559

Relation Between Leisure-Time Physical

Activity and Blood Pressure in Older Women*
Peter D. Reaven, MD; Elizabeth Barrett-Connor, MD; and Sharon Edelstein, ScM

Although there is some evidence that physical activity may decrease blood pressure in young
and middle-aged women, the physical activity-blood pressure association in older women has
rarely been studied. As part of an ongoing community-based study of chronic disease, 641
Caucasian women between the ages of 50 and 89 years had blood pressure measured following
the Hypertension Detection and Follow-up Program protocol. They also answered selected
Health Interview Survey questions about their leisure-time activity and were classified into
categories of light (58%), moderate (24%), heavy (6%), or no physical activity (12%) by the
estimated metabolic rate required for each activity. Women who engaged in any physical
activity were significantly younger and thinner than sedentary women and had lower fasting
and 2-hour postchallenge insulin levels. They did not differ in alcohol consumption, cigarette
use, or prevalence of coronary heart disease or diabetes. Rates of systolic and diastolic
hypertension were significantly lower in women participating in light, moderate, or heavy
physical activity compared with sedentary women. Blood pressure levels decreased with each
increase in reported activity intensity (p<0.005 for trend), with systolic blood pressure
approximately 20 mm Hg lower in the heaviest activity group compared with systolic blood
pressure in sedentary women. Intergroup differences remained statistically significant after
adjustment for age and body mass index. Although physical activity was associated with lower
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fasting and 2-hour postchallenge insulin levels (p<0.01 for trend), adjustment for insulin
levels did not alter blood pressure differences among activity groups. We conclude that habitual
physical activity in older women is associated with clinically important lower systolic and
diastolic blood pressures and that this benefit is independent of physical activity-related
changes in obesity and plasma insulin. (Circulation 1991;83:559-565)

