Table 14.

Studies examining the relationship between physical activity and hypertension.

Publication Country Study Design Quality Score	Objective	Population	Methods	Outcome	Comments and Conclusions
Rankinen et al 2007 [75]	To investigate the contributions of DNA sequence variation in candidate genes, PF and BMI, as well as their interactions to the incidence of hypertension.	• n = 629 cases; 605 controls	10 year follow up	PF showed the strongest association with HTN risk among all subjects as well as sex-specific models. Each 1- MET increment in PF was associated with 19% (12- 14%), 16% (9-22%), 32% (17- 45%) risk reduction in all subjects, men and women respectively.	PF is a significant predictor of the risk of hypertension.
USA		• Sex: Men and women	All subjects required to have 2 clinic visits at least 2 years apart.
Case control		• Age: Case: 43.3 (9.2) yr Control: 42.7 (8.9) yr	PF assessment: treadmill test (Blake protocol)
D & B score = 13		• Characteristics: Healthy with BP 134/86 mmHg or less at their first clinic visit. Cases: those who developed hypertension during the follow-up period. Controls were those who did not develop hypertension	Outcome measure: Incidence of hypertension during follow-up. Incident cases of hypertension were defined as physician diagnosed hypertension with medication or SBP ≥ 140 mmHg and/of DBP ≥ 90 mmHg t-tests and chi-square tests Logistic regression modelling	When divided into quartiles on the basis of sex specific MET cut-offs, the third and fourth quartiles had a 58% (41-71%) and 63% (47-75%) lower risk of hypertension compared to the 1st quartile.
Pereira et al 1999 [76]	To examine PA and incident hypertension in men and women.	• n = 7,459	PA Assessment: Questionnaire for leisure, sport and work index, divided into quartiles	White Men	There is an inverse association between PA and incident hypertension in White middle aged men. White men in the highest quartiles of sport and leisure activity had statistically significant reductions in the odds of developing hypertension of 23 and 34% respectively, compared to men in the lower quartiles.
USA		• Sex: Men and women	Q1 = Lowest	Leisure Index Model 1
Prospective cohort		• Age: 45-65 yr	Q2	• Q1 = 1.00 (referent)
D & B score = 12		• Characteristics: No history of angina, MI, evidence of MI, angioplasty or other CV surgery or hypertension	Q3	• Q2 = 0.95 (0.70-1.28)
		• Atherosclerosis Risk in Communities Study	Q4 = Highest	• Q3 = 0.83 (0.63-1.09)
			Model 1 adjusted for: Age, education, baseline BP and study centre	• Q4 = 0.64 (0.46-0.89)
			Model 2 adjusted for: Covariates in model 1 and smoking, alcohol consumption, parental history of hypertension, energy, sodium, potassium and caffeine intake, BMI, waist to hip ratio, menopausal status and hormone use	Trend p = 0.01
			Outcome Measure: Incidence of hypertension as defined as a SBP 140 mmHg and/or a DBP 90 mmHg or use of antihypertensive medications.	Leisure Index Model 2
			Unconditional logistic regression Orthogonal polynomial coefficients	• Q1 = 1.00 (referent)
				• Q2 = 0.99 (0.72-1.35)
				• Q3 = 0.86 (0.65-1.13)
				• Q4 = 0.66 (0.47-0.94)
				Trend p = 0.01
				Women
				Sport Index Model 1
				• Q1 = 1.00 (referent)
				• Q2 = 1.26 (0.78-2.05)
				• Q3 = 1.06 (0.61-1.84)
				• Q4 = 1.92 (1.12-3.29)
				Trend p = 0.04
				Men
				Sport Index Model 1
				• Q1 = 1.00 (referent)
				• Q2 = 1.23 (0.91-1.66)
				• Q3 = 0.92 (0.70-1.22)
				• Q4 = 0.74 (0.54-1.02)
				Trend p = 0.02
				Sport Index Model 2
				• Q1 = 1.00 (referent)
				• Q2 = 1.26 (0.93-1.71)
				• Q3 = 0.95 (0.71-1.26)
				• Q4 = 0.77 (0.55-1.08)
				Trend p = 0.05
Haapanen et al 1997 [77]	To assess the association between PA and hypertension.	• n = 732 men; 796 women	10 year follow up (1980 baseline)	Age adjusted incidence rates ofhypertension Total energy expenditure High as referent:	Increased EE during LTPA and increased intensity of these activities were associated with reduced risk for incident hypertension (age adjusted) in men but not women.
