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Published ahead of print on June 5, 2003, doi:10.1164/rccm.200208-954OC
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American Journal of Respiratory and Critical Care Medicine Vol 168. pp. 494-499, (2003)
© 2003 American Thoracic Society

Original Article

Delaying Decline in Pulmonary Function with Physical Activity

A 25-Year Follow-up

Margit Pelkonen, Irma-Leena Notkola, Timo Lakka, Hannu O. Tukiainen, Paula Kivinen and Aulikki Nissinen

Department of Public Health and General Practice, University of Kuopio; Department of Pulmonary Diseases, Kuopio University Hospital; Research Institute of Public Health, University of Kuopio; and Department of Neurology, Kuopio University Hospital, Kuopio; Department of Epidemiology and Health Promotion, National Public Health Institute, Helsinki, Finland; Human Genomics Laboratory, Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana

Correspondence and request for reprints should be addressed to Margit Pelkonen, M.D., University of Kuopio, Department of Public Health and General Practice, P.O. Box 1627, FIN-70211 Kuopio, Finland. E-mail: margit.pelkonen{at}uku.fi


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The importance of physical activity for health is well recognized, but little is known about the influence of physical activity on pulmonary function. We have examined whether physical activity could slow down the decline in pulmonary function among the southwestern rural Finnish cohort of the Seven Countries Study. Physical activity was estimated by kilometers walked, cycled, and skied daily. We had complete data for 429 men for 10 years, 275 men for 20 years, and 186 men for 25 years. During the first 10 years, the decline in FEV was 9.8 ml/year less among men in the highest tertile of baseline physical activity than in men in the lowest tertile. According to the mean physical activity over either 20 or 25 years, men in the highest tertile also lost less pulmonary function (p = 0.009 and p = 0.043, respectively). A similar beneficial effect was observed in all smoking categories. In mortality analysis, continued high physical activity and an increase in activity to high level were associated with lower mortality. In conclusion, results indicated that physical activity is associated with a slower decline in pulmonary function and with lower mortality, and thus, middle-aged and older people should be encouraged to enjoy exercise.

Key Words: pulmonary function • FEV • physical activity • smoking • mortality

Physical activity can enhance health in many ways. Physical training has been shown to increase muscular strength (1), to improve cardiovascular performance (2, 3), and to reduce obesity (4). Physical exercise has also been found to prevent premature death (5) and promote longevity (6–9). However, it is not known whether physical activity can retard the long-term, age-dependent deterioration of pulmonary function.

The aging process itself results in a decline in pulmonary function (10, 11); the major environmental factor that modifies the effects of aging on pulmonary function is smoking (11–15). However, there may be other factors that could modify the decline in pulmonary function in addition to smoking. In previous cross-sectional studies, regular exercise training and good physical fitness have been related to better pulmonary function (16–21). In one longitudinal study, changes in physical activity positively correlated with the level of FVC between the ages of 13–27 years (22). In another longitudinal study, those who participated in vigorous activity showed a slower rate of decline in FEV during a 3.7-year follow-up (23). However, there is no prospective evidence for any association between physical activity and long-term changes in pulmonary function in middle-aged and older individuals.

In this study, we examined the influence of physical activity on the longitudinal decline in pulmonary function among middle-aged men. We evaluated the decline in pulmonary function according to the baseline physical activity and mean physical activity during the follow-up. We also studied how changes in physical activity level during the follow-up had affected pulmonary function and the survival prospects of the participants.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
In 1959, all men (n = 1,711) aged 40–59 years from two rural areas in Finland were invited to participate in an international longitudinal study called the Seven Countries Study (24–26). Reexaminations for the Finnish cohorts were performed in 1964, 1969, 1974, 1984, 1989, and 2000. The latest examination did not include a measurement of pulmonary function. This study started in 1964 when habitual physical activity was assessed by an interview (24, 25) and includes only the southwestern cohort (n = 888 in 1959) in whom physical activity was measured more extensively (5).

In the southwestern cohort, there were 675 men in 1964 for whom data were available on baseline physical activity. A total of 525 men survived until 1974, and there were complete data on physical activity, smoking habits, and decline in pulmonary function for 429 individuals between 1964 and 1974. Of those 429 men, 295 subjects survived until 1984, and for 275 of these subjects, data on physical activity were available in 1984. Finally, in 1989, 207 subjects were still alive, and for 186 of these subjects, there were complete data on physical activity.