T here is good evidence that physical activity at
work or during leisure time may reduce rates
of cardiovascular disease.'-6 In addition to the
benefits of physical activity to lipid and lipoprotein
levels,78 physical activity may protect against these
diseases in part through effects on blood pressure.9-13
Studies have often compared blood pressure before
with that after short-term physical activity training
regimens in normotensive or hypertensive men.9 10'12,13
Although these studies generally show that strenuous
physical activity training can modestly reduce systolic
*All editorial decisions for this article, including selection of
reviewers and the final decision, were made by a guest editor. This
procedure applies to all manuscripts with authors from the Uni-
versity of California San Diego or UCSD Medical Center.
From the Departments of Endocrinology and Metabolism and
of Community and Family Medicine, School of Medicine, Univer-
sity of California San Diego, La Jolla, Calif.
Supported by the National Institute of Diabetes and Digestive
and Kidney Disease grant DK-31801.
Address for correspondence: Elizabeth Barrett-Connor, MD,
Division of Epidemiology-M-007, Department of Community
and Family Medicine, University of California San Diego, La Jolla,
CA 92093-0607.
Received May 22, 1990; revision accepted September 25, 1990.
and diastolic blood pressures, these results are not
directly applicable to most North Americans who do
not regularly perform such strenuous physical activity.
Importantly, most studies have not evaluated the
benefits of physical activity on blood pressure in
older populations, who are those most at risk for
cardiovascular disease, nor do they control for
other variables, such as obesity, alcohol ingestion,
and medication use, that are known to affect blood
pressure levels. Furthermore, only limited data are
available on the physical activity-blood pressure
association in women. Although rates of cardiovas-
cular disease are lower in women than in men,
coronary heart disease and strokes are common
causes of morbidity and mortality in middle-aged
and older women.14-'7 Elevated blood pressure has
been implicated as an important risk factor in both
of these disease processes.9"18-20 The possibility of
modifying this risk factor in older women through
physical activity and providing a safe way to de-
crease cardiovascular disease risk merits further
study. The present cross-sectional population-based
study investigates the effect of reported leisure-time
 560 Circulation Vol 83, No 2, February 1991
activity on blood pressure levels and rates of hyper-
tension in older women.
Methods
From 1972 through 1974, 82% of women in a
predominantly white, upper-middle-class community
in southern California participated in a risk-factor
screening survey as part of a Lipid Research Clinics
Prevalence Study.21 From 1984 through 1987, 84% of
the surviving women from the earlier study partici-
pated in an ongoing population-based study designed
to examine life-styles and chronic disease incidence
in older adults. The study was approved by the
University of California San Diego Human Subjects
Committee. Participants came to the clinic between
8:00 and 11:00 AM after a 12-hour fast. Weight and
height were measured with the subject in light cloth-
ing and without shoes. The body mass index, com-
puted as weight divided by height squared (kg/M2),
was used to estimate obesity. Twelve-lead electrocar-
diograms were performed on participants using a
Hewlett-Packard Pagewriter model 4750-A cardio-
graph. Resting heart rate was determined by taking
the average of three normal QRS complexes. After a
12-hour fast, insulin levels were measured by a
double-antibody radioimmunoassay method before
and 2 hours after a standard 75-g glucose tolerance
test. The coefficient of variation for measurement of
insulin levels was 8.5%. Trained personnel using the
Hypertension Detection and Follow-up Program pro-
tocol measured blood pressure twice in the seated
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position after 5 minutes of rest.22 The average of two
blood pressure measurements was used in this study.
All participants were interviewed by trained per-
sonnel about their medical history and current use of
cigarettes, alcoholic beverages, and medications;
these variables as well as measurements of obesity,
fat distribution, and physical activity were part of the
chronic disease assessment. All subjects evaluated
after May 1985 completed a questionnaire that as-
sessed participation in 17 leisure-time activities dur-
ing the 2-week period preceding their visit. This
questionnaire, which was adapted from the 1985
Health Interview Survey23 and has been described
previously,24 is presented in the "Appendix." For
analysis, activities were classified on the basis of
relative intensity, using the activity intensity codes
(ICs) established and validated by the Minnesota
Heart Survey.25 The IC represents the ratio of met-
abolic rate during work to the basal metabolic rate.26
Light activities (IC, >1-4.5) included walking, gar-
dening, dancing, calisthenics, golfing, bowling, and
horseback riding; moderate activities (IC, >4.5-7.5)
included hiking, tennis, biking, water exercises, and
swimming; and heavy activities (IC, .7.5) included
jogging or running, handball, racquetball, squash,
and aerobic exercise classes. Light, moderate, and
heavy exercisers were those who reported participat-
ing in at least one activity at that estimated intensity
level during the previous 2 weeks. Duration or fre-
quency of activities was not considered in the classi-
fication of activity intensity to keep physical activity
assessments as objective and free of bias as possible.
Participants reporting physical activity in more than
one intensity level during this period were classified
by the estimated IC of their most strenuous physical
activity.
Alcohol consumption in the week preceding the
visit was calculated by summing the total number of
milliliters of alcohol consumed in beer, wine, mixed
drinks, and liqueurs according to the following for-
mula: ml alcohol=(n beersx15.98 ml alcohol/12-oz
beer) + (n glasses of wine x 10.83 ml alcohol/3 -oz glass
of wine) + (n mixed drinks x 19.09 ml alcohol/1.5 -oz
mixed drink)+(n liqueursx8.88 ml alcohol/1-oz li-
queur).27
Current smokers were those who reported smoking
one or more cigarettes per day. Current estrogen use
was defined as any use of estrogen in the 2 weeks
before evaluation. Estrogen and antihypertensive
medication use was confirmed by examination of
prescriptions or medicine containers brought to the
clinic for that purpose.
Systolic hypertension was defined as systolic blood
pressure equal to or more than 160 mm Hg, and
diastolic hypertension was defined as diastolic blood
pressure equal to or more than 90 mm Hg. Overall
hypertension represents either systolic or diastolic
hypertension.
Data are presented for the 641 women who were
seen consecutively after July 1985 (when the physical
activity intensity questionnaire was initiated) and
who were 50-89 years old at the time of the visit.
Those without blood pressure measurements or ver-
ification of medication use were excluded from these
analyses (n =2). Women using antihypertensive med-
ications were included in all analyses except where
specifically stated as otherwise.
Age-adjusted mean blood pressure levels, insulin
levels, and relevant population characteristics were
computed for each physical activity group using anal-
ysis of covariance for continuous variables and by the
direct method for categorical variables. To assess
whether the association of physical activity intensity
to blood pressure was mediated through reductions
in body mass index or insulin, each of these variables
was entered into a multiple linear regression model
with age, alcohol, and smoking statistics. Statistical
significance for linear trends was calculated using
analysis of covariance with a linear contrast between
activity intensity categories.
Results
In the portion of the population queried about
specific types of physical activity, approximately 12%
were classified as sedentary, 58% as light exercisers,
24% as moderate exercisers, and 6% as engaging in
at least one form of heavy physical activity during the
previous 2 weeks. The prevalence rates of known
coronary heart disease and diabetes in this popula-
tion of older adults were relatively low (<11%), and
there were no significant differences in their preva-
 Reaven et al Blood Pressure and Leisure-Time Activity in Older Women 561

