The prevalence of hypertension increases with age, and more than 65% of American older adults ages 60 to 69 have hypertension (Mozaffarian et al., 2015). Compared with younger adults, those older than 65 tend to have the lowest hypertension control rate but the highest mortality and morbidity from hypertension-related diseases (Hyman & Pavlik, 2001). Physical activity is a well-known nonpharmaceutical behavioral approach for reducing blood pressure (BP) and hypertension-related mortality (Brook et al., 2013). The effects of physical activity on healthy BP outcomes are even more prominent in hypertensive patients than in the nonhypertension population (Cornelissen & Smart, 2013). Current physical activity guidelines recommend at least 150 minutes of moderate intensity physical activity weekly for substantial health benefits in older adults (U.S. Department of Health & Human Services [USDHHS], 2018). However, this goal may not be realistically attainable for older adults. Older adults have greater difficulty performing high-intensity or moderate-to-vigorous physical activity due to age-related decline of physical functioning or comorbidities. In addition, there may be some safety concerns such as falls and injuries from these activities (Chase, 2013; Stathokostas, Theou, Little, Vandervoort, & Raina, 2013). In contrast, older adults tend to participate in functional and light activities such as walking, stair climbing, and household chores in their daily lives (Lawlor, Taylor, Bedford, & Ebrahim, 2002).
Leisure-time walking is popular in older adults' daily life, especially for those living with a disability or chronic illness (Amireault, Baier, & Spencer, 2017). Apart from promoting fitness, leisure-time walking also can expand an individual's social networks (Eyler, Brownson, Bacak, & Housemann, 2003) and serve as a temporary break from family and work (Chase, 2013). Despite the popularity and feasibility of leisure-time walking, clear guidelines on the amount of walking needed to help prevent and manage hypertension in older adults are still lacking. Physical activity guidelines for Americans recommend a variety of exercise type, dose, and duration for general health benefits in older adults, and walking is specified as being especially beneficial for the health of older adults with a low risk of injury. However, there are no guidelines regarding the amount of walking to obtain optimal BP benefits in older adults (USDHHS, 2018). One guideline recommends 10,000 steps per day to prevent hypertension in the general population (Tudor-Locke & Bassett, 2004). However, it is unclear whether this goal is suitable or feasible for older adults.
In Chinese older adults, the walking pattern is quite different than in their American counterparts. Research has shown that the time spent on leisure-time daily walking (LTDW) among Chinese older adults is two to four times greater than that of their Western counterparts (Ma, 2002). Chinese older adults' preference for walking, especially outdoor walking, is influenced by traditional Taoist values to maintain harmony with nature via gentle and light physical activity (Chen, 2001). Although there are various forms of physical activities, including running and resistance training, that may be more effective than walking in reducing BP (Swain & Franklin, 2006), these forms of activities might not be readily accepted by Chinese older adults because most of them do not know how to take part in these activities. In addition, Chinese older adults rarely calculate their daily walking steps because of limited access to an accelerometer. Instead, they often use walking duration time to assess the intensity or effects of walking (Barnett, Cerin, Cheung, & Chan, 2015). Therefore, the recommended 10,000 steps of LTDW for health benefits, particularly BP, are not readily applicable in Chinese older adults.
The current study had three aims. First, the characteristics of Chinese older adults who engaged in LTDW were described using national population-based data. Second, the associations between various LTDW durations and BP readings were examined among Chinese older adults. Third, the association between LTDW time and BP outcomes were examined in Chinese older adults with hypertension. The hypotheses based on the second and third aims were that more LTDW time would be associated with lower BP readings in Chinese older adults and that such an effect would be more prominent among those with hypertension. The findings from this study can generate culturally relevant evidence on the patterns and levels of LTDW and associations with BP, which can inform future physical activity intervention studies for Chinese older adults.
Design and Sample
This cross-sectional study analyzed the baseline survey dataset (2011–2012) collected by an ongoing study, the China Health and Retirement Longitudinal Study (CHARLS). CHARLS is a national representative longitudinal study of Chinese community-dwelling adults ages 45 and older conducted by the National School of Development (China Center for Economic Research) at Peking University (Zhao, Hu, Smith, Strauss, & Yang, 2014). The primary aim of CHARLS is to develop a high-quality scientific database to understand the socioeconomic determinants and consequences of aging in China and to facilitate cross-country research on aging. The Institutional Review Board at Peking University in China approved the original CHARLS study, and written informed consent was obtained from each participant. The current study used deidentified data provided by the Peking University Data Service Portal.
The current analysis included participants ages 65 and older (range = 65 to 92 years), yielding a sample of 2,694 older adults. To minimize the confounding effect of walking with other physical activities including moderate and vigorous activities, older adults who reported both walking and moderate physical activities (e.g., bicycling, carrying light loads) or vigorous physical activities (e.g., heavy lifting, digging, plowing, aerobics, fast bicycling) were excluded (n = 244). To ensure findings were comparable and consistent with the current recommendation of walking 10,000 steps daily and to minimize misinterpretation of the question, “How much time did you usually spend walking on one of those days?,” which implied a commitment to daily walking when translated in Chinese, those who walked less than 7 days per week (n = 93) also were excluded. Finally, those who did not provide information on either BP or walking (n = 1,577) were excluded, leaving a final sample of 780 older adults.
