European Journal of Epidemiology

, Volume 24, Issue 4, pp 181–192 | Cite as

Quantifying the dose-response of walking in reducing coronary heart disease risk: meta-analysis

  • Henry Zheng
  • Nicola Orsini
  • Janaki Amin
  • Alicja Wolk
  • Van Thi Thuy Nguyen
  • Fred Ehrlich
Cardiovascular Disease


The evidence for the efficacy of walking in reducing the risk of and preventing coronary heart disease (CHD) is not completely understood. This meta-analysis aimed to quantify the dose-response relationship between walking and CHD risk reduction for both men and women in the general population. Studies on walking and CHD primary prevention between 1954 and 2007 were identified through Medline, SportDiscus and the Cochrane Database of Systematic Reviews. Random-effect meta-regression models were used to pool the relative risks from individual studies. A total of 11 prospective cohort studies and one randomized control trial study met the inclusion criteria, with 295,177 participants free of CHD at baseline and 7,094 cases at follow-up. The meta-analysis indicated that an increment of approximately 30 min of normal walking a day for 5 days a week was associated with 19% CHD risk reduction (95% CI = 14–23%; P-heterogeneity = 0.56; I 2 = 0%). We found no evidence of heterogeneity between subgroups of studies defined by gender (P = 0.67); age of the study population (P = 0.52); or follow-up duration (P = 0.77). The meta-analysis showed that the risk for developing CHD decreases as walking dose increases. Walking should be prescribed as an evidence-based effective exercise modality for CHD prevention in the general population.


Coronary heart disease Exercise Meta-analysis Physical activity Walking 



The authors wish to acknowledge the valuable comments by two anonymous reviewers.


