Prospective Study of Bicycling and Risk of Coronary Heart Disease in Danish Men and Women
2016; Lippincott Williams & Wilkins; Volume: 134; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.116.024651
ISSN1524-4539
AutoresKim Blond, Majken K. Jensen, Martin Gillies Banke Rasmussen, Kim Overvad, Anne Tjønneland, Lars Østergaard, Anders Grøntved,
Tópico(s)Cardiovascular and exercise physiology
ResumoHomeCirculationVol. 134, No. 18Prospective Study of Bicycling and Risk of Coronary Heart Disease in Danish Men and Women Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBProspective Study of Bicycling and Risk of Coronary Heart Disease in Danish Men and Women Kim Blond, MSc, Majken K. Jensen, PhD, Martin G. Rasmussen, MSc, Kim Overvad, MD, PhD, Anne Tjønneland, MD, DMSc, Lars Østergaard, PhD and Anders Grøntved, PhD Kim BlondKim Blond From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). , Majken K. JensenMajken K. Jensen From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). , Martin G. RasmussenMartin G. Rasmussen From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). , Kim OvervadKim Overvad From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). , Anne TjønnelandAnne Tjønneland From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). , Lars ØstergaardLars Østergaard From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). and Anders GrøntvedAnders Grøntved From Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, University of Southern Denmark, Campusvej (K.B., M.R.G., L.Ø., A.G.); Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (M.K.J.); Department of Medicine, Channing Division of Network Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA (M.K.J.); Department of Cardiology, Aalborg University Hospital, Denmark (K.O.); Department of Public Health, Section for Epidemiology, Aarhus University, Denmark (K.O.); and Danish Cancer Society Research Center, Copenhagen, Denmark (A.T.). Originally published1 Nov 2016https://doi.org/10.1161/CIRCULATIONAHA.116.024651Circulation. 2016;134:1409–1411IntroductionBicycling for transportation and recreation is considered an important strategy for prevention of coronary heart disease (CHD) in many populations. It is a low-impact type of physical activity that can be used for exercise purposes or incorporated in everyday living without requiring allocation of time to more structured exercise. Although the benefits of nonspecific active transportation and walking on CHD risk have been examined extensively, prospective studies evaluating the relationship between cycling habits and risk of CHD are scarce, and the relationship remains inconclusive. The aim of this prospective study was to examine the association among cycling, changes in cycling habits, and risk of incident CHD in a cohort study of Danish men and women.We followed 53 723 Danes (25 329 men and 28 394 women) 50 to 65 years of age at recruitment in 1993 to 1997 from the prospective cohort study, "Diet, Cancer, and Health" for 20 years. The study was approved by the Scientific Ethical Committee of Copenhagen (no H-KF-01-345/93) and conducted in accordance with the Helsinki Declaration. Written informed content was obtained from all study subjects. At baseline, overall cycling (commuter or leisure time cycling), other physical activities, educational level, diet, alcohol, smoking, and other putative CHD risk factors were assessed in a questionnaire. At a second examination from 1999 through 2003, a similar questionnaire assessed commuter cycling to and from work, leisure time cycling, and other exposures among 45 264 participants. Fatal and nonfatal cases of CHD, classified according to International Classification of Disease, Tenth Revision codes I21.0-I.21.9 and I46.0-I46.9, were identified through July 2, 2013, with Danish registers. The Danish Civil Registration System provided vital status, death date, and emigration date. We excluded participants with prevalent stroke, CHD, or cancer at baseline. In analyses of cycling at second examination and changes in cycling habits, we additionally excluded participants diagnosed with stroke or CHD between baseline and second examination. Furthermore, retired and unemployed individuals at the time of the second examination were excluded in the analyses of commuter cycling. Cox proportional hazards regression was used to estimate CHD risk in relation to categories of weekly cycling duration and changes in cycling habits from baseline to second examination. We carried out multivariable-adjusted analyses, including major confounding factors. In addition, we further adjusted for objectively measured body mass index, hypertension medication, hypercholesterolemia medication, and self-reported diabetes at baseline to explore the possibility of additional confounding or mediation by these established CHD risk factors. To estimate the proportion of CHD cases that could be prevented if noncyclists started cycling in this population, the population attributable fraction was calculated according to Greenland and Drescher,1 assuming a causal and unbiased association.During 846 487 person-years of follow-up, 2892 incident cases of CHD were identified. In the multivariable-adjusted analysis of overall cycling, the CHD risk was 11% to 18% lower in cyclists compared with noncyclists (Table). According to