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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: Prev Med. 2023 Nov 19;177:107781. doi: 10.1016/j.ypmed.2023.107781

Associations of Pedometer-Measured Ambulatory Activity with Incidence of Atherosclerotic Cardiovascular Diseases: Strong Heart Family Study

Steven Pan 1,*, Sixia Chen 1, Amanda M Fretts 2, Tauqeer Ali 3
PMCID: PMC10872869  NIHMSID: NIHMS1947880  PMID: 37984645

Abstract

Objective:

Coronary heart disease has several risk factors that require a multifactorial community intervention approach in prevention efforts. Prevalence of coronary heart disease and its risk factors have been disproportionately high among American Indians. The objective of this study is to evaluate the impact of ambulatory activity levels on the development of coronary heart disease in this population.

Methods:

Using pedometer data and other lifestyle and clinical factors from 2,492 participants in the Strong Heart Family Study, we examined the associations of average daily step counts with incident coronary heart disease during an 18 to 20 year follow-up.

Results:

After adjusting for potential confounders, participants with daily step counts in the 4th quartile (>7,282 steps per day) had significantly lower odds of developing coronary heart disease compared to those in the 1st quartile (<3010 steps per day) (p=0.035).

Conclusions:

Higher daily step count (over 7,282 steps per day) is significantly associated with lower incidence of coronary heart disease among American Indian participants of the Strong Heart Family Study in a 20-year follow-up period.

Keywords: coronary heart disease, physical activity, Strong Heart Family Study, step counts, American Indian, cardiovascular disease prevention

Introduction

There is substantial evidence that establishes the benefits of being physically active on prevention of cardiovascular diseases and diabetes [1–8], and the 2019 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines highlight physical activity as a key component of prevention efforts [1]. The guideline recommends 150 minutes per week of moderate-intensity (or 75 minutes of vigorous-intensity) aerobic physical activity, such as brisk walking, for adults to reduce risk of atherosclerotic cardiovascular diseases (ASCVD) [1]. This is consistent with AHA’s Life’s Essential 8 recommendations for lowering risks of coronary heart disease (CHD) [9].

CHD is the progressive narrowing of the arteries that supply blood and oxygen to the heart due buildup of cholesterol deposits in the arterial wall [10]. CHD events, such as angina or myocardial infarction, can occur when blood flow to the heart becomes significantly occluded [10,11]. In this study, we assessed the impact of physical activity on the risk of CHD among American Indians, who historically have been disproportionately affected by heart diseases and underrepresented in past cardiovascular disease studies, compared to other ethnicities [12–14]. In fact, heart disease was the leading cause of death in American Indian men (18.9%) and second leading cause of death in American Indian women (17.1%) of all ages in 2018 [15,16]. In addition, prevalence of physical inactivity, obesity, diabetes, and other lifestyle-based risk factors in American Indians may be higher compared to the general population [2,17]. Combined Behavioral Risk Factor Surveillance System (BRFSS) data from 2017 to 2020 estimated physical inactivity outside of work to be 29.1% in American Indian adults compared to 23.0% in non-Hispanic White adults [18]. Therefore, due to the differences in population characteristics, it is unclear if the findings in other studies can be easily generalized to the American Indian communities.

Our study results will describe the effects of ambulatory activity on CHD prevention among the American Indian participants of the Strong Heart Family Study (SHFS). Specifically, our objective is to evaluate the association between average daily step counts and incidence of CHD in the SHFS cohort.

Methods

Study Population

The SHFS is a multi-center, family-based prospective cohort study of cardiovascular diseases in American Indians. It includes 12 American Indian communities and tribes in Arizona, Oklahoma, North Dakota, and South Dakota. Participants completed 2 exams over an 8 year period: a baseline exam in 2001–2003 and a follow-up exam in 2006–2009. Since 2009, participants have been contacted annually to update health status. Among the SHFS participants in the baseline exam, we included those who were 18 years or older. Participants with a history of CHD, or other ASCVD, such as ischemic stroke and transient ischemic attack (TIA), who were pregnant, without a family ID, or had less than 4 days of pedometer data were excluded. We excluded participants with history of ischemic stroke and TIA, because they share similar pathophysiology with CHD and most survivors have extensive coronary atherosclerosis and significantly higher risk of developing CHD within the study time frame [19–21]. Following these eligibility criteria, we included 2492 participants in our analytic sample. Number of missing values for each covariate was reported in Table 1. Only non-missing values were used in our descriptive and regression analyses. Participants with missing covariates were excluded from the multivariate analyses.

