwasnotmeasuredatyear2.5.)

Adifferentanalysisispossibleincohortstudiesexemplifiedbythecardiovascularhealthstudy,which
measuredphysicalactivityeveryyearandhealthstatusevery6months.Thislimitedbiasdesign,diagrammedin
Figure1,mimicsanRCTbyrestrictinganalysistopersonswhowerehealthyandsedentaryinthefirst2yearsof
datacollection.Byyear3,referredtohereastheanalyticbaseline,somepersonswillhaveincreasedtheirwalking
level,whichmayhaveaffectedtheirhealthinyear5.Healthatyear5,asdefinedbythestudy,wouldberegressed
onwalkinglevelinyear3.Healthvariablesmeasuredatyear2(whenallweresedentary)andperhapsatyear2.5
areusedascovariates.
ThisdesignhasseveralfeaturesincommonwiththeRCT:(a)itdoesaddressthequestionofinterest
becauseitisrestrictedtopreviouslysedentaryandhealthypersons,(b)thetimewhenexercisecommencedis
knowntobesometimebetweenyears2and3,(c)healthstatuswhenexercisestartedisknowntowithin6months
andsocanbecontrolledforapproximately,and(d)allcovariatesbutone(healthatyear2.5)weremeasuredatyear
2,beforeanyexercisestarted,andthereforearenotinthecausalpathway.Theyear2.5healthmeasurewas
includedasacompromisecovariate.Forpersonswhosehealthchangedbetweenyears2and2.5,whothen
startedtoexercise,andwhoreceivedbenefitsofexerciseafteryear2.5,thisanalysisisappropriatebecauseit
controlsforhealthatyear2.5.Thedesignmayovercontrolforvariablesinthecausalpathwayforanypersonswho
bothstartedtoexerciseandthenchangedtheirhealthbetweenyears2and2.5.Thedesignmayundercontrolfor
healthatthestartofexerciseforpersonswhobothchangedtheirhealthandthenstartedtoexercisebetweenyears
2.5and3.0.
BecausethisdesignismoresimilartotheRCTthanisthetypicaldesignandbecausethepossibilitiesof
overandundercorrectionarelimitedtotheprobablysmallnumberofpersonswhohadalltheirexerciseandhealth
changeswithina6monthperiod,werefertoitasthelimitedbiasdesign.inthisstudy,weimplementedthe
limitedbiasdesigntoestimatethehealthbenefitofmovingfromsedentarytoactiveforhealthyolderadults.Ten
differentdefinitionsofhealthwereused,andallhealthmeasureswerecodedtoaccountfordeath.Resultswere
comparedwiththoseofthetypicalanalysis.