Finland		• Sex: Men and women	PA assessement: Questionnaire for EE (kcal/wk), divided into tertiles
Prospective cohort		• Age: 35-65 years	Male	Male:
D & B score = 11		• Characteristics: Free of hypertension at baseline. Excluded those unable to participate in regular PA due to poor health	T1 = Low = 0-1100	• T1 = 1.00 (referent)
			T2 = Medium = 1101-1900	• T2 = 1.66
			T3 = High >1900	• T3 = 1.73
				Trend p = 0.021
			Female	Female:
			T1 = Low = 0-900	• T1 = 1.00 (referent)
			T2 = Medium = 901-1500	• T2 = 0.94
			T3 = High = >1500	• T3 = 1.16
			Outcome measure: Incidence of hypertension through self reported diagnosis and death certificates	Trend p = 0.648
			Cox proportional HR
Paffenbarger et al 1983 [78]	To examine the relationship of student and alumnus PA patterns and other characteristics with incident hypertension.	• n = 14,998	PA Assessment: Questionnaire for PA based on number of stairs ascended, blocks walked and hours per week of light and vigorous sports play, yard work etc.	There was no significantly reduced risk for hypertension in men who climbed 50 plus stairs per day (compared to < 50 stairs); who walked 5 plus blocks per day (compared to < 5 blocks); or who played light sports (compared to those who did not).	Contemporary vigorous exercise was inversely related to hypertension risk.
USA		• Sex: Men
Prospective cohort		• Age: 35-74 yr	Outcome measure: Diagnosis of hypertension by physicians using criteria of SBP > 160 mmHg and/or DBP > 95 mmHg	The 59% of men who did engage in vigorous sports were at 35% greater risk of hypertension than the 41% who did not.
				RR = 1.35
				Trend p = <0.001
D & B score = 12		• Characteristics: free of hypertension Harvard Alumni Study	Multivariate estimates	Alumni on the low side of the physical activity index (< 2000 kcal/wk) had a 30% increased risk of hypertension then those ≥ 2000 kcal/wk.
				RR = 1.30
				Trend p = 0.004
Paffenbarger et al 1997 [79]	To investigate the quantity and intensity of energy expenditure required to delay hypertension and prevent premature death.	• n = 6,390	PA Assessment: Questionnaire for weekly sports play, divided into tertiles	RR (95% CI)	Lack of vigorous sports play independently increased the risk of developing hypertension.
USA		• Sex: Men	T1 = None	• T1 = 1.00 (referent)
Prospective cohort		• Age: 45-84 yr	T2 = Light Only (< 4.5 METs)	• T2 = 1.04 (0.77-1.40)
D & B score = 12		• Characteristics: Free of hypertension, CHD, diabetes, COPD and potentially malignant cancer in 1977	T3 = Moderately vigorous (≥ 4.5 METs)	• T3 = 0.77 (0.62-0.96)
		• Harvard Alumni Study	Outcome measure: Incident hypertension	Trend p = 0.004
Hu et al 2004 [81]	To discover whether regular PA can reduce the risk of hypertension in normal weight and overweight men and women.	• n = 8,302 men; 9,139 women	11 year follow up	Multivariate adjusted HR (95% CI), men	Regular PA can reduce the risk of hypertension. The protective effect of PA was observed in both sexes regardless of level of obesity.