Assessment of Physical Activity
In 1964, commuting and leisure time physical activity as well as occupational activity were recorded by a trained nurse according to a standard questionnaire that was developed for the Seven Countries Study (25). In the questionnaire, there were six standard questions about habitual walking, cycling, and cross-country skiing. The questions concerned kilometers walked daily (last year), months of cycling (last year), cycling per day per week, kilometers cycled per day per week, months of cross-country skiing, and kilometers skied during the whole winter. In addition, the interviewer classified every subject into one of four categories according to occupational activity: sedentary and light (mostly office work), moderate (e.g., shop keeping), heavy (mainly farming), and very heavy (mainly lumberjacking) (5). In 1984, the questions concerning cross-country skiing were omitted, but the same four questions about walking and cycling remained. Because all men had retired by 1984, the question concerning occupational activity was no longer applicable. In 1989, the interview on physical activity also included the same four questions about walking and cycling.

The questions of physical activity provided the possibility to estimate the mean kilometers walked, cycled, and skied per day in 1964 and the mean kilometers walked and cycled daily in 1984 and 1989. In an attempt to construct a sum variable of physical activity from the differently strenuous activities, a multiple of resting metabolic rate (MET score) (27) was assigned to every activity describing energy expenditure in each activity. The MET is the ratio of metabolic rate during the activity compared with the metabolic rate at rest (28). Because the duration of activity was not enquired, the intensity of each activity had to be estimated as being the same for all subjects (the mean intensity of walking was estimated to be 4.8 km/hour, which corresponds to four METs, the mean intensity of cycling 12.9 km/hour corresponding to five METs, and the mean intensity of skiing 6.4 km/hour corresponding to nine METs) (27). Because one MET is approximately 1 kcal/kg (= 4.2 kilojoules [kJ]/kg) per hour, energy expenditure in kJ for each physical activity was computed by multiplying its MET score by 4.2, body weight in kilograms, and kilometers per day of activity divided by the estimated intensity of activity. The following equations for daily activities were derived:



Then energy expenditure of daily walking, cycling, and skiing was summed to provide baseline physical activity per day (kJ/day). These values were classified into three tertiles. Tertile limits for baseline physical activity were less than 734 kJ/day, 743–1,361 kJ/day, and more than 1,361 kJ/day. Occupational activity was taken into account in the analyses as a cofactor.

Physical activity in 1984 (kJ/day) was obtained by summing the energy expenditure from walking and cycling. To estimate the mean physical activity throughout the 20 years, baseline physical activity was added to physical activity in 1984, and then that sum was divided by two. The quotients were classified into tertiles using the same limits as for baseline physical activity.

Physical activity in 1989 (kJ/day) was obtained by summing energy expenditure from walking and cycling. To estimate the mean physical activity throughout the 25 years, baseline physical activity and physical activity in 1984 were added to physical activity in 1989, and then the sum was divided by three. The quotients were classified into tertiles with the same limits as at the baseline.

Lung Function Measurements and Calculation of Rate of Change
In this study, FEV0.75 derived from spirometric tests was used as a measurement of pulmonary function (when the Seven Countries Study started during the 1950s, FEV0.75 was used as a measure of obstruction). Between 1964 and 1974, the spirometry was performed with the McKerrow spirometer (as described previously in detail) (26). In 1984 and 1989, spirometric recordings were performed with the Vitalograph (as explained previously in detail) (15).

The adjustment of FEV0.75 values for height was achieved by dividing the observed values by the square of each subject's standing height and then multiplying these figures by the square of the mean sample height (12). The annual change in height-adjusted FEV0.75 values was calculated by using within-person linear regression for each subject for whom at least three acceptable FEV0.75 measurements were available. Of all of the subjects from whom we had data on baseline physical activity, a total of 468 men had three measurements of pulmonary function during 1964–1974 (with full data on the smoking habits for 429 men). A total of 26 men with data on physical activity and smoking were excluded from the study because they had only two measurements of pulmonary function between 1964 and 1974. Those subjects for whom we had data on pulmonary function and smoking habits but with missing data on physical activity (n = 70) did not show a different decline in FEV0.75 compared with those men from whom we had data on activity. Of the men with data on physical activity over the 20 years (n = 275), 8 subjects had undergone three and 267 had had four measurements of pulmonary function during the period 1964–1984. Of the men for whom we had data on physical activity over the 25 years (n = 186), 2 had undergone three, 16 had had four, and 168 had taken part in all five measurements of pulmonary function between 1964 and 1989.