Table 1.

Baseline Characteristics by Categories of Average Daily Step Counts, Strong Heart Family Study, 2000 – 2005 (n=2492)

Quartiles of Average Daily Step Count Total Missing
Q1: < 3010 Q2: 3010 – 4924 Q3: 4925 – 7282 Q4: > 7282
(n=622) (n=624) (n=622) (n=624)
n (%) Mean (Std) n (%) Mean (Std) n (%) Mean (Std) n (%) Mean (Std)
Sex, female** 488 (31.4) 430 (27.7) 362 (23.3) 275 (17.7) 0
Center**
AZ 247 (31.9) 202 (26.1) 182 (23.5) 143 (18.5) 0
OK 224 (24.6) 235 (25.8) 210 (23.1) 242 (26.6) 0
SD 151 (18.7) 187 (23.2) 231 (28.6) 238 (29.5) 0
Age** (years) 45.9 (16.3) 40.8 (14.7) 38.5 (13.4) 36.2 (12.4) 0
Education** (years) 11.8 (2.2) 12.2 (2.2) 12.3 (2.2) 12.4 (2.1) 9
BMI** 35.3 (8.6) 32.9 (7.9) 31.4 (7.0) 30.7 (6.7) 9
TC 183 (38.2) 185 (34.2) 185 (36.4) 184 (34.1) 9
LDL* (mg/dl) 97.6 (27.5) 99.2 (29.0) 102.2 (30.2) 102.9 (29.7) 23
HDL 51.1 (14.8) 52.0 (14.4) 51.8 (15.1) 52.0 (14.4) 19
AHEI 43.63 (8.44) 43.88 (8.68) 43.70 (9.01) 43.77 (9.65) 189
Smoking Status*
Current 204 (22.3) 216 (23.6) 253 (27.6) 243 (26.5) 0
Former 173 (28.1) 147 (23.9) 152 (24.7) 143 (23.3)
Alcohol use**
Current 326 (52.4) 386 (61.9) 399 (64.2) 434 (69.8) 2
Former 219 (35.2) 184 (29.5) 182 (29.3) 154 (24.8)
Never 77 (12.4) 54 (8.7) 41 (6.6) 34 (5.5)
Diabetes Status**
DM 204 (38.6) 141 (26.7) 121 (22.9) 63 (11.9) 9
IFG 151 (28.0) 137 (25.4) 124 (23.0) 127 (23.6)
Hypertension* 263 (33.4) 202 (25.6) 179 (22.7) 144 (18.3) 6
CHF** 12 (1.9) 3 (0.5) 2 (0.3) 1 (0.2) 0
PAD** 43 (7.2) 24 (3.9) 13 (2.1) 19 (3.1) 52
Albuminuria**
Micro 108 (17.5) 87 (14.0) 75 (12.1) 63 (10.2) 19
Macro 35 (5.7) 26 (4.2) 16 (2.6) 7 (1.1)
Incident CHD* 96 (15.4) 78 (12.5) 76 (12.2) 51 (8.2) 0
Incident MI 27 (4.3) 24 (3.9) 24 (3.9) 17 (2.7) 0
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Abbreviations: Std, standard deviation; AZ, Arizona; OK, Oklahoma; SD, North Dakota and South Dakota; TC, total cholesterol; LDL, low density lipoprotein; HDL, high density lipoprotein; AHEI, alternative healthy eating index; DM, diabetes mellitus; IFG, impaired fasting glucose; CHF, congestive heart failure; PAD, peripheral artery disease; CHD, coronary heart disease; MI, myocardial infarction