  1. 1.
    World Health Organisation. Cardiovascular diseases. [Online] Geneva: WHO; 2002 [updated 2002; cited 12 January, 2008]; Available from:
  2. 2.
    World Health Organisation. World health report 2002: reducing risk, promoting healthy life. Geneva: WHO; 2002.Google Scholar
  3. 3.
    Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:253–87. doi: 10.1146/annurev.pu.08.050187.001345.PubMedCrossRefGoogle Scholar
  4. 4.
    Berlin JA, Colditz GA. A meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol. 1990;132:612–28.PubMedGoogle Scholar
  5. 5.
    US Department of Health and Human Services. Physical activity and health: a report of the surgeon general. Atlanta: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.Google Scholar
  6. 6.
    Wannamethee SG, Shaper AG. Physical activity in the prevention of cardiovascular disease: an epidemiological perspective. Sports Med. 2001;31:101–14. doi: 10.2165/00007256-200131020-00003.PubMedCrossRefGoogle Scholar
  7. 7.
    Eaton CB. Relation of physical activity and cardiovascular fitness to coronary heart disease, part I: a meta-analysis of the independent relation of physical activity and coronary heart disease. J Am Board Fam Pract. 1992;5:31–42.PubMedGoogle Scholar
  8. 8.
    Bauman A. Updating the evidence that physical activity is good for health: an epidemiological review 2000–2003. J Sci Med Sport. 2004;7:6–19. doi: 10.1016/S1440-2440(04)80273-1.PubMedCrossRefGoogle Scholar
  9. 9.
    Kraemer WJ, Ratamess NA. Fundamentals of resistance training: progression and exercise prescription. Med Sci Sports Exerc. 2004;36:674–88. doi: 10.1249/01.MSS.0000121945.36635.61.PubMedCrossRefGoogle Scholar
  10. 10.
    Goldberg AP. Aerobic and resistive exercise modify risk factors for coronary heart disease. Med Sci Sports Exerc. 1989;21:669–74. doi: 10.1249/00005768-198912000-00008.PubMedGoogle Scholar
  11. 11.
    Egger G, Champion N, Bolton A. The fitness leader’s handbook. 4th ed. Sydney: Kangaroo Press; 1998.Google Scholar
  12. 12.
    Australian Bureau of Statistics. Physical activity in Australia: a snapshot, 2004–05 Canberra; 2006 [updated 2006; cited 2008 January 12]; Available from:
  13. 13.
    Reis JP, Macera CA, Ainsworth BE, Hipp DA. Prevalence of total daily walking among US adults, 2002–2003. J Phys Act Health. 2008;5:337–46.PubMedGoogle Scholar
  14. 14.
    The National Travel Survey. Walking in Great Britain 1996 [updated 1996; cited 2007 December 12]; Available from:
  15. 15.
    Morris JN, Hardman AE. Walking to health. Sports Med. 1997;23:306–32. doi: 10.2165/00007256-199723050-00004.PubMedCrossRefGoogle Scholar
  16. 16.
    Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med. 2002;347:716–25. doi: 10.1056/NEJMoa021067.PubMedCrossRefGoogle Scholar
  17. 17.
    Oguma Y, Shinoda-Tagawa T. Physical activity decreases cardiovascular disease risk in women: review and meta-analysis. Am J Prev Med. 2004;26:407–18. doi: 10.1016/j.amepre.2004.02.007.PubMedCrossRefGoogle Scholar
  18. 18.
    Hamer M, Chida Y. Walking and primary prevention: a meta-analysis of prospective cohort studies. Br J Sports Med. 2008;42:238–43. doi: 10.1136/bjsm.2007.039974.PubMedCrossRefGoogle Scholar
  19. 19.
    Kesaniemi YK, Danforth E Jr, Jensen MD, Kopelman PG, Lefebvre P, Reeder BA. Dose-response issues concerning physical activity and health: an evidence-based symposium. Med Sci Sports Exerc. 2001;33:S351–8. doi: 10.1097/00005768-200106001-00003.PubMedCrossRefGoogle Scholar
  20. 20.
    Williams PT. Physical fitness and activity as separate heart disease risk factors: a meta-analysis. Med Sci Sports Exerc. 2001;33:754–61. doi: 10.1097/00005768-200105000-00012.PubMedGoogle Scholar
  21. 21.
    Kohl HW III. Physical activity and cardiovascular disease: evidence for a dose response. Med Sci Sports Exerc. 2001;33:S472–83. doi: 10.1097/00005768-200106001-00017. discussion S93-4.PubMedCrossRefGoogle Scholar
  22. 22.
    Morris JN, Clayton DG, Everitt MG, Semmence AM, Burgess EH. Exercise in leisure time: coronary attack and death rates. Br Heart J. 1990;63:325–34. doi: 10.1136/hrt.63.6.325.PubMedCrossRefGoogle Scholar