Other Measurements
The recording of smoking habits has been described in detail previously (15, 26). For this study, men were classified into never-smokers, quitters, and continuous smokers. During the first 10 years, quitters were either past smokers in 1964 or those baseline smokers who quit smoking permanently between 1964 and 1974. During 20–25 years, those recorded as quitters were baseline past smokers or those subjects who gave up smoking between 1964 and 1984. To be recorded as a quitter in an examination, a subject had to have given up smoking more than 1 year previously. Smokers who gave up smoking only after 1984 were included as continuous smokers. The duration of smoking was measured in 1959 by asking the number of years of smoking (15).

The measurement of weight, blood pressure, and total cholesterol has been described elsewhere (25). The presence of respiratory disease (physical or history of bronchial asthma, pulmonary emphysema, chronic bronchitis, pulmonary tuberculosis, bronchiectasis, pulmonary fibrosis, and thorax deformity) was evaluated at each examination by the examining physician.

Statistical Analysis
Statistical analyses were performed by SPSS for Windows (SPSS, Inc., Chicago, IL). One-way analysis of variance was used to compare the means of age, baseline level of pulmonary function, and baseline duration of smoking in the tertiles of baseline physical activity. Between the tertiles of baseline physical activity, the differences in occupational activity and smoking habits during the follow-up (on the basis of smoking data from 1964–1974) were examined using {chi}2 analysis.

The effect of potential determinants on the mean annual change in FEV0.75 during 10 years of follow-up was calculated by a linear regression model (n = 429). The main determinant of interest was baseline physical activity; other variables were age, smoking habits, and initial level of pulmonary function. Analysis of covariance analyses were used to describe the differences in the mean annual decline in FEV0.75 between the levels of physical activity with an adjustment for age, initial level of pulmonary function, and smoking habits during the follow-up. The number of men included in the analysis of covariance analyses was 275 between 1964 and 1984 and 186 between 1964 and 1989. For addition, the following additional adjustments were performed. An additional adjustment for occupational activity was performed using a dichotomous variable (sedentary, light, and moderate occupational activity compared with heavy/very heavy occupational activity). An adjustment for tobacco consumption was made using first the baseline duration of smoking as a continuous variable and then the mean of reported cigarette consumption during the follow-up as a secondary continuous variable (for quitters only, the data from those examinations when they reported smoking were used in calculating this variable). An adjustment was also made for the presence of respiratory disease (a dichotomous variable).

The influence of the changes in physical activity over 20 years (1964–1984) on mortality during the subsequent 15 years (1984–1999) was studied by Cox's proportional hazards regression model. The analysis was adjusted for potential confounders (values in 1984), namely, age, height-adjusted FEV0.75, diastolic blood pressure, and total cholesterol as continuous variables, body mass index as a dichotomous variable (less than 20, and 20 or more), and smoking habits as a three-category variable (never-smokers, quitters, and continuous smokers). An additional adjustment for tobacco consumption was performed in the same way as in previous analysis. All deaths between 1984 and 1999 are known, but there were nine men with missing values in the multivariate analyses. Thus, altogether, 266 out of 275 men were included in the mortality analyses, and there were a total of 202 deaths.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The baseline characteristics of study subjects are shown by the tertiles of baseline physical activity in Table 1 . The means of age, adjusted FEV0.75, and duration of smoking were not significantly different across the tertiles. During the first 10 years, the proportions of never-smokers, quitters, and continuous smokers did not differ significantly in the tertiles, although there were less never-smokers among men with the lowest physical activity. Men in the middle and highest tertile of baseline physical activity were also significantly (p < 0.001) more engaged in heavy or very heavy occupational activities (mainly farming) than men in the lowest tertile.