METHODS
Data

DatacamefromtheCHS,apopulationbasedlongitudinalstudyofriskfactorsforheartdiseaseandstrokein5,888
adultsaged65yearsandolderatbaseline.ParticipantswererecruitedfromarandomsampleofMedicareeligiblein
fourU.S.communities,andextensivedatawerecollectedduringannualclinicvisitsandtelephonecalls.Theoriginal
cohortof5,201participants,recruitedinabout1990,hadupto10annualclinicexaminations.asecondcohortof687
AfricanAmericans,enrolled in about1993, hadup to sevenannualexaminations.Limiteddatawerecollectedby
telephone6monthsaftereachclinicvisit.Followupwasvirtuallycompleteforsurvivingparticipants.
Thereportednumberofcityblocksortheequivalentwalkedoutsidethehomeinthepreviousweekwascollectedin
1990andannuallyfrom1992to1999.WalkingisamajorcomponentofphysicalactivityasmeasuredintheMinnesota
leisureTimeactivities(MlTA)questionnaire.In1990,thenumberofblockswalkedwasmoderatelycorrelated(r=.45)
withtheMlTA(excludingchores,onthelogscale),suggestingthatthereportednumberofblockswalkedhasbothface
and construct validity as a measure of physical activity. The blocks data were coded into approximate textiles as
sedentary(lessthan7blocksperweek),somewhatactive(727blocks),andactive(28ormoreblocksperweek).This
definitionofsedentaryisconsistentwiththatusedinotherstudiesofolderadults.Becausethenumberofcityblocksper
mileisnotstandard(oftenfrom10to20blockspermile),wemustassumethatpersonsdefinitionofacityblockwas
thesame,onaverage,inthethreeactivitygroups.
Theprimaryoutcome,measuredevery6months,wasselfratedhealth:isyourhealthexcellent,verygood,good,fair,or
poor?Thiswellrecognizedpredictorofhealth,function,andsurvivalwasdichotomizedtoindicatewhethertheperson
washealthy(excellent,verygood,orgood)ornothealthy(fair,poor,ordead).Thisoutcomemeasurethusaccountsfor
peoplewhodiedandtheanalysiscanbetrulyprospective.
Toincreasethegeneralizabilityofthefindings,weconsiderednineadditionalhealthoutcomesanddefinitionsofbeing
healthy.Allvariablesweredichotomizedtohealthy/nothealthy.DefinitionsofhealthyincludedhavingaModified
MiniMentalstateExaminationscore90(19);nodifficultieswithactivitiesofdailyliving(ADL)walking,transfer
ring,eating,dressing,bathing,ortoileting;nodifficultieswithinstrumentalactivitiesofdailyliving(IADL)heavyor
lighthousework,shopping,mealpreparation,moneymanagement,ortelephoning;acenterforEpidemiologicstudies
shortDepressionscore<10(20,21);measuredgait>0.8m/s;neverhadangina,coronaryheartdisease,congestiveheart
failure,claudication,myocardialinfarction,stroke,transientischemicattack,angioplasty,orcoronaryarterybypass
surgery(CVD);nodaysinbedintheprevious2weeks;nothospitalizedinthepreviousyear;andbeingalive.Data
missingbetweenapersonsfirstandlastobservedmeasures(about5%)wereimputedfromapersonspecificregression
ofthevariableonthelogoftimefromthelastknownmeasure.
The10healthrelatedvariableswereusedinseveralways.Thesamplewasrestrictedtopersonswhoweresedentaryand
healthyatyears1and2.(Healthyisabinaryvariablethatwasdefinedinseveraldifferentways,asdescribedlater.)
Theyear5valueofhealthywastheoutcomevariable,andtheyear2valuesofall10healthvariableswereusedas
covariatesintheregressions.WealsocreatedacombinedvariabledenotinghavingneitherADLnorIADLdifficulties.
ToimplementthedesigninFigure1,wesortedthrougheachpersonsdatatolocate(atmost)oneperiodoffive
consecutiveyearsinwhichthepersonwashealthyandsedentaryinthefirst2years,thenumberofblockswalkedwas
knownatyear3(referredtohenceforthastheanalyticbaseline),andthehealthstate(healthy,sick,ordead)was
knownatyear5(referredtohenceforthasfollowup).Thedependentvariableisabinaryvariableindicatingwhether
thepersonwashealthyatfollowup(year5).Theprimaryanalysis,basedonselfratedhealth,wasdescribedabove.For
theotheroutcomevariables,healthywasdefinedspecifictothatvariable.Forexample,intheADLanalysis,healthy
meanshavingnoADLdifficulties(coded1)andnothealthyrepresentseitherhavingADLdifficultiesorbeingdead
(coded0).ThesamplewasrestrictedtopersonswhoweresedentaryandhadnoADLdifficultiesinyears1and2.