Resting Blood Pressure. Resting BP (mmHg), including systolic BP (SBP) and diastolic BP (DBP), was measured using an Omron HEM-7200 Monitor with participants in a seated position (Zhao et al., 2014). Three measures at 45-second intervals were obtained, and the average reading was used for the current study. Hypertensive older adults were considered to have well-controlled BP if their SBP and DBP were <140 mmHg and <90 mmHg, respectively, during their examination. Because self-reported hypertension is reliable (Andresen, Malmgren, Carter, & Patrick, 1994) and has been used by other large cohort studies (Schaffler et al., 2018; Wu et al., 2013), including the Nurses' Health Study (Zhang, Liu, Bromley, & Tang, 2007), participants were considered to have hypertension if they either self-reported a physician diagnosis of hypertension or were taking antihypertensive medications, including Chinese traditional medicine and Western medicine.
Leisure-Time Daily Walking. In this study, LTDW was referred to as walking on a daily basis in 1 week, including walking to commute for work or solely for the purposes of recreation, exercise, and leisure (Zhao et al., 2014). The LTDW was assessed by participants' response to the question, “During a usual week, did you walk for at least 10 minutes continuously?” Participants who answered “yes” also were asked, “How much time did you usually spend in walking on one of those days?” The duration of LTDW was classified into the following five categories:
Not walking or engaged in 10 minutes of continuous walking.
Walking <30 minutes.
Walking at least 30 minutes but <2 hours.
Walking at least 2 hours but <4 hours.
Walking at least 4 hours.
Participants were classified as either “active” if they walked for at least 30 minutes or “sedentary” if they did not walk or walked continuously for <10 minutes.
Covariates. Demographic covariates included age, gender, education, and marital status. Covariates on health behaviors associated with BP readings included smoking, drinking, and taking medications for hypertension. Average nighttime sleep duration (hours) was obtained from participants' answers to the question, “During the past month, how many hours of actual sleep did you get at night (average hours for one night)?” Body mass index (BMI) and an index of chronic conditions also were included as covariates. Participants' BMI was calculated as the mean of three measures of body weight in kilograms divided by the mean of height in meters squared (kg/m2) by trained staff using a health meter (Omron HN-286) and a stadiometer (Seca™ 213), respectively. An index of chronic conditions or comorbidity was created as the total number of diagnosed chronic health conditions, including diabetes, dyslipidemia, cancer or malignant tumor (excluding minor skin cancers), cardiac disease (e.g., myocardial infarction, coronary heart disease, angina pectoris, heart failure, other heart problems), stroke, pulmonary disease, liver disease, kidney disease, stomach disease, arthritis or rheumatism, asthma, and emotional or psychiatric problems. The comorbidity index ranged from 0 to 13.
Preliminary analysis for demographic characteristics of the entire sample and specifically hypertensive participants was conducted; chi-squared test and one-way analysis of variance were used to compare the demographic characteristics, daily walking status, and BP across hypertensive and nonhypertensive groups. Ordinal logistic regression and multiple linear regression, treating the same outcome as an ordinal variable and a continuous variable, were used to compare the characteristics of participants across different walking groups with the purpose of replicating robust findings using different modeling approaches.
To test hypotheses on the association between walking and BP in general and hypertensive older adults, multiple linear regression was conducted using SBP and DBP as the outcomes and daily walking status as the primary predictor. Model 1 controlled for demographic variables, BMI, and medication treatment for hypertension. To assess whether the effects of walking on BP would be confounded by behavioral factors and health conditions, Model 2 controlled for smoking, drinking, sleep, and comorbidity. Statistical analyses and data screening were performed using R version 3.5.0. All tests were two-sided, and the level of significance level was set at p < 0.05.
Demographic Characteristics by Hypertensive Status
Table 1 shows the demographic characteristics of participants. Mean age of participants was 71.95 years (SD = 5.7 years); slightly more than one half were women (n = 397, 50.9%). One fourth of participants (n = 207, 26.5%) were overweight or obese (BMI ≥ 25 kg/m2), and more than one in five drank alcohol more than once per month (n = 175, 22.4%) or were current smokers (n = 216, 27.7%). Twenty-nine percent of participants (n = 167) had sleep duration of 7 to 9 hours per night, and the majority of participants (n = 523, 67.1%) had at least one comorbid condition.
Characteristics of Participants by Hypertensive Status
Approximately one third of participants (n = 272, 35.4%) were classified as having hypertension according to self-reported hypertension diagnosis (n = 272, 34.9%) and use of antihypertensive medication (n = 232, 29.7%). Hypertensive participants had higher SBP and DBP than nonhypertensive participants (150.50/78.77 mmHg vs. 132.92/72.90 mmHg, respectively, p < 0.05). Among the hypertensive participants, the majority (n = 232, 84.1%) received antihypertensive medications, and approximately one third (n = 85, 30.8%) had controlled BP (e.g., BP < 140/90 mmHg). The hypertensive group differed significantly from the nonhypertensive group in gender composition, smoking and drinking status, BMI, and levels of comorbidity.