*

p-value < 0.05

**

p-value < 0.0001

Outcome was defined as incident CHD cases that occurred during the time period encompassing Phase 4 examination cycle until the end of year 2020, as determined by the morbidity and mortality surveillance review committee. CHD includes diagnoses of non-fatal MI (definite, probable, or possible), non-fatal CHD (definite or possible), fatal MI (definite or probable), and fatal CHD (definite or possible). Detailed diagnostic criteria for these fatal and non-fatal events have been described previously [22,23]. Non-missing daily step counts measured by the pedometer were averaged across the seven-day monitoring period. Covariates include age, sex, SHS study center (AZ/SD/OK), years of education, Alternative Healthy Eating Index (AHEI) score, smoking status (current, former, or never), alcohol use status (current, former, or never), diabetes status, low-density lipoprotein (LDL) level, and hypertension status. AHEI is a measure of dietary quality based on prevention of chronic diseases and higher scores have been shown to be associated with reduced cardiovascular disease risks [24,25]. Diabetes status was defined by the 1997 American Diabetes Association criteria as having fasting plasma glucose (FPG) of 126 mg/dL or higher, being treated with insulin, hypoglycemic drugs, or having self-reported history of diabetes on the questionnaire. Participants without diabetes were categorized into normal fasting glucose tolerance and impaired fasting glucose tolerance based on FPG threshold of 110 mg/dL. Hypertension status was defined as taking antihypertensive drugs, having systolic blood pressure of 140 mmHg or higher, or having diastolic blood pressure of 90 mmHg or higher. Peripheral artery disease was indicated by ankle brachial index values less than 0.9. Micro- and macroalbuminuria were indicated by urine albumin-creatinine ratio values between 30 and 299 mg/g, and 300 mg/g or higher, respectively.

Statistical Analyses

Participant demographics, lifestyle factors, and comorbidities at baseline and their outcome status, as of 2020, were summarized descriptively. Sample-based quartiles of average daily step counts were constructed and ranged from 159 to 3009, 3010 to 4924, 4925 to 7282, and 7283 to 38756.

Prespecified population-averaged generalized estimation equation (GEE) models with exchangeable correlation structure were used to assess the association of baseline ambulatory activity levels (quartiles) with incident CHD, while accounting for potential correlation in risk factors among members of the same family. Each model contains increasing number of covariates. Model 1 was adjusted for age, sex, and study center. Model 2 was additionally adjusted for education level, AHEI score, smoking, and alcohol status. Model 3 adjusted for diabetes status, hypertension status, LDL level, and BMI in addition to covariates in model 2. These demographic, lifestyle, and clinical factors have been known to affect CHD risk and their roles are described in detail in the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease[1]. Continuous covariates were assessed for functional forms and categorized if linearity was not observed. Effect modifications by study center, age, and sex were explored using the continuous form of average daily step counts. Odds ratios from each model were summarized. To better examine the association of step quartiles and progression of CHD in relation to time, we analyzed the data using Cox regression models with frailty terms for correlated observations as an alternative assessment. Findings are described in the supplement. All statistical analyses were conducted in SAS 9.4. This secondary analysis was conducted using de-identified data with approvals from participating institutional review boards.

Results

Among 2492 participants, average daily step count ranged from 159 to 38755 with the average of 5609 (SD = 3799). Average participant age was 40 years old (SD = 14.69) and comprised of 1555 (62.4%) women. 916 (36.8%) were smokers. 529 (21.3%) participants had diabetes and 788 (31.7%) had hypertension at baseline. Average LDL was 100.5 mg/dl (SD = 29.2) and participants had an average AHEI score of 43.7 (SD = 8.95). During up to 20 years of follow-up, 301 (12.1%) participants developed CHD. Among incident CHD cases, 92 (30.6%) were myocardial infarctions of which 21 (6.98%) were fatal. Participant characteristics according to step quartiles at baseline are outlined in Table 1. Proportion of women, mean age, prevalence of diabetes and hypertension, and more importantly, incidence of CHD was lower in higher step quartiles.

Odds ratios (OR) from the multivariate GEE models are summarized in Table 2. In the fully adjusted model, participants who accumulated at least 7283 steps per day had a 35.0% lower odds (OR = 0.650, 95% CI: 0.435, 0.970) of developing CHD when compared to those who took less than 3010 steps per day (p=0.035). The odds of developing CHD comparing step quartile 2 to 1 (OR = 0.959, 95% CI: 0.649, 1.418) and 3 to 1 (OR = 0.896, 95% CI: 0.612, 1.311) were not statistically significant, but showed a decreasing trend (p<0.0001). There were no statistically significant interactions between average daily step counts and study center, age, or sex on risk of CHD.

Table 2.