cycling at the second examination, leisure time cycling but not commuter cycling was associated with lower CHD risk in multivariable-adjusted analyses. Changing cycling behavior between baseline and second examination from no cycling to cycling was associated with a 26% lower CHD risk compared with no cycling at either examination. An estimated 7.4% (95% confidence interval, 3.6–11.1) of all CHD cases could have been prevented if all participants participated in cycling or continued their engagement in recreational or commuter cycling in this population. Additional adjustment for body mass index, hypertension medication, hypercholesterolemia medication, and diabetes at baseline did not materially affect the results of analyses of baseline cycling, cycling at second examination, or changes in cycling habits (Table).Table. Risk of CHD According to Cycling LevelCycling CategoryCHD Event Rate*(Cases/Person-Time)Hazard Ratio (95% CI)†Hazard Ratio (95% CI)‡Overall cycling (n=53 723)3.42 (2892/846 487)0 (mean=0.0) h/w cycling4.31 (1133/263 147)1.001.00>0–1 (mean=0.8) h/w cycling3.16 (596/188 986)0.84 (0.76–0.93)0.87 (0.79–0.97)>1– 0–1.5 (mean=0.7) h/w cycling1,75 (57/32 499)0.78 (0.58–1.03)0.81 (0.60–1.07)>1.5 (mean=3.6) h/w cycling2.12 (69/32 513)0.88 (0.68–1.15)0.94 (0.72–1.22)Leisure time cycling (n=31 632 ¶)3.49 (1233/352 879)0 (mean=0.0) h/w cycling4.30 (517/120 144)1.001.00>0–1 (mean=0.5) h/w cycling2.54 (340/113 597)0.80(0.70–0.93)0.84 (0.73–0.97)>1– <2.5 (mean=1.7) h/w cycling2.96 (168/56 832)0.77 (0.65–0.92)0.80 (0.67–0.96)≥2.5 (mean=5.7) h/w cycling3.33 (208/62 306)0.78 (0.66–0.92)0.80 (0.68–0.94)Changes in overall cycling (n=30,440 ¶)3.44 (1169/339 771)Not cycling at baseline or at second examination4.51 (307/68 067)1.001.00Cycling at baseline (mean=2.0 h/w), not at second examination3.73 (133/35 705)0.88 (0.72–1.08)0.88 (0.72–1.08)Not cycling at baseline, cycling at second examination (mean=1.4 h/w)3.21 (109/33 914)0.74 (0.59–0.92)0.76 (0.61–0.95)Cycling at both baseline (mean=3.3 h/w) and second examination (mean=2.9 h/w)3.08 (622/202 086)0.80 (0.69–0.92)0.84 (0.73–0.97)CHD indicates coronary heart disease; CI, confidence interval; h/w, hours/week; and PY, person-years.*Per 1000 person-years.†Adjusted for age, gender, years of school, educational level, smoking, frequency of alcohol intake, coffee intake, total energy intake, cereal whole grain intake, fruit intake, vegetable intake, glycemic load, ratio of polyunsaturated to saturated fat, occupational physical activity, leisure time physical activity, and family history of CHD.‡Also adjusted for body mass index, diabetes, hypercholesterolemia medication, and hypertension medication.§The n value is reduced because retired and unemployed persons were excluded.¶The n value is reduced because some participants did not respond to questions regarding cycling and confounding exposures at the second examination.The size of the estimated associations between CHD risk and overall cycling as well as leisure time cycling in this study is largely in agreement with the summary estimate of a meta-analysis comparing physical activity according to international guidelines with no activity2 and a Dutch study reporting 18% lower cardiovascular disease incidence associated with participation in overall cycling.3 However, other studies have found no relationship between cycling and CHD or cardiovascular disease mortality.4,5 Selection bias, recall bias, social desirability bias, generalizability to other populations, limited statistical power in the commuter cycling analysis, and inaccuracy regarding CHD cases are possible weaknesses of this study. Yet, we do not expect that misclassification of CHD incidence and cycling exposure is related. Although residual and unknown confounding cannot be excluded, the adjustment for multiple possible confounders is a major strength in this study. The prospective design, repeated measurements, and the careful exclusion of participants with baseline CHD, stroke, or cancer are other strengths.In conclusion, our study suggests that engagement in overall and leisure time cycling was associated with a lower CHD risk in Danish middle-aged and older adults. The study also suggests that initiating or continuing cycling is valuable for CHD prevention. Collectively, the findings support wide encouragement to participate in cycling as an approach to prevent development of CHD.Sources of FundingThe "Diet, Cancer, and Health" study was funded by the Danish Cancer Society. Dr Grøntved was supported by the Lundbeck Foundation (R151-2013–14641) and the Danish Council for Independent Research (DFF-4004-00111).DisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.Correspondence to: Anders Grøntved, PhD, Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise Epidemiology, Centre of Research in Childhood Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark. E-mail [email protected]References1. Greenland S, Drescher K. Maximum likelihood estimation of the attributable fraction from logistic models.Biometrics. 1993; 49:865–872.CrossrefMedlineGoogle Scholar2. Sattelmair J, Pertman J, Ding EL, Kohl HW, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis.Circulation. 2011; 124:789–795. doi: 10.1161/CIRCULATIONAHA.110.010710.LinkGoogle Scholar3. Hoevenaar-Blom MP, Wendel-Vos GC, Spijkerman AM, Kromhout