Daily Walking Characteristics and Association With Demographic Factors
Table 2 shows the LTDW characteristics of participants, and Table 3 shows the parameter estimates on demographic predictors of LTDW among Chinese older adults. Approximately one third of participants (n = 238, 30.7%) were sedentary, and more than one half (n = 443, 57.1%) were physically active (i.e., having more than 30 minutes of daily walking per week). Participants with higher education levels or those who drank less alcohol tended to have higher LTDW levels than participants with less education levels or those who drank more alcohol (Table 2). However, this was slightly different from the results of the multivariate analyses (Table 3). Both the ordinal logistic model and linear regression models indicated participants were more likely to engage in LTDW if they were younger (ß = −0.02, p = 0.012) and had higher education (ß = 0.52, p = 0.018). Those who were married were less likely to perform LTDW (ß = −0.24, p = 0.025). Other factors such as gender, smoking, drinking, sleeping, BMI, and comorbidity did not have significant associations with BP outcomes.
Demographic Characteristics of Participants by Leisure-Time Daily Walking Status (N = 780)
Ordinal Logistic and Linear Regression Results of Leisure-Time Daily Walking (N = 780)
Association Between LTDW and BP
Table 4 shows the parameter estimates on the association between LTDW and SBP and DBP for the entire sample, as well as the hypertensive and nonhypertensive sub-samples. Model 1 suggested that walking 2 to 4 hours per day was associated with reduced DBP (ß = −4.36, p = 0.001) adjusted for demographics, BMI, and medication use in the entire sample. Model 2 suggested similar findings (ß = −4.13, p = 0.002) with additional adjustment for health behaviors and number of comorbidities. Similarly, walking 2 to 4 hours per day was inversely associated with DBP (ß = −6.89, p = 0.005) in hypertensive participants when adjusted for all covariates of interest. In addition, LTDW of 30 minutes to 2 hours was inversely associated with DBP in hypertensive participants (ß = −4.42, p = 0.024). There was no significant association between different levels of LTDW and DBP among nonhypertensive participants; similarly, LTDW was not related to SBP in the entire sample nor in the hypertensive and nonhypertensive samples. Interestingly, excessive LTDW (>4 hours per day) was not negatively associated with BP in the entire sample nor across hypertensive and nonhypertensive groups.
Crude and Adjusted Associations Between Leisure-Time Daily Walking and Blood Pressure (N= 780)
This is the first study to address the relationship of LTDW and BP among Chinese older adults. It presents an overview of Chinese older adults' walking behavior and how it is associated with BP. Because the majority of previous studies focused on the effects of daily steps or calorie expenditure on BP, the current study expands the knowledge in this field by examining the association of LTDW and BP. In addition, the dose-dependent association of LTDW time and BP was explored. These results have more practical implications to Chinese older adults because many Chinese older adults do not know how to use accelerometers to calculate their daily steps or everyday calorie expenditure. The results from this study also can provide evidence for future studies on physical activity interventions among Chinese older adults.
The current study demonstrated the majority of participants (69.3%) engaged in an average of more than 30 minutes of LTDW. This number is similar to that of 74.5% reported by Deng et al. (2008), which suggests walking is a popular form of physical activity among Chinese older adults. Chinese older adults walked more if they were younger, not married, or had better education, which is consistent with prior studies (Dollman, Hull, Lewis, Carroll, & Zarnowiecki, 2016; Sundquist et al., 2011).
However, the effect of marital status on walking is still unclear. One study demonstrated marital status was not related to walking among Japanese American older adults in the Honolulu Aging Study (Smith et al., 2010). The data in the current study indicated married Chinese older adults walked less than those who were not married or widowed. Such a result was consistent with several previous studies in which a negative association of marriage and physical activity was found (Brown, Heesch, & Miller, 2009). A recent study using longitudinal data analysis also confirmed marriage was associated with reduced physical activity in German older adults (Rapp & Schneider, 2013). It is possible that having a spouse can decrease discretionary time (Brown et al., 2009) or that married women spend less time in physical activity because of increased housework hours after marriage (Nomaguchi & Bianchi, 2008). Cultural factors also may affect physical activity. In China, married older adults spend a lot of time taking care of their family members, especially grandchildren (Ko & Hank, 2013), which may affect their physical activities.
The current study also found that 2 to 4 hours of LTDW was associated with lower resting DBP, but not with lower SBP in Chinese older adults. This association was more prominent in hypertensive older adults than in nonhypertensive older adults, and was independent of several important covariates, including demographic variables, health behaviors, antihypertensive medication, and comorbidity. More importantly, for hypertensive older adults, LTDW between 30 minutes and 2 hours was sufficient to obtain health benefits (i.e., lower DBP). However, when older adults walked more than 4 hours per day, this association was not retained. Four hours of LTDW may be too much for Chinese older adults, and it is possible that unlike young adults, older adults exhibit deranged pressure reflex (Markel et al., 2003), which may lead to exaggerated increase of BP and consequent cardiovascular events during or after exercise (Siscovick, Weiss, Fletcher, & Lasky, 1984). Therefore, walking more than 4 hours per day may not have a comparable benefit on BP among Chinese older adults.