TABLE 1. Mean Age-Adjusted Population Characteristics by Ex- TABLE 3. Mean Systolic and Diastolic Blood Pressures by Exer-
ercise Category in Women Aged 50-89 Years, Rancho Bernardo, cise Category in Women Aged 50-89 Years, Rancho Bernardo,
Calif., 1984-1987 Calif., 1984-1987
Exercise intensity p for Exercise intensity p for
None Light Moderate Heavy trend None Light Moderate Heavy trend
n 78 373 154 36 n 78 373 154 36
Age (yr)* 67.4 68.0 64.1 59.6 <0.001 Systolic (mm Hg)
Heart rate (beats/min) 66.5 64.8 63.9 61.4 0.01 Unadjusted 143.3 136.8 130.3 122.6 <0.001
Body mass index (kg/m2) 26.3 24.1 25.1 23.4 0.05 Adjusted
Alcohol (ml/wk) 76.2 86.3 81.0 75.7 0.86 Age 142.1 135.5 133.0 130.3 0.003
Smoking (cigarettes/day) 4.6 2.9 2.7 2.9 0.29 Age and BMI 140.8 135.6 132.5 131.3 0.012
Blood pressure Age, BMI, alcohol,
Medication (% yes) 36.1 26.4 22.2 27.5 0.27 estrogen 140.7 135.6 132.5 131.4 0.013
Postmenopausal Age, BMI, fasting
insulin 140.7 135.5 132.5 131.4 0.014
estrogen use (% yes) 30.0 33.4 32.4 27.3 0.80
Age, BMI, 2-hr
Coronary heart disease insulin 140.9 134.9 131.0 131.3 0.010
(% yes) 10.9 10.1 9.9 7.2 0.54
Diastolic (mm Hg)
Diabetes (% yes) 9.8 11.2 8.3 6.5 0.50
Unadjusted 77.2 74.5 74.2 72.5 0.183
Fasting insulin (,units/ml) 16.9 13.7 12.4 11.2 0.002
Adjusted
2-hour insulin (1.units/ml) 15.0 88.5 79.2 66.2 0.001
Age 77.3 74.7 73.9 71.8 0.006
*Unadjusted. Age and BMI 76.4 74.9 73.7 72.5 0.044
Age, BMI, alcohol,
lences between physical activity intensity groups (Ta- estrogen 76.4 74.9 73.6 72.7 0.049
ble 1). Women reporting moderate or heavy physical Age, BMI, fasting
activity were younger than their sedentary counter- insulin 76.5 74.9 73.6 72.7 0.034
parts. Even after adjustment for this age difference, Age, BMI, 2-hr
physically active women had significantly lower rest- insulin 76.7 75.0 73.2 72.7 0.025
ing heart rates and body mass indexes, serving as an BMI, body mass index.
indirect validation of their reported physical activity.
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Alcohol ingestion, cigarettes smoked per day, and