Summary of Odds Ratios for Developing Coronary Heart Disease from Model 1 – 3 Comparing Quartile 2, 3, and 4 to Quartile 1, Strong Heart Family Study, 2000 – 2005

OR (95% CI)
< 3010 steps 3010 – 4924 steps 4925 – 7282 steps > 7282 steps
Model 1 (n=2492) 1.00 (ref) 0.890 (0.611, 1.295) 0.899 (0.629, 1.285) 0.587 (0.403, 0.857)
Model 2 (n=2295) 0.921 (0.624, 1.357) 0.888 (0.609, 1.294) 0.582 (0.395, 0.856)
Model 3 (n=2267) 0.912 (0.614, 1.353) 0.858 (0.584, 1.261) 0.650 (0.435, 0.970)
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Model 1 adjusted for age, sex, and study center

Model 2 additionally adjusted for education level, AHEI score, smoking, and alcohol status

Model 3 additionally adjusted for diabetes status, hypertension status, LDL level, and BMI

Discussion

Among the SHFS participants, those who averaged more steps per day had lower risk of developing CHD during the follow-up period. We found significant risk reduction in participants with daily step counts in the top quartile compared to those in the bottom quartile. Specifically, our results suggest that American Indian community members who consistently incorporates more than 7,282 steps into daily activities may delay the onset of, if not prevent, CHD when compared to those who take less than 3,010 steps per day. This finding has important public health implications in the American Indian population. It shows that incident CHD may be partially attributed to physical inactivity and that prevalence of CHD can be lowered over time by encouraging the community members to take more steps every day. It will also help set specific and measurable physical activity goals and contribute to the awareness in CHD prevention efforts.

Coronary heart disease and its risk factors were previously studied in the original Strong Heart Study (SHS) cohort with baseline examinations in 1989 to 1991 [26–28]. The study by Lee, et al. in 2006 has identified many significant risk factors for CHD in the underlying American Indian population and led to the development of the risk calculator that estimates the 10-year risk of developing CHD for American Indians who are 30 years and older [26,29]. However, self-reported level of physical activity based on occupational and leisure-time activities was not statistically significant after adjusting for diabetes and therefore its impact on CHD development was not reported [26]. This was likely due to the association between inactivity and diabetes. Physical inactivity has been shown to be a significant risk factor in the development of diabetes and this connection has been demonstrated in prior studies within the SHS cohort [2,3,30].

In this study, we reevaluated a similar relationship using ambulatory activity in a much more recent and considerably younger cohort in the SHFS with baseline examinations in 2001 to 2003. In more recent SHS studies, Fretts, et al. have found lower risk of incident diabetes in those who reported being physically active and those who averaged over 3,500 steps per day [2,3]. This aligns with our finding given that diabetes is a significant risk factor and often a comorbidity for those with CHD.

Many other studies have found health and survival benefits associated with increased physical activity levels in various different populations. Studies using pedometer data showed decreased risks of cardiovascular disease and all-cause mortality with higher number of steps per day [31–35]. Similar to our study, they suggest a dose-response relationship between step count and cardiovascular disease morbidity and mortality. However, their results are not entirely applicable to our SHFS cohort due to differences in step count classification, outcome definition, and characteristics of the underlying population. There are also several studies that examined the relationship of physical activity and CHD using energy expenditure, such as metabolic equivalent of task, or time spent engaging in physical activity of various intensities [4,5,36–38]. Greater weekly energy expenditure and length of physical activity time demonstrated protection against CHD with varying magnitudes when compared to their more sedentary counterparts. However, these studies measured leisure-time physical activities, which were self-reported, subjective, and difficult to standardize. Due to the differences in study characteristics, we find it difficult to directly compare the CHD risk reduction associated with increased physical activity observed in our study to those described in other cohorts. However, it has been shown that CHD risks are greater in American Indians compared to their white counterparts due to higher prevalence of risk factors, including smoking, hypertension, diabetes, and obesity, as well as factors related to genetics and social determinants of health [39,40].

In a relatively inactive population with high prevalence of diabetes and hypertension at baseline, we believe that ambulatory activity more objectively represents the physical activity level of each participant. With many wearable devices now having the capability to track step counts, number of average daily steps has become a more measurable way of quantifying physical activity and setting goals. In addition, the development of CHD occurs over time and may remain asymptomatic and unidentified until an acute event presents [41]. The SHFS longitudinal data and ongoing cardiovascular disease-related morbidity and mortality surveillance allow us to effectively observe incidences of CHD in the span of 20 years.