  23. 23.
    Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and coronary heart disease in men: The Harvard Alumni Health Study. Circulation. 2000;102:975–80.PubMedGoogle Scholar
  24. 24.
    Hakim AA, Curb JD, Petrovitch H, Rodriguez BL, Yano K, Ross GW, et al. Effects of walking on coronary heart disease in elderly men: the Honolulu Heart Program. Circulation. 1999;100:9–13.PubMedGoogle Scholar
  25. 25.
    Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol. 1978;108:161–75.PubMedGoogle Scholar
  26. 26.
    LaCroix AZ, Leveille SG, Hecht JA, Grothaus LC, Wagner EH. Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults? J Am Geriatr Soc. 1996;44:113–20.PubMedGoogle Scholar
  27. 27.
    Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women: is “no pain, no gain” passe? JAMA. 2001;285:1447–54. doi: 10.1001/jama.285.11.1447.PubMedCrossRefGoogle Scholar
  28. 28.
    Shaper AG, Wannamethee G, Weatherall R. Physical activity and ischaemic heart disease in middle-aged British men. Br Heart J. 1991;66:384–94. doi: 10.1136/hrt.66.5.384.PubMedCrossRefGoogle Scholar
  29. 29.
    Tanasescu M, Leitzmann MF, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Exercise type and intensity in relation to coronary heart disease in men. JAMA. 2002;288:1994–2000. doi: 10.1001/jama.288.16.1994.PubMedCrossRefGoogle Scholar
  30. 30.
    Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampfer MJ, Willett WC, et al. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. N Engl J Med. 1999;341:650–8. doi: 10.1056/NEJM199908263410904.PubMedCrossRefGoogle Scholar
  31. 31.
    Folsom AR, Arnett DK, Hutchinson RG, Liao F, Clegg LX, Cooper LS. Physical activity and incidence of coronary heart disease in middle-aged women and men. Med Sci Sports Exerc. 1997;29:901–9. doi: 10.1097/00005768-199707000-00009.PubMedGoogle Scholar
  32. 32.
    Bassett DR Jr, Cureton AL, Ainsworth BE. Measurement of daily walking distance-questionnaire versus pedometer. Med Sci Sports Exerc. 2000;32:1018–23. doi: 10.1097/00005768-200005000-00021.PubMedCrossRefGoogle Scholar
  33. 33.
    Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000;32:S498–504. doi: 10.1097/00005768-200009001-00009.PubMedCrossRefGoogle Scholar
  34. 34.
    Fleiss JL. The statistical basis of meta-analysis. Stat Methods Med Res. 1993;2:121–45. doi: 10.1177/096228029300200202.PubMedCrossRefGoogle Scholar
  35. 35.
    Orsini N, Bellocco R, Greenland S. Generalized least squares for trend estimation of summarized dose-response data. Stata J. 2006;6:40–57.Google Scholar
  36. 36.
    Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol. 1992;135:1301–9.PubMedGoogle Scholar
  37. 37.
    Hamling J, Lee P, Weitkunat R, Ambuhl M. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med. 2008;27:954–70. doi: 10.1002/sim.3013.PubMedCrossRefGoogle Scholar
  38. 38.
    Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58. doi: 10.1002/sim.1186.PubMedCrossRefGoogle Scholar
  39. 39.
    Egger M, Smith GD, Altman DG. Systematic reviews in health care: meta-analysis in context London. UK: The BMJ Publishing Group; 2001.Google Scholar
  40. 40.
    Pereira MA, Kriska AM, Day RD, Cauley JA, LaPorte RE, Kuller LH. A randomized walking trial in postmenopausal women: effects on physical activity and health 10 years later. Arch Intern Med. 1998;158:1695–701. doi: 10.1001/archinte.158.15.1695.PubMedCrossRefGoogle Scholar
  41. 41.
    Shephard RJ. Absolute versus relative intensity of physical activity in a dose-response context. Med Sci Sports Exerc. 2001;33:S400–18. doi: 10.1097/00005768-200106001-00008. discussion S19-20.PubMedCrossRefGoogle Scholar
  42. 42.
    Shephard RJ. Intensity, frequency and duration of exercise as determinants of the response to a training regimen. Int Z Angew Physiol. 1968;26:272–8.PubMedGoogle Scholar
  43. 43.
    Kriska A. Ethnic and cultural issues in assessing physical activity. Res Q Exerc Sport. 2000;71:S47–53.PubMedGoogle Scholar
  44. 44.