estrogen use did not differ significantly by physical
activity status. The frequency of antihypertensive
medication use was highest in sedentary women,
although the difference was not significant. Age-
adjusted insulin levels, both fasting and postchal-
lenge, decreased in proportion to physical activity
intensity (p.0.002 for linear trend).
As shown in Table 2, systolic blood pressure in-
creased by decade in every physical activity category.
Within each 10-year age group, however, blood pres-
sure decreased stepwise with greater reported phys-
ical activity intensity. Diastolic blood pressure was
also lower in active women compared with their
sedentary counterparts within each 10-year age
group. Mean age-adjusted systolic blood pressure
(Table 3) was 7 mm Hg lower in the light physical
activity category, 9 mm Hg lower in the moderate
physical activity category, and approximately 13
mm Hg lower in the heavy physical activity category
compared with the sedentary group. The trend across
physical activity categories was significant (p<0.05).
Diastolic blood pressure also decreased across phys-

TABLE 2. Unadjusted Mean (SD) Blood Pressure by Exercise Category in Women by 10-Year Age Groups, Rancho
Bernardo, Calif., 1984-1987
Exercise intensity
Age (yr) n None Light Moderate Heavy
Systolic (mm Hg)
50-59 185 132.3 (23.2) 122.3 (17.4) 121.3 (16.8) 118.1 (18.9)
60-69 198 143.2 (25.8) 131.0 (19.7) 131.2 (21.3) 119.2 (12.1)
70-79 178 149.8 (20.2) 144.4 (21.2) 140.0 (18.6) *
80-89 80 151.0 (15.7) 155.9 (24.4) 142.7 (19.2) *
Diastolic (mm Hg)
50-59 185 77.8 (11.3) 76.1 (9.2) 74.9 (8.9) 73.2 (8.6)
60-69 198 80.8 (13.3) 75.1 (9.1) 75.0 (9.8) 68.7 (7.8)
70-79 178 75.3 (10.1) 73.1 (9.9) 73.0 (7.8) *
80-89 81 74.3 (9.4) 74.7 (10.7) 68.9 (12.3) *
*Insufficient number of participants; all other cells represent mean values from .14 participants.
 562 Circulation Vol 83, No 2, February 1991

TABLE 4. Mean Systolic and Diastolic Blood Pressures by Exer- physical activity-related blood pressure differences
cise in Women Not Using Blood Pressure-Lowering Medication (Table 3). Similarly, adjustments for fasting insulin
Aged 50-89 Years, Rancho Bernardo, Calif., 1984-1987
levels did not diminish differences in blood pressure
Exercise intensity for p among physical activity classes. When analyses were
None Light Moderate Heavy trend performed excluding all users of antihypertensive
n 49 269 124 29 medications, similar blood pressure differences were
Systolic (mm Hg) present among physical activity groups (Table 4).
Unadjusted 137.7 132.1 127.5 120.6 <0.001
Similarly, analyses limited to those using antihyper-
tensive medications or those free of coronary heart
Adjusted disease and diabetes revealed similar patterns, al-
Age 138.1 130.2 130.0 127.2 0.014 though sample size was reduced (data not shown).
Age and BMI 136.9 130.5 129.1 127.9 0.031 Prevalence rates of categorical systolic, diastolic,
Age, BMI, alcohol, and overall hypertension were significantly lower
estrogen 136.7 130.5 129.2 128.2 0.042 (p<0.05) in active women at all physical activity
Age, BMI, fasting intensities compared with sedentary women (Figure
insulin 136.6 130.5 128.9 127.9 0.035 1). Prevalence of diastolic hypertension decreased
Age, BMI, 2-hr nearly stepwise with each higher physical activity
insulin 136.5 130.2 127.9 128.1 0.037
classification (p.0.005 for linear trend). Adjustment
Diastolic (mm Hg) for age and body mass index did not alter these results.
Unadjusted 75.9 73.2 73.9 72.1 0.095
Adjusted Discussion
Age 75.9 73.4 73.6 71.4 0.044 In this older population of women, significantly
Age and BMI 75.0 73.7 73.2 71.9 0.130 lower systolic and diastolic blood pressures were
Age, BMI, alcohol, seen with light-intensity leisure-time physical activ-
estrogen 74.9 73.7 73.3 72.0 0.160 ity, and further reductions were present with
Age, BMI, fasting heavier physical activity. In addition, significantly
insulin 75.1 73.7 73.1 71.9 0.115
lower rates of systolic and diastolic hypertension
Age, BMI, 2-hr were present in all physically active women com-
insulin 75.1 73.7 73.1 71.9 0.112
pared with sedentary women. As classification of
BMI, body mass index. physical activity intensity was based on the highest
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intensity activity reported, even if it was performed