This study has several limitations. The pedometer only measured participant’s level of ambulatory activity, which would not reflect the intensities of other physical activities, such as strength training exercises. As a result, using only step counts would not entirely account for each participant’s level of baseline daily physical activities and this would distort the associations in our finding. Secondly, CHD is a multifactorial disease with several risk factors and some of which were not adjusted for in our models. This results in residual confounding. Lastly, we only considered CHD as our outcome of interest. However, there are other ASCVDs that can result from physical inactivity [1]. Depending on the location of atherosclerosis, the reduced blood flow can manifest as ischemic stroke, transient ischemic attack, or peripheral artery disease. Therefore, these ASCVD events may be competing risks that were not accounted for in the analyses. The lack of statistical significance for quartile 2 and 3 may be due to low event rate (12.1%) and inadequate power.

Conclusion

Sample-based quartiles of average steps per day showed a decreasing trend in odds of developing CHD over the period of 20 years with each increase in quartile among various American Indian communities. An average of more than 7,282 daily steps was significantly associated with lower odds of developing CHD compared to an average of fewer than 3,010 steps per day. We intend to use findings from this work to promote physical activity within the tribal communities participating in the SHS. Future research using a longer time window may better estimate the effect of physical activity, or other risk factors, on development of CHD, over the life-course.

Figure 1.

Figure 1.

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Participant Flow Diagram of Analytic Sample Sizes, Strong Heart Family Study, 2000 – 2005

Highlights:

  • High daily step counts lower risk of coronary heart disease among American Indians

  • Ambulatory activity levels reflect trend in coronary heart disease prevention

  • Results show public health implications in population with prevalent risk factors

Acknowledgements and Sources of Funding

The SHS has been funded in whole or in part with federal funds from the National Heart, Lung, and Blood Institute, National Institute of Health, Department of Health and Human Services, under contract numbers 75N92019D00027, 75N92019D00028, 75N92019D00029, & 75N92019D00030 and research grants: R01HL109315, R01HL109301, R01HL109284, R01HL109282, and R01HL109319 and cooperative agreements: U01HL41642, U01HL41652, U01HL41654, U01HL65520, and U01HL65521. The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health or the Indian Health Service.

Dr. Sixia Chen was partially supported by the Oklahoma Shared Clinical and Translational Resources (U54GM104938) with an Institutional Development Award (IDeA) from NIGMS.

Appendix

For the time-to-event analysis, we defined the outcome as time, in months, from initial examination date to development of CHD. Participants who did not develop CHD were censored at the end of year 2020. We started with univariate analyses and included relevant covariates in subsequent multivariate analyses based on the p-value threshold of 0.2. We then screened for significant covariates at the 0.05 level and explored two-way interactions with average daily step counts. Proportional hazard was assessed by including time-dependent variables, examining heterogeneity across time intervals, applying the Supremum Test, and plotting stratified Cox models. Hazard ratios for step quartiles from the univariate and multivariate models were summarized.

Preliminary Kaplan-Meier curves and log-rank test by step quartiles showed significantly lower probability of developing CHD over time when comparing step quartile 2, 3, and 4 to quartile 1 (p=0.0002 for trend). Hazard ratios from univariate and multivariate analyses with frailty models are reported in Table A.1. Only significant covariates, which were age, study center, diabetes status, and LDL, were included in the multivariate model. We stratified by study center due to evidence of deviation from the proportional hazard assumption. Hazard ratio for step quartile 4 vs. 1 was no longer statistically significant at the multivariate stage.

Table A.1.

Summary of Hazard Ratios for Developing Coronary Heart Disease from Univariate and Multivariate Frailty Models, Strong Heart Study, 2000 – 2005

HR (95% CI)
< 3010 steps 3010 – 4924 steps 4925 – 7282 steps > 7282 steps
Univariate 1.00 (ref) 0.783 (0.580, 1.058) 0.765 (0.564, 1.038) 0.506 (0.360, 0.711)
Multivariate* 0.973 (0.716, 1.321) 1.003 (0.730, 1.379) 0.768 (0.535, 1.104)
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*

Adjusted for significant covariates: age, diabetes status, LDL and stratified by study center

Abbreviations: HR, hazard ratio; CI, confidence interval

Footnotes

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Disclosures: None

Credit Author Statement

Steven Pan: Conceptualization, Formal analysis, Software, Investigation, Writing – Original Draft,

Sixia Chen: Writing – Review & Editing, Supervision, Validation

Amanda Fretts: Writing – Review & Editing, Supervision, Project administration

Tauqeer Ali: Conceptualization, Methodology, Resources, Project administration, Funding acquisition

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