Finland		• Sex: Men and women	PA assessement: Questionnaire for OPA, LTPA and commuting PA, divided into tertiles	• T1 = 1.00 (referent)
Prospective cohort		Age: 25-64 yr	T1 = Low	• T2 = 0.63
D & B score = 13		Characteristics: Healthy and free of hypertension at baseline	T2 = Medium	• T3 = 0.59
			T3 = High	Trend p = < 0.001
			Outcome Measure: Incidence of drug treated hypertension	Multivariate adjusted HR (95% CI), women
			Cox proportional HR	• T1 = 1.00
				• T2 = 0.82
				• T3 = 0.71
				Trend p = 0.005
Gu et al 2007 [82]	To determine the 8-year incidence of HTN and its risk factors among Chinese adults.	• n = 10,525	Baseline Examination in 1991 with 8 year follow up	RR (95% CI), men	Increasing PA has the potential to reduce incidence of hypertension.
China		• Sex: Men and women	PA assessment: Questionnaire administered by trained staff, divided into groups	• G1 = 1.00 (referent)
Prospective cohort		Age: ≥ 40 yr	G1 = Low	• G2 = 1.12 (0.86-1.46)
D & B score = 13		Characteristics: Healthy and free from hypertension at baseline.	G2 = Medium	• G3 = 1.27 (1.10-1.47)
			G3 = High	RR (95% CI), women
			Outcome measure: HTN as defined at SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg or current use of antihypertensive medication	• G1 = 1.00 (referent)
			t-tests, chi squared tests, Cochran-Armitage modeling, Modified Poisson approach	• G2 = 1.14 (0.98-1.34)
				• G3 = 1.22 (1.02-1.45)
Hayashi et al 1999 [83]	To investigate the association of the duration of the walk to work and LTPA with the risk for hypertension.	• n = 6,017	PA assessment: Questionnaire on health related behaviours and exercise Walk time to work	RR (95% CI) Frequency walk time to work (minutes	The duration of walk to work was associated with a decreased risk of hypertension even after adjustment.
Japan		• Sex: Men	T1 = 0-10 min	• T1 = 1.00 (referent)	Regular PA (at least once weekly) was inversely related to the risk of incident hypertension
Prospective cohort		• Age: 35-60 yr	T2 = 11-20 min	• T2 = 0.65 (0.47-0.90)
D & B score = 12		• Characteristics: Free from HTN at baseline. All employees at gas company in Osaka Japan. All had sedentary jobs.	T3 = ≥ 21 min	• T3 = 0.72 (0.59-0.88)
			Outcome measure: Diagnosed with hypertension (as defined by a SBP ≥ 160 mmHg, a DBP ≥ 95 mmHg, or use of antihypertensive medication)	Trend p = < 0.001
			Cox proportional HR
Nakanishi et al 2005 [84]	To examine the relationship of overall PA to the risk of developing hypertension in normotensive Japanese male office workers over a 7 year observation period.	• n = 2,548	7 year follow up	Multivariate adjusted RR (95% CI) by PA level only	The rate of rise in both SBP and DBP in each follow-up year decreased with higher EE and that the risk of developing hypertension decreased in a dose dependent manner with higher daily life activity level.
Japan		• Sex: Men		Q1 = 1.00 (referent)	Analysis stratified by the presence of or absence of a risk factor showed the negative association of daily life activity with the risk of developing hypertension for men at both low and high risk. This tendency was also observed among men in all 3 categories of normotension.