ical activity categories (p<0.05 for linear trend),
although differences among groups were smaller
(Table 3). Differences in diastolic and systolic blood
pressure levels among sedentary and physically active
groups persisted after adjustment for age and body
mass index. Additional adjustment for alcohol inges-
tion or estrogen use did not alter these results.
Despite large differences in mean 2-hour insulin
levels among physical activity categories, additional
adjustments for these insulin levels did not alter the
only once during the 2-week period, it likely over-
estimates the true physical activity intensity of this
population. Therefore, the results represent a con-
servative estimate of the association between phys-
ical activity and blood pressure in older women and
offer support for the benefit of even light-intensity
physical activity.
The results of the present study confirm the large
differences in blood pressure between sedentary
and active subjects reported in the few studies

40 -
E OVERALL HTN
E SYSTOLIC HTN
30- * DIASTOLIC HTN

z
20- * FIGURE 1. Bargraph of age-adjusted hyper-
z tension rates by exercise category in women,
W Rancho Bemardo, Calif:, 1984-1987. HTN,
~10
* *
hypertension.
W 10

0-
None Light Moderate Heavy
EXERCISE CATEGORY
* p < .05 compared to comparable hypertension rate in sedentary group
 Reaven et al Blood Pressure and Leisure-Time Activity in Older Women
evaluating physical activity training effects on blood
pressure in older populations.28-32 Results very
similar to ours were reported by Hagberg et a132
from a study of 60-69-year-old men and women
who underwent exercise training. Both systolic and
diastolic blood pressures were markedly lower, even
with low-intensity physical activity. Together, these
studies suggest that physical activity of light-to-
moderate intensity may be a particularly effective
and simple nonpharmacological method of lowering
blood pressure in older adults.
Despite lower body mass indexes in exercising
women, blood pressure differences remained clini-
cally and statistically significant between physical
activity intensity categories after adjusting for body
mass index differences. This suggests that physical
activity in older women may have effects on blood
pressure beyond its role in weight control. The
inverse association between physical activity and
blood pressure was independent of age, alcohol
consumption, and estrogen use, attributes known to
have important effects on blood pressure.9,33 In
addition, blood pressure levels were lower in each
physical activity category regardless of whether
participants used antihypertensive medications.
This suggests that benefits of physical activity may
exist for those with recognized hypertension as well
as for those with normal blood pressure. Studies in
younger adults have also demonstrated physical
activity to be modestly effective in lowering blood
pressure in normotensive and hypertensive sub-
Downloaded from http://ahajournals.org by on March 13, 2022
jects.10,12,34
As in any cross-sectional study, we cannot ex-
clude the possibility that health differences between
active and sedentary participants explain the in-
verse association between physical activity and
blood pressure. This is unlikely, however, for two
reasons. First, all participants were ambulatory and
relatively healthy. All acutely ill participants were
rescheduled for visits when in their usual health.
Second, the prevalences of both coronary heart
disease and diabetes (diseases that could limit
physical activity and influence blood pressure) were
relatively low and were similar in physically active
and sedentary participants. Finally, the exclusion of
participants with either or both of these diseases
did not alter the inverse association between phys-
ical activity and blood pressure.
Self-reported physical activity assessments have
well-known limitations.35 These result primarily
from problems in questionnaire bias or recall bias
and contribute to subject misclassification, which
may diminish the strength of the physical activity-
blood pressure association. This fact along with our
decision to classify subjects by their most strenuous
physical activity regardless of the frequency or
duration of that activity makes it likely that we have
underestimated the relation between leisure-time
physical activity and blood pressure in this cohort.
Eliminating the duration or frequency of reported
activities precludes a truly accurate estimate of the
563
relation between energy expenditure and blood
pressure. However, it does eliminate much of the
recall bias that may occur with self-reported physi-
cal activity. A specific limitation of any brief assess-
ment of usual physical activity is the necessary
exclusion of some specific activities from the ques-
tionnaire. In this cohort, less than 10% of the
women reported participating in physical activities
that were not listed on the exercise questionnaire.24
It is unlikely that the omission of these activities
from the 14-day physical activity recall altered the
results of the study as the number of subjects
affected was small and most were classified through
their participation in other listed activities. Sea-
sonal variation in activity and activity reporting, a
common problem in cross-sectional studies of exer-
cise, was minimal,24 probably a benefit of the year-
round temperate climate in southern California.
The ability of self-report physical activity assess-
ments to measure "true" fitness or physical activity
patterns is always difficult to assess in population
studies. The validity of this physical activity scale
was indirectly supported by other measures of
fitness such as resting heart rate and body mass
index,36 which were significantly lower in physically
active women. Importantly, these estimates of phys-
ical fitness reflected the reported physical activity in
a graded, dose-response fashion. This simple phys-
ical activity questionnaire appears to provide a
relatively objective and valid estimate of activity in
this older cohort.
The mechanism by which physical activity may
lower blood pressure is not known. Many studies
have demonstrated decreased insulin levels with
physical activity,37'38 and recent studies have shown
lower catecholamine levels with physical activity.32 It
has been suggested that insulin may increase blood
pressure by increasing sodium reabsorption and/or
catecholamine secretion39-42 and that reductions in
insulin levels with physical activity may reverse this
process.37 Although insulin levels were inversely re-
lated to intensity of reported physical activity in this
study, which is consistent with the possibility that
physical activity-induced changes in insulin modulate
blood pressure, adjustment for insulin levels did not
reduce blood pressure differences among physical
activity categories. This suggests that insulin may not
be the final or most important mediator in physical
activity-induced changes in blood pressure in older
women. However, this study does not address insu-
lin's role in nonphysical activity-related blood pres-
sure modulation.
The results of this study demonstrate that physical
activity routinely performed by older women is asso-
ciated with lower blood pressure and a lower preva-
lence of hypertension. Importantly, it appears that
even light or moderately intense physical activity may
be sufficient to obtain these benefits. If similar results
are found in prospective studies, the public health
implications would be very important. Several popu-
lation studies have shown that systolic and diastolic
 564 Circulation Vol 83, No 2, February 1991