Analysis

Thelimitedbiasanalysiswasrestrictedtopersonswhowerebothsedentaryandhealthyinthe2yearsbeforethe
analyticbaseline(year3).Theindependentvariableofinterestwasthewalkinglevelatbaseline(sedentary,some
whatactive,andactive).Theprimarydependentvariable(Y)indicatedwhetherthepersonwashealthy(notsickor
dead)atfollowup.Ywasregressedondummyvariablesforwalkinglevelatbaseline(year3)andoncovariates
measuredatyears2and2.5.Weusedordinaryleastsquaresregressionsothatcoefficientscouldbeinterpretedas
the(adjusted)differenceinthepercentagehealthyrelativetothosewhoremainedsedentary.Thisisalsoknownas
theriskdifference.Usingleastsquareswhenthedependentvariableisbinaryisappropriateforlargesamples
whentheproportionhealthyisnotcloseto0or1.Weusedthecontinuous(notthebinary)versionofthevariables
atyear2asregressioncovariates,tocontrolaswellaspossibleforpreexistingdifferencesamongthegroups.
Forcomparison,weperformedadditionalanalysesthatdidcontrolforhealthrelatedvariablesmeasuredatthe
analyticbaseline,thatdidnotrequirepersonstobesedentaryorhealthyintheprevious2years,orthatdidnot
includedeathintheoutcome.Weexpectedthatanalysesthatadjustedforbaselinehealthorthatanalyzedonly
survivorswouldunderestimatetheeffectofwalkingonhealth.Becauserandomizedtrialsoftenhavedifferent
outcomemeasuresandselectioncriteriathanselfratedhealth,weconducted10additionallimitedbiasanalyses,
substituting each of the other health measures in turn for selfrated health. For example, in one analysis we
restrictedanalysistopersonswithnoADLdifficultiesinyears1and2,andtheoutcomeatyear5waswhetherthe
personwasfreeofADLdifficulties(healthy,codedas1)versushavingADLdifficultiesorhavingdied(codedas
0).

Findings

DescriptiveLongitudinalAnalysis
Fortheprimaryanalysis,ofselfratedhealth,weidentifiedasubsetof1,409CHSparticipantswhoweresedentaryandhealthy
inyears1and2.Table1showsdescriptivestatisticsforallvariablesinyears1through5asafunctionofthewalkingcategory
atyear3(theanalyticbaseline).(Thesomewhatactivegroupwasomittedfromthetable,tosavespace,butisdescribed
online.)Wenextpointoutafewfeaturesofthedatatohelpfamiliarizethereaderwiththiscomplextable.
Columnsarelabeledbytheyearofthedataandbythetreatmentgroup(exerciselevelatyear3).Atyears1and2,allwere
sedentary,bydesign(line2).Byyear3(theanalyticbaseline),829personsremainsedentary,422weresomewhatactive(not
shown),and158personshadbecomeactive.Line3showsthemediannumberofblockswalkedineachperiod.Intheactive
category,thisdroppedfrom48atbaselineto10atfollowupbutwasstillhigherthanintheothergroups.Inyears1and2,
100%werehealthy,bydesign(line4).Atbaseline,thosepercentageshaddroppedto82.3%and92.4%forthetwowalking
groups.Thatis,atbaselinetheactivegroupwasalreadyhealthierthanthesedentary.Thereisasimilarrelationshipatfollow
up,wheretheunadjustedeffectofbecomingactivewas83.563.9=19.6percentagepoints.Line5inthetableshowsthe
percentagewhowerehealthyatyear2.5,6monthsbeforebaseline,whichwasalsohigherfortheactive.Thepercentagealive
atfollowup(line6)wasalsohigherfortheactive.Thesedentarygroupwasslightlyolderandincludedfewerblacksandmen
thantheactive(lines79).
Lines1017showtheadditionalhealthrelatedvariables.Atallyears,forallhealthmeasures,personsactiveinyear3were
healthierthanthosesedentary,andthetwogroupsweresignificantlydifferentoneveryvariablebutgenderandrace(results

notshown).Theearlydifferencesamonggroupssuggesttheimportanceofcontrollingforhealthrelatedcovariatesatthestart
ofexerciseintheregressionanalysis.