Prospective cohort		• Age: 35-59 yr	PA assessment: 1-day activity record and reported the type and frequency on a weekly basis of LTPA, divided into quartiles (kcal/kg/d)	Q2 = 0.84 (0.72-0.98)
D & B score = 12		• Characteristics Healthy at baseline. No hypertension or CHD. All office workers for a Japanese company	• Q1 = <33.3	• Q3 = 0.75 (0.63-0.88)
			• Q2 = 33.3-36.9	• Q4 = 0.54 (0.45-0.64)
			• Q3 = 37.0-40.3	Trend p = < 0.001
			• Q4 = 40.4	Multivariate adjusted RR (95% CI) by PA level, low normal BP
			3 categories of normotensive BP Low Normal: SBP < 120, DBP < 80 Normal: SBP 120-130, DBP 80- 85 High Normal: SBP 130-139 DBP 85-89	• Q1 = 1.00 (referent)
			3 categories of normotensive BP Low Normal: SBP < 120, DBP < 80 Normal: SBP 120-130, DBP 80- 85 High Normal: SBP 130-139 DBP 85-89	• Q2 = 0.70 (0.47-1.05)
			Cox proportional hazard model	• Q3 = 0.55 (0.37-0.83)
				• Q4 = 0.43 (0.28-0.65)
				Trend p = <0.001
				Multivariate adjusted RR (95% CI) by PA level, normal
				BP
				• Q1 = 1.00 (referent)
				• Q2 = 0.89 (0.68-1.16)
				• Q3 = 0.69 (0.52-0.91)
				• Q4 = 0.50 (0.37-0.68)
				Trend p = <0.001
				Multivariate adjusted RR (95% CI) by PA level, high normal BP
				• Q1 = 1.00 (referent)
				• Q2 = 0.86 (0.69-1.07)
				• Q3 = 0.88 (0.69-1.11)
				• Q4 = 0.60 (0.46-0.78)
				Trend p = 0.001
Foy et al 2006 [85]	To examine whether insulin resistance is associated with the effect of vigorous or moderate PA on baseline BP.	• n = 1,599	Baseline examination in 1992-1993	Unadjusted OR (95% CI)	Participants who meet or exceed current caloric expenditure recommendations for VPA demonstrate significantly less hypertension than do sedentary or underactive individuals.
USA		• Sex: Men and women	PA assessment: VPA over the past year was determined via a 1-year recall of physical activity (kcal/d), divided into 3 groups	• T1 = 1.00 (referent)
Cross sectional		• Age: 40-69 yr	• T1 = O	• T2 = 0.69 (0.53-0.88)
D & B score = 12		• Characteristics: Community dwelling adults	• T2 = 1-149 kcal/day	• T3 = 0.57 (0.45-0.74)
		• Insulin Resistance Atherosclerosis Study	• T3 = >150 kcal/day	• Trend p = < 0.001
				Adjusted OR (95% CI)
				• T1 = 1.00 (referent)
				• T2 = 0.82 (0.62-1.09)
				• T3 = 0.73 (0.55-0.98)
				Trend p = 0.004
Folsom et al 1990 [270]	To examine the relationship between fat distribution and the 2-yr incidence of hypertension and stroke.	• n = 41,837	Baseline mailed survey in 1986: Pa assessment: Questionnaire for LTPA	• 978 cases	High PA reduced the risk of hypertension only before adjusting for other factors.
USA		• Sex: Women	T1 = Low	Age Adjusted RR (95% CI)
Prospective cohort		• Age: 55-69 years (yr)	T2 = Medium	• T1 = 1.00 (referent)
D & B score = 12		• Characteristics: All free of HTN at baseline	T3 = High	• T2 = 0.9 (0.7-1.1)
			Mantel-Haenszel method	• T3 = 0.7 (0.6-0.9)
			Multiple logistic regression
Levenstein et al 2001 [271]	To examine the effects of a variety of psychosocial factors on the development of HTN in men and women in the general population.	• n = 1,031 men, 1,326 women	Questionnaires in 1965 and 1974, cohort followed until 1994	LTPA predictor of hypertension OR (95% CI)	Risk of HTN was reduced with increases in LTPA in women.
USA		• Sex: Men and women	PA assessment: LTPA rated on a scale of 0-16 points and analysed as a continuous variable	• All Subjects: 0.94 (0.91-0.97)
Prospective cohort		• Characteristics: Free of hypertension at baseline	Outcome measure: Incidence of hypertension (defined as those who are taking antihypertensive medications)	• Women: 0.90 (0.87-0.94)
D & B score = 13		• Alameda cohort study	Logistic regression analysis	• Men: 0.98 (0.94-1.02)

D & B score, Downs and Black quality score; YR, years; PF, physical fitness; BMI, body mass index; MET, metabolic equivalent; PA, physical activity; MI, myocardial infarction; G, groups; Q, quartile or quintile; 95% CI, confidence interval; SBP, systolic blood pressure; DBP, diastolic blood pressure; EE, energy expenditure; kcal/wk, kilocalories per week; T, tertile; RR, risk ratio; HR, hazard ratio; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; OPA, occupational physical activity; LTPA, leisure-time physical activity; BP, blood pressure; kcal/day, kilocalories per day.