As for the null association between LTDW and SBP, one possible explanation is due to the intensity of walking. In a randomized controlled trial, Nemoto, Gen-no, Masuki, Okazaki, and Nose (2007) found that high-intensity interval walking defined by peak aerobic capacity for 5 months was more effective in reversing vascular remolding process and lowering age-associated increases in SBP than continuous moderate-intensity walking. Older adults in the current study performed LTDW, which might not be sufficient to affect the vascular remodeling process and thus was not associated with SBP. Noticeably, such a differing effect of walking on SBP and DBP was not unique in the current study, and many other studies on resistant and intensive exercise among young adults have suggested similar results. Some studies found resistant exercise was effective in lowering only DBP but not SBP (Cornelissen, Fagard, Coeckelberghs, & Vanhees, 2011; Rossi, Moullec, Lavoie, Gour-Provencal, & Bacon, 2013). Because the current study only assessed LTDW measured by time duration, data on the specific mode of walking, especially whether 2 to 4 hours of LTDW reached peak aerobic capacity among Chinese older adults, could not be assessed.
The findings of the current study on the association between LTDW duration time and BP are slightly different from previous studies conducted in other Asian countries. In a cross-sectional study on Japanese adults (ages 35 to 69), there was no association between once per week or more frequent forest walking and BP, including SBP and DBP (Morita et al., 2011). However, another cross-sectional study on Indian middle-aged adults (age 40) found walking to work decreased the risk of having doctor-diagnosed hypertension by 23% compared with traveling to work by car (Millett et al., 2013).
The diverse results between the current study and previous studies in Asian populations might be due to different study participants with different ages, as well as a different mode and duration of walking. Participants in the current study were older adults with a mix of hypertension and normal BP, whereas participants in other studies (Millett et al., 2013; Morita et al., 2011) were young or middle-aged adults with normal or prehypertensive BP. Because the aging process is accompanied by progressive stiffness of the artery, the reverse of remolding the artery may require longer and relatively intensive physical activity to gain a health benefit. This might explain why less frequent forest walking or nondaily walking was not associated with reduced BP in the study by Morita et al. (2011) but walking was a significant factor in the current study and the study conducted by Millett et al. (2013). In the study by Morita et al. (2011), the participants were a mix of young and older adults, whereas in the study by Millett et al. (2013), the participants were younger. Although participants in the current study were older than participants in the other two studies, they walked on a daily basis.
Because objective accelerometers are not widely used by Chinese older adults, the current authors sought to find an equivalent form of 10,000 steps per day that could be measured using a more acceptable method by Chinese older adults, specifically, walking time duration. Although the walking duration time in the current study could not be directly compared to walking steps, there are some studies that have addressed this. Ohta et al. (2015) found 30 to 60 minutes of walking can achieve 10,000 steps per day in Japanese older adults (age 60 [SD = 9 years]). A pilot study by Barnett et al. (2015) demonstrated older adults in Hong Kong walked 735 minutes per week on average (approximately 100 minutes per day). Deng et al. (2008) found the mean number of walking steps for Cantonese older adults was 10,069 steps for women and 9,609 steps for men per day. Therefore, it would seem that the LTDW steps for Chinese older adults in the current study exceeded the threshold of 10,000 steps per day if they walked more than 60 minutes per day. This also could explain the significant finding on the association between lower BP and walking between 30 minutes and 2 hours per day in the current study.
The current study has several limitations. First, it is a cross-sectional study that can be subject to reverse correlation and residual confounding. Randomized controlled trials are needed to determine whether LTDW at a precise dose in hypertensive older adults is associated with improvements in SBP and DBP. Second, self-reported walking is prone to recall and reporting biases, and thus is subject to measurement errors, which may underestimate the association of walking and BP in Chinese older adults. Future studies using more precise measures such as an accelerometer to examine the association of walking with BP across the spectrum of walking intensity are needed to make a direct comparison with previous studies. Similarly, self-reported diagnosis of hypertension and use of antihypertensive medications are also subject to reporting biases. In addition, it is also possible for older adults to experience “white coat” high BP at the examination. These biases could affect the results. Third, missing data were handled using listwise deletion under the assumption of missing completely at random (i.e., there was no obvious reason why some variables were more likely to be missing than others). The estimation of parameters might be biased if this assumption is violated. Finally, several other confounding variables, such as dietary factor and cultural values on physical activity, were not collected in CHARLS and thus were not analyzed in this study.
The current study showed younger older adults with higher education who were not married were more likely to engage in LTDW. There was a negative association between LTDW and resting DBP, but not SBP in Chinese older adults. Such an association differed on different levels of walking duration. Walking 2 to 4 hours daily was beneficial for DBP reduction in Chinese older adults, particularly those with hypertension. Walking for more than 4 hours daily was not recommended. Future studies are warranted that examine whether LTDW may be helpful in decreasing the dosage of antihypertensive drugs, which are associated with some adverse effects and subsequently medication nonadherence (Tedla & Bautista, 2016). In addition, the efficacy and feasibility of using LTDW to influence other health outcomes in diverse samples are needed, especially in those who are frail, have multiple chronic health conditions, and are unable to perform vigorous exercises.