Appendix
In the past 14 days, have you done any of the following exercises, sports, or physically active hobbies?
On the average, About how many
how many times in minutes did you
the past 14 days actually spend on
Yes No did you play/go/do: each occasionn?
1) Walking for exercise? times minutes
2) Jogging or running? F] times minutes
3) Hiking? times minutes
4) Gardening or yard work? 1: 1El times minutes
5) Aerobics or aerobic dancing? n times minutes
6) Other dancing? L1
iiE]
n
Fl times minutes
7) Calisthenics or general exercise? times minutes
8) Golf? Li
El
n times minutes
9) Tennis? El times minutes
10) Bowling? Fl times minutes
11) Bicycle riding? r1
LFI times minutes
12) Swimming or water exercises? Fl times minutes
13) Horseback riding? times minutes
El times minutes
14) Handball, racquetball, or squash?
15) Have you done any other
exercises, sports, or physically
active hobbies in the past 2 weeks times minutes
other than the ones listed above? times minutes
If yes, what were they? times minutes

blood pressures are important predictors of coronary 8. Goldberg L, Elliot DL: The effect of physical activity on lipid
Downloaded from http://ahajournals.org by on March 13, 2022

heart disease at all ages.20,4344 Systolic hypertension
may be a particularly important determinant of cere-
brovascular disease in older populations.44 46 Lei-
sure-time physical activity may therefore prove to be
an effective and safe way to reduce cardiovascular
disease risk in older women.
Acknowledgment
We are indebted to Robie Brien for her help in
preparing this manuscript.
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KEY WORDS * leisure-time physical activity * older women e
blood p essure * hypertension