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  		TABLE 1. Baseline characteristics of study subjects by tertile of baseline physical activity

 
The linear regression model showed that the annual decline in FEV0.75 increased with smoking, initial pulmonary function, and age during the first 10 years (Table 2) . In the highest tertile of mean physical activity, the yearly decrease in FEV0.75 was 9.8 ml/year smaller than in the lowest tertile. However, the effect of physical activity on the yearly change in FEV0.75 was smaller than that of smoking (among quitters and continuous smokers, FEV0.75 decreased yearly by 13.1 and 18.8 ml, respectively, more than among never-smokers). When we examined the data from 20 years of follow-up, those men in the highest tertile of mean physical activity had also a significantly less severe decline in FEV0.75, and the trend between tertiles was significant (Table 3) . Additional adjustment for occupational activity, the duration of smoking, the mean of reported cigarette consumption during the follow-up, or a prevalent respiratory disease during the follow-up did not change the result (data not shown).


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  		TABLE 2. Estimated mean effect (ml/yr) of baseline physical activity on yearly change in fev0.75 during 10 years: comparison with the effects of other variables

 

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  		TABLE 3. Mean annual decline in fev0.75 (95% confidence interval) during 20 years by smoking category and physical activity throughout 20 years

 
During the follow-up, physical activity associated with a slower decline in FEV0.75 in all smoking categories, and the interaction of the effects of smoking habits and physical activity on FEV0.75 was not significant. However, because of the additive effects of physical activity and nonsmoking, the decline in FEV0.75 in the never-smokers in the highest tertile of physical activity was less than half of that experienced by smokers in the lowest tertile of physical activity (Table 3).

At the baseline, there were no significant differences in FEV0.75 values between the tertiles among those surviving 25 years (n = 186) (Table 4) . However, over the 25 years, the men in the highest tertile lost significantly less FEV0.75, and thus, after 25 years, significant differences in FEV0.75 values can be detected between the tertiles.


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  		TABLE 4. Mean annual decline in fev0.75 (95% confidence interval) during 25 years by physical activity throughout 25 years

 
During the follow-up, continued high physical activity and a change in physical activity to a high level are associated with younger age, a slower decline in FEV0.75, and higher FEV0.75 values after 20 years (Table 5) . The effect of changes in physical activity on survival time is illustrated in Figure 1 . Among those with continued high activity or an increase in activity to the highest tertile, the adjusted hazard ratio for total mortality was 0.62 (0.38 to 1.00; p value = 0.0499) compared with that remained with continued low activity. The hazard ratios among those in the middle tertile or among those who decreased activity to the lowest tertile were 0.77 (0.52 to 1.12) and 0.83 (0.57 to 1.22), respectively. Additional adjustment for tobacco consumption was not statistically significant.


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  		TABLE 5. Selected characteristics of study subjects by change in physical activity throughout 20 years

 


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  		Figure 1. Cumulative survival probability curves for changes in physical activity during the preceding 20 years based on Cox's proportional hazards regression model (adjusted for age, smoking habits, body mass index, diastolic blood pressure, total cholesterol, and pulmonary function). Thin gray line = high (constant or increased to high); thin black line = middle (constant or changed to middle); thick gray line = decreased to low; and thick black line = low (constant).

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our results suggest that physical activity may delay the decline in pulmonary function occurring in middle and old age. The beneficial effect of physical activity on pulmonary function was independent of smoking and was similar in all smoking categories. In our study, the adjusted decline in FEV0.75 was significantly slower among men in the highest tertile of physical activity at the baseline and during the follow-up. The 25-year follow-up was long enough to permit us to carry out long-term comparisons. In agreement with our results, highly fit older subjects have had better pulmonary function (17, 20, 21), and physical activity has been positively associated with pulmonary function (16, 18, 19) in previous cross-sectional studies. In the Amsterdam Growth and Health Study, physical activity was observed to be positively correlated to changes in FVC between ages 13–27 years over a period of 15 years (22). On the other hand, no advantageous effect of physical activity on the decline in resting lung function (29) was found among 18 nonsmoking older athletes in their 60s and 70s during a 6-year follow-up.