- Amireault, S., Baier, J.M. & Spencer, J.R. (2017). Physical activity preferences among older adults: A systematic review. Journal of Aging and Physical Activity, 27, 128–138. doi:10.1123/japa.2017-0234 [CrossRef]
- Andresen, E.M., Malmgren, J.A., Carter, W.B. & Patrick, D.L. (1994). Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). American Journal of Preventive Medicine, 10, 77–84. doi:10.1016/S0749-3797(18)30622-6 [CrossRef]
- Barnett, A., Cerin, E., Cheung, M.C. & Chan, W.M. (2015). An in-depth pilot study on patterns, destinations, and purposes of walking in Hong Kong older adults. Journal of Aging and Physical Activity, 23, 144–152. doi:10.1123/JAPA.2013-0026 [CrossRef]
- Brook, R.D., Appel, L.J., Rubenfire, M., Ogedegbe, G., Bisognano, J.D., Elliott, W.J. & Rajagopalan, S. (2013). Beyond medications and diet: Alternative approaches to lowering blood pressure: A scientific statement from the American Heart Association. Hypertension, 61, 1360–1383. doi:10.1161/HYP.0b013e318293645f [CrossRef]
- Brown, W.J., Heesch, K.C. & Miller, Y.D. (2009). Life events and changing physical activity patterns in women at different life stages. Annals of Behavioral Medicine, 37, 294–305. doi:10.1007/s12160-009-9099-2 [CrossRef]
- Chase, J.A. (2013). Methodological challenges in physical activity research with older adults. Western Journal of Nursing Research, 35, 76–97. doi:10.1177/0193945911416829 [CrossRef]
- Chen, Y.C. (2001). Chinese values, health and nursing. Journal of Advanced Nursing, 36, 270–273. doi:10.1046/j.1365-2648.2001.01968.x [CrossRef]
- Cornelissen, V.A., Fagard, R.H., Coeckelberghs, E. & Vanhees, L. (2011). Impact of resistance training on blood pressure and other cardiovascular risk factors: A meta-analysis of randomized, controlled trials. Hypertension, 58, 950–958. doi:10.1161/HYPERTENSIONAHA.111.177071 [CrossRef]
- Cornelissen, V.A. & Smart, N.A. (2013). Exercise training for blood pressure: A systematic review and meta-analysis. Journal of the American Heart Association, 2, e004473. doi:10.1161/JAHA.112.004473 [CrossRef]
- Deng, H.B., Macfarlane, D.J., Thomas, G.N., Lao, X.Q., Jiang, C.Q., Cheng, K.K. & Lam, T.H. (2008). Reliability and validity of the IPAQ-Chinese: The Guangzhou Biobank Cohort study. Medicine and Science in Sports and Exercise, 40, 303–307. doi:10.1249/mss.0b013e31815b0db5 [CrossRef]
- Dollman, J., Hull, M., Lewis, N., Carroll, S. & Zarnowiecki, D. (2016). Regional differences in correlates of daily walking among middle age and older Australian rural adults: Implications for health promotion. International Journal of Environmental Research and Public Health, 13, 116–125. doi:10.3390/ijerph13010116 [CrossRef]
- Eyler, A.A., Brownson, R.C., Bacak, S.J. & Housemann, R.A. (2003). The epidemiology of walking for physical activity in the United States. Medicine and Science in Sports and Exercise, 35, 1529–1536. doi:10.1249/01.MSS.0000084622.39122.0C [CrossRef]
- Hyman, D.J. & Pavlik, V.N. (2001). Characteristics of patients with uncontrolled hypertension in the United States. New England Journal of Medicine, 345, 479–486. doi:10.1056/NEJMoa010273 [CrossRef]
- Ko, P.C. & Hank, K. (2013). Grandparents caring for grandchildren in China and Korea: Findings from CHARLS and KLoSA. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 69, 646–651. doi:10.1093/geronb/gbt129 [CrossRef]
- Lawlor, D.A., Taylor, M., Bedford, C. & Ebrahim, S. (2002). Is housework good for health? Levels of physical activity and factors associated with activity in elderly women: Results from the British Women's Heart and Health Study. Journal of Epidemiology & Community Health, 56, 473–478. doi:10.1136/jech.56.6.473 [CrossRef]
- Ma, W.J. (2002). Associations of physical activity and chronic disease in residents aged 15 and above in Guangdong Province. In Survey on nutritional and health conditions in Guangzhou Province 2002 (pp. 80–86). Guangzhou, China: Guangdong People's Press.