    Ainsworth BE, Leon AS, Richardson MT, Jacobs DR, Paffenbarger RS Jr. Accuracy of the College Alumnus Physical Activity Questionnaire. J Clin Epidemiol. 1993;46:1403–11. doi: 10.1016/0895-4356(93)90140-V.PubMedCrossRefGoogle Scholar
  45. 45.
    Lee IM, Hsieh CC, Paffenbarger RS Jr. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA. 1995;273:1179–84. doi: 10.1001/jama.273.15.1179.PubMedCrossRefGoogle Scholar
  46. 46.
    Thorstensson A, Roberthson H. Adaptations to changing speed in human locomotion: speed of transition between walking and running. Acta Physiol Scand. 1987;131:211–4. doi: 10.1111/j.1748-1716.1987.tb08228.x.PubMedCrossRefGoogle Scholar
  47. 47.
    Duncan JJ, Gordon NF, Scott CB. Women walking for health and fitness. How much is enough? JAMA. 1991;9:266–3295. doi: 10.1001/jama.266.23.3295.Google Scholar
  48. 48.
    Kelley GA, Kelley KS, Tran ZV. Walking, lipids, and lipoproteins: a meta-analysis of randomized controlled trials. Prev Med. 2004;38:651–61. doi: 10.1016/j.ypmed.2003.12.012.PubMedCrossRefGoogle Scholar
  49. 49.
    Tucker LA, Friedman GM. Walking and serum cholesterol in adults. Am J Public Health. 1990;80:1111–3. doi: 10.2105/AJPH.80.9.1111.PubMedCrossRefGoogle Scholar
  50. 50.
    Wood PD, Haskell WL, Blair SN, Williams PT, Krauss RM, Lindgren FT, et al. Increased exercise level and plasma lipoprotein concentrations: a one-year, randomized, controlled study in sedentary, middle-aged men. Metabolism. 1983;32:31–9. doi: 10.1016/0026-0495(83)90152-X.PubMedCrossRefGoogle Scholar
  51. 51.
    Gordon NF, Cooper KH. Controlling cholesterol levels through exercise. Compr Ther. 1988;14:52–7.PubMedGoogle Scholar
  52. 52.
    Mayer-Davis EJ, D’Agostino R Jr, Karter AJ, Haffner SM, Rewers MJ, Saad M, et al. Intensity and amount of physical activity in relation to insulin sensitivity: the insulin resistance atherosclerosis study. JAMA. 1998;279:669–74. doi: 10.1001/jama.279.9.669.PubMedCrossRefGoogle Scholar
  53. 53.
    Hughes RA, Thorland WG, Housh TJ, Johnson GO. The effect of exercise intensity on serum lipoprotein responses. J Sports Med Phys Fitness. 1990;30:254–60.PubMedGoogle Scholar
  54. 54.
    Donahue RP, Abbott RD, Reed DM, Yano K. Physical activity and coronary heart disease in middle-aged and elderly men: the Honolulu Heart Program. Am J Public Health. 1988;78:683–5. doi: 10.2105/AJPH.78.6.683.PubMedCrossRefGoogle Scholar
  55. 55.
    Andrew M, Carter C, O’Brodovich H, Heigenhauser G. Increases in factor VIII complex and fibrinolytic activity are dependent on exercise intensity. J Appl Physiol. 1986;60:1917–22.PubMedGoogle Scholar
  56. 56.
    Duncan JJ, Farr JE, Upton SJ, Hagan RD, Oglesby ME, Blair SN. The effects of aerobic exercise on plasma catecholamines and blood pressure in patients with mild essential hypertension. JAMA. 1985;254:2609–13. doi: 10.1001/jama.254.18.2609.PubMedCrossRefGoogle Scholar
  57. 57.
    Gokce N, Vita JA, Bader DS, Sherman DL, Hunter LM, Holbrook M, et al. Effect of exercise on upper and lower extremity endothelial function in patients with coronary artery disease. Am J Cardiol. 2002;90:124–7. doi: 10.1016/S0002-9149(02)02433-5.PubMedCrossRefGoogle Scholar
  58. 58.
    Moyna NM, Thompson PD. The effect of physical activity on endothelial function in man. Acta Physiol Scand. 2004;180:113–23. doi: 10.1111/j.0001-6772.2003.01253.x.PubMedCrossRefGoogle Scholar
  59. 59.
    Pollock ML, Carroll JF, Graves JE, Leggett SH, Braith RW, Limacher M, et al. Injuries and adherence to walk/jog and resistance training programs in the elderly. Med Sci Sports Exerc. 1991;23:1194–200. doi: 10.1249/00005768-199110000-00014.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  • Henry Zheng
    • 1
  • Nicola Orsini
    • 2
  • Janaki Amin
    • 3
  • Alicja Wolk
    • 2
  • Van Thi Thuy Nguyen
    • 1
  • Fred Ehrlich
    • 1
  1. 1.School of Public Health and Community MedicineThe University of New South WalesSydneyAustralia
  2. 2.Division of Nutritional EpidemiologyInstitute of Environmental Medicine, Karolinska InstituteStockhlomSweden
  3. 3.National Centre in HIV Epidemiology and Clinical ResearchThe University of New South WalesSydneyAustralia

Personalised recommendations