In the Harvard Alumni Health Study, those individuals expending 2,000 or more kcal per week in walking, climbing stairs, and playing sports reduced their risk of death by 28% compared with less active men (6). The association of physical activity was strongest for cardiovascular deaths, but the amount of exercise was also inversely related to deaths due to respiratory diseases (6). In our study, energy expenditure of more than 2,268 kcal/week was shown to reduce the decline in pulmonary function (the limit for our highest tertile was 1,361 kJ/day, which is equivalent to a weekly energy expenditure of 7 x 1,361 kJ = 9,527 kJ = 9,527/4.2 kcal = 2,268 kcal). In addition, in this study, those subjects with continued high activity or those who increased their physical activity so that they were entered into the highest tertile had lower all-cause mortality. In the Harvard Alumni Health Study, the subjects who took up moderately vigorous sports activity experienced a substantial reduction in mortality from all causes (30).

Our study subjects lived in a nonpolluted rural area, and most of them were farmers. The measure of physical activity was based on the amount of daily walking, cycling, and skiing measured at the baseline and the amount of daily walking and cycling during the follow-up. We consider that the sum of these activities most probably provides a reasonable estimate of the subjects' physical activity because other types of exercise were uncommon among the men studied (5). The correlation coefficients obtained for the correlations between measured physical activity at each examination point and our calculated average measures were high and thus further support our justification for using mean physical activity variables. The intensity of each activity was not known. However, it might be less variable in this population of rural men than would be detected in more heterogeneous study populations because among the study subjects, physical activities consisted mostly of activities conducted at work or on the way to work. We had different follow-up times on our study subjects. Those subjects seen only initially and during the first 10 years were older and had lower baseline FEV0.75 values than those surviving 20 and 25 years. However, between these groups, there were no differences in relationship to occupational activity, smoking habits, or duration of smoking; therefore, these groups were comparable, and no bias was created in the data in this sense.

The results in this study can be compared with other studies that have used FEV1 because FEV0.75 can be assumed to measure approximately the same as FEV1 (FEV0.75 needs to be multiplied by 1.09 to calculate the FEV1) (31). The estimated mean annual decline in FEV0.75 between examinations could theoretically have been affected by the change in the equipment used to measure FEV0.75 during the follow-up. However, this does not disturb the comparisons between the tertiles of physical activity because all participants were measured using identical equipment at each examination.

A loss of lung elastic recoil, increased chest wall compliance, and a decrease in the strength of respiratory muscles have been proposed to be the most important factors contributing to the decline in pulmonary function with age (32). The loss of elastic recoil can lead to premature airway closure, resulting in air trapping during forced expiration (33). It is possible that physical activity could counteract this stiffening tendency in the chest wall. Older endurance athletes have been shown to suffer less aging-related effects on lung elastic recoil and diffusion surface (34). It has also been claimed that physical activity can enhance inspiratory muscle endurance (18).

In general, the amount of physical activity declines with age (35). According to surveys conducted in Australia, Canada, Finland, and the United States, one-quarter to one-third of the adult population are sedentary in their leisure time (36). However, there is clear evidence that there has been a (modest) increase in the prevalence of exercise (for moderate levels of activity) over at least the past decade (36). Thus, it is possible that more people may be now expected to preserve moderate pulmonary function into old age.

In conclusion, higher physical activity was related to a slower decline in pulmonary function. The physical activities assessed in this study (walking and cycling) can be performed by all individuals. Our study subjects lived in a rural environment, and thus, some caution is needed in interpretation of the results with respect to outdoor exercise in heavily polluted environments. Although smoking cessation is certainly an important way to reduce the decline in pulmonary function in smokers, physical activity appears to be beneficial in both smokers and nonsmokers. These findings are potentially important from a public health and clinical point of view. For example, among chronic obstructive pulmonary disease patients, exercise training could be used to delay the deterioration in pulmonary function.


   Acknowledgments
 
The authors thank Juha Pekkanen, M.D., Ph.D.


   FOOTNOTES
 
Supported by grants from the Finnish Academy, the Finnish Anti-Tuberculosis Association Foundation, the Finnish Lung Health Association, and the National Institute on Aging (grant EDC-1 1 RO1 AGO8762–01A1).

Conflict of Interest Statement: M.P. has no declared conflict of interest; I.-L.N. has no declared conflict of interest; T.L. has no declared conflict of interest; H.O.K. has no declared conflict of interest; P.K. has no declared conflict of interest; A.N. has no declared conflict of interest.

Received in original form August 28, 2002; accepted in final form May 29, 2003


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Proc. Am. Thorac. Soc. Am. J. Respir. Cell Mol. Biol.
Copyright © 2003 American Thoracic Society