- Markel, T.A., Daley, J.C. III. , Hogeman, C.S., Herr, M.D., Khan, M.H., Gray, K.S. & Sinoway, L.I. (2003). Aging and the exercise pressor reflex in humans. Circulation, 107, 675–678. doi:10.1161/01.CIR.0000055190.81716.AB [CrossRef]
- Millett, C., Agrawal, S., Sullivan, R., Vaz, M., Kurpad, A., Bharathi, A.V. & Ebrahim, S. (2013). Associations between active travel to work and overweight, hypertension, and diabetes in India: A cross-sectional study. PLoS Medicine, 10, e1001459. doi:10.1371/journal.pmed.1001459 [CrossRef]
- Morita, E., Naito, M., Hishida, A., Wakai, K., Mori, A., Asai, Y. & Hamajima, N. (2011). No association between the frequency of forest walking and blood pressure levels or the prevalence of hypertension in a cross-sectional study of a Japanese population. Environmental Health and Preventive Medicine, 16, 299–306. doi:10.1007/s12199-010-0197-3 [CrossRef]
- Mozaffarian, D., Benjamin, E.J., Go, A.S., Arnett, D.K., Blaha, M.J., Cushman, M. & Huffman, M.D. (2015). Executive summary: Heart disease and stroke statistics—2015 update: A report from the American Heart Association. Circulation, 131, 434–441. doi:10.1161/CIR.0000000000000157 [CrossRef]
- Nemoto, K., Gen-no, H., Masuki, S., Okazaki, K. & Nose, H. (2007). Effects of high-intensity interval walking training on physical fitness and blood pressure in middle-aged and older people. Mayo Clinic Proceedings, 82, 803–811. doi:10.4065/82.7.803 [CrossRef]
- Nomaguchi, K.M. & Bianchi, S.M. (2004). Exercise time: Gender differences in the effects of marriage, parenthood, and employment. Journal of Marriage and Family, 66, 413–430. doi:10.1111/j.1741-3737.2004.00029.x [CrossRef]
- Ohta, Y., Kawano, Y., Minami, J., Iwashima, Y., Hayashi, S., Yoshihara, F. & Nakamura, S. (2015). Effects of daily walking on office, home and 24-h blood pressure in hypertensive patients. Clinical and Experimental Hypertension, 37, 433–437. doi:10.3109/10641963.2015.1013115 [CrossRef]
- Rapp, I. & Schneider, B. (2013). The impacts of marriage, cohabitation and dating relationships on weekly self-reported physical activity in Germany: A 19-year longitudinal study. Social Science & Medicine, 98, 197–203. doi:10.1016/j.socscimed.2013.09.024 [CrossRef]
- Rossi, A.M., Moullec, G., Lavoie, K.L., Gour-Provencal, G. & Bacon, S.L. (2013). The evolution of a Canadian Hypertension Education Program recommendation: The impact of resistance training on resting blood pressure in adults as an example. Journal of Cardiology, 29, 622–627. doi:10.1016/j.cjca.2013.02.010 [CrossRef]
- Schaffler, J., Leung, K., Tremblay, S., Merdsoy, L., Belzile, E., Lambrou, A. & Lambert, S.D. (2018). The effectiveness of self-management interventions for individuals with low health literacy and/or low income: A descriptive systematic review. Journal of General Internal Medicine, 33, 510–523. doi:10.1007/s11606-017-4265-x [CrossRef]
- Siscovick, D.S., Weiss, N.S., Fletcher, R.H. & Lasky, T. (1984). The incidence of primary cardiac arrest during vigorous exercise. New England Journal of Medicine, 311, 874–877. doi:10.1056/NEJM198410043111402 [CrossRef]
- Smith, T.L., Masaki, K.H., Fong, K., Abbott, R.D., Ross, G.W., Petrovitch, H. & White, L.R. (2010). Effect of walking distance on 8-year incident depressive symptoms in elderly men with and without chronic disease: The Honolulu-Asia Aging Study. Journal of the American Geriatrics Society, 58, 1447–1452. doi:10.1111/j.1532-5415.2010.02981.x [CrossRef]
- Stathokostas, L., Theou, O., Little, R.M., Vandervoort, A.A. & Raina, P. (2013). Physical activity-related injuries in older adults: A scoping review. Sports Medicine, 43, 955–963. doi:10.1007/s40279-013-0076-3 [CrossRef]
- Sundquist, K., Eriksson, U., Kawakami, N., Skog, L., Ohlsson, H. & Arvidsson, D. (2011). Neighborhood walkability, physical activity, and walking behavior: The Swedish Neighborhood and Physical Activity (SNAP) study. Social Science & Medicine, 72, 1266–1273. doi:10.1016/j.socscimed.2011.03.004 [CrossRef]
- Swain, D.P. & Franklin, B.A. (2006). Comparison of cardioprotective benefits of vigorous versus moderate intensity aerobic exercise. American Journal of Cardiology, 97, 141–147. doi:10.1016/j.amjcard.2005.07.130 [CrossRef]
- Tedla, Y.G. & Bautista, L.E. (2016). Drug side effect symptoms and adherence to antihypertensive medication. American Journal of Hypertension, 29, 772–779. doi:10.1093/ajh/hpv185 [CrossRef]
- Tudor-Locke, C. & Bassett, D.R. Jr. . (2004). How many steps/day are enough? Preliminary pedometer indices for public health. Sports Medicine, 34, 1–8. doi:10.2165/00007256-200434010-00001 [CrossRef]
- U.S. Department of Health and Human Services. (2018). Physical activity guidelines for Americans (5th ed.). Retrieved from https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf
- Wu, F., Guo, Y., Kowal, P., Jiang, Y., Yu, M., Li, X. & Xu, J. (2013). Prevalence of major chronic conditions among older Chinese adults: The Study on Global AGEing and adult health (SAGE) wave 1. PLoS One, 8, e74176. doi:10.1371/journal.pone.0074176 [CrossRef]
- Yang, G., Wang, Y., Zeng, Y., Gao, G.F., Liang, X., Zhou, M. & Murray, C.J. (2013). Rapid health transition in China, 1990–2010: Findings from the Global Burden of Disease Study 2010. Lancet, 381, 1987–2015. doi:10.1016/S0140-6736(13)61097-1 [CrossRef]
- Zhang, T., Liu, X., Bromley, H. & Tang, S. (2007). Perceptions of tuberculosis and health seeking behaviour in rural Inner Mongolia, China. Health Policy, 81, 155–165. doi:10.1016/j.healthpol.2005.12.009 [CrossRef]
- Zhao, Y., Hu, Y., Smith, J.P., Strauss, J. & Yang, G. (2014). Cohort profile: The China Health and Retirement Longitudinal Study (CHARLS). International Journal of Epidemiology, 43, 61–68. doi:10.1093/ije/dys203 [CrossRef]
Characteristics of Participants by Hypertensive Status
|Characteristic||Entire Sample (N = 780)||Hypertension (n = 276)||Nonhypertension (n = 502)||p Value|
|Age (years), mean (SD)||71.95 (5.7)||71.60 (5.28)||72.13 (5.92)||0.214|
|Female, n (%)||397 (50.9)||163 (59.1)||233 (46.4)||0.001|
|Education, n (%)||0.782|
| Illiterate||339 (43.5)||118 (42.8)||219 (43.6)|
| Elementary school or less||308 (39.5)||114 (41.3)||194 (38.6)|
| High school or less||95 (12.2)||33 (12)||62 (12.4)|
| Postsecondary||38 (4.9)||11 (4)||27 (5.4)|
|Married, n (%)||564 (72.3)||203 (73.6)||359 (71.5)||0.601|
|Smoking, n (%)||0.018|
| Nonsmoker||455 (58.3)||180 (65.2)||275 (54.8)|
| Former smoker||109 (14)||33 (12)||76 (15.1)|
| Current smoker||216 (27.7)||63 (22.8)||151 (30.1)|
|Alcohol use, n (%)||0.006|
| Nondrinker||558 (71.5)||215 (77.9)||342 (68.1)|
| Drink less than once per month||47 (6)||17 (6.2)||30 (6)|
| Drink more than once per month||175 (22.4)||44 (15.9)||130 (25.9)|
|Average nighttime sleep (hour)||6.11 (2.11)||5.99 (2.13)||6.18 (2.09)||0.215|
|Body mass index (kg/m2), mean (SD)||22.78 (3.83)||24.23 (3.75)||21.98 (3.64)||<0.05|
|Medication treatment, n (%)||232 (84.1)|
|Well-controlled hypertension, n (%)||85 (30.8)|
|No. comorbidities, mean (SD) (range = 0 to 13)||1.34 (1.28)||1.56 (1.33)||1.21 (1.24)||<0.05|
|Daily walking, n (%)||0.176|
| Sedentary||238 (30.7)||78 (28.4)||159 (31.9)|
| <30 min||95 (12.2)||43 (15.6)||52 (10.4)|
| 30 min to 2 hr||279 (36)||101 (36.7)||178 (35.7)|
| 2 to 4 hr||121 (15.6)||42 (15.3)||79 (15.8)|
| >4 hr||43 (5.5)||11 (4)||31 (6.2)|
|Blood pressure (mmHg), mean (SD)|
| Systolic (range = 80 to 204)||139.05 (23.34)||150.50 (22.18)||132.92 (21.62)||<0.05|
| Diastolic (range = 45 to 136)||74.93 (11.77)||78.77 (12.19)||72.90 (11.01)||<0.05|
Ordinal Logistic and Linear Regression Results of Leisure-Time Daily Walking (N = 780)
|Characteristic||Ordinal Logistic Model||Linear Regression Model|
|OR||95% CI||p Value||ß||95% CI||p Value|
|Age||0.96||[0.94, 0.99]||0.007||−0.02||[−0.04, −0.01]||0.012|
|Female||0.74||[0.52, 1.06]||0.104||−0.17||[−0.41, 0.07]||0.171|
| Elementary school or less||1.04||[0.76, 1.41]||0.828||0.04||[−0.17, 0.25]||0.695|
| High school or less||1.07||[0.68, 1.68]||0.784||0.04||[−0.27, 0.35]||0.809|
| Postsecondary||1.90||[1.04, 3.46]||0.036||0.52||[0.09, 0.95]||0.018|
|Married||0.68||[0.49, 0.93]||0.015||−0.24||[−0.46, −0.03]||0.025|
| Former smoker||1.03||[0.67, 1.59]||0.885||0.03||[−0.26, 0.32]||0.835|
| Current smoker||0.79||[0.55, 1.14]||0.208||−0.13||[−0.38, 0.11]||0.292|
| Drink less than once per month||0.88||[0.47, 1.62]||0.671||−0.08||[−0.48, 0.33]||0.713|
| Drink more than once per month||1.07||[0.76, 1.50]||0.704||0.05||[−0.19, 0.28]||0.700|
|Average nighttime sleep (hr)||0.99||[0.93, 1.06]||0.875||−0.01||[−0.05, 0.04]||0.770|
|Body mass index (kg/m2)||0.99||[0.96, 1.03]||0.737||0.00||[−0.03, 0.02]||0.847|
|No. comorbid conditions||1.06||[0.95, 1.18]||0.313||0.04||[−0.03, 0.11]||0.312|
Demographic Characteristics of Participants by Leisure-Time Daily Walking Status (N = 780)
|Characteristic||Sedentary (n = 238)||Time||p Value|
|<30 min (n = 95)||30 min to 2 hr (n = 279)||2 to 4 hr (n = 121)||>4 hr (n = 43)|
|Age (years), mean (SD)||72.67 (6.27)||71.91 (5.9)||71.85 (5.39)||70.93 (5.13)||71.33 (4.67)||0.078|
|Female, n (%)||136 (57.1)||49 (51.6)||128 (45.9)||57 (47.1)||26 (60.5)||0.066|
|Education, n (%)||0.016|
| Illiterate||116 (48.7)||45 (47.4)||108 (38.7)||52 (43)||16 (37.2)|
| Elementary school or less||96 (40.3)||33 (34.7)||110 (39.4)||45 (37.2)||22 (51.2)|
| High school or less||24 (10.1)||13 (13.7)||37 (13.3)||18 (14.9)||3 (7)|
| Postsecondary||2 (0.8)||4 (4.2)||24 (8.6)||6 (5)||2 (4.7)|
|Married, n (%)||178 (74.8)||69 (72.6)||197 (70.6)||86 (71.1)||32 (74.4)||0.857|
|Smoking, n (%)||0.645|
| Nonsmoker||145 (60.9)||54 (56.8)||158 (56.6)||70 (57.9)||27 (62.8)|
| Former smoker||25 (10.5)||14 (14.7)||43 (15.4)||22 (18.2)||4 (9.3)|
| Current smoker||68 (28.6)||27 (28.4)||78 (28)||29 (24)||12 (27.9)|
|Alcohol use, n (%)||0.036|
| Nondrinker||181 (76.1)||71 (74.7)||179 (64.2)||90 (74.4)||34 (79.1)|
| Drink less than once per month||15 (6.3)||4 (4.2)||17 (6.1)||6 (5)||4 (9.3)|
| Drink more than once per month||42 (17.6)||20 (21.1)||83 (29.7)||25 (20.7)||5 (11.6)|
|Average nighttime sleep (hr)||6.21 (2.15)||6.07 (2.14)||5.90 (2.02)||6.54 (2.05)||5.85 (2.38)||0.058|
|Body mass index (kg/m2), mean (SD)||22.41 (4.3)||23.49 (3.95)||23.08 (3.49)||22.37 (3.48)||22.64 (3.51)||0.071|
|No. comorbidities, mean (SD) (range = 0 to 13)||1.26 (1.36)||1.41 (1.29)||1.40 (1.26)||1.23 (1.14)||1.48 (1.31)||0.535|
Crude and Adjusted Associations Between Leisure-Time Daily Walking and Blood Pressure (N= 780)
|ß||95% CI||p Value||ß||95% CI||p Value||ß||95% CI||p Value|
|Systolic blood pressure|
| Model 1|
| <30 min/day||−3.33||[−8.60, 1.95]||0.216||1.81||[−6.63, 10.25]||0.673||−6.24||[−13.02, 0.54]||0.071|
| 30 min to 2 hr/day||−2.94||[−6.83, 0.95]||0.138||−4.31||[−11.11, 2.48]||0.213||−1.25||[−5.96, 3.46]||0.602|
| 2 to 4 hr/day||−4.25||[−9.09, 0.59]||0.085||−4.06||[−12.55, 4.42]||0.346||−4.10||[−9.95, 1.76]||0.170|
| >4 hr/day||−3.71||[−10.87, 3.46]||0.310||−3.54||[−18.27, 11.18]||0.636||−2.16||[−10.43, 6.10]||0.607|
| Model 2|
| <30 min/day||−2.29||[−7.62, 3.04]||0.399||1.08||[−7.52, 9.69]||0.804||−4.74||[−11.63, 2.16]||0.178|
| 30 min to 2 hr/day||−2.37||[−6.35, 1.62]||0.244||−5.45||[−12.54, 1.63]||0.131||−0.62||[−5.47, 4.23]||0.801|
| 2 to 4 hr/day||−3.02||[−7.94, 1.91]||0.230||−3.41||[−12.29, 5.46]||0.449||−3.08||[−9.02, 2.85]||0.308|
| >4 hr/day||−3.60||[−10.78, 3.59]||0.326||−6.26||[−21.22, 8.70]||0.411||−1.92||[−10.20, 6.36]||0.649|
|Diastolic blood pressure|
| Model 1|
| <30 min/day||−0.11||[−2.88, 2.66]||0.936||−0.38||[−4.99, 4.24]||0.872||−0.01||[−3.50, 3.49]||0.996|
| 30 min to 2 hr/day||−1.39||[−3.43, 0.65]||0.183||−4.07||[−7.79, −0.36]||0.032||0.44||[−1.99, 2.87]||0.722|
| 2 to 4 hr/day||−4.36||[−6.90, −1.82]||0.001||−6.56||[−11.20, −1.92]||0.006||−3.12||[−6.14, −0.10]||0.043|
| >4 hr/day||−3.72||[−7.48, 0.04]||0.052||−2.11||[−10.17, 5.94]||0.605||−2.79||[−7.05, 1.47]||0.199|
| Model 2|
| <30 min/day||0.58||[−2.25, 3.40]||0.690||−0.87||[−5.54, 3.80]||0.715||0.84||[−2.76, 4.43]||0.648|
| 30 min to 2 hr/day||−0.87||[−2.98, 1.25]||0.421||−4.42||[−8.27, −0.58]||0.024||0.99||[−1.54, 3.52]||0.442|
| 2 to 4 hr/day||−4.13||[−6.75, −1.52]||0.002||−6.89||[−11.71, −2.08]||0.005||−2.89||[−5.99, 0.20]||0.067|
| >4 hr/day||−3.21||[−7.02, 0.60]||0.099||−3.87||[−11.99, 4.25]||0.348||−2.65||[−6.97, 1.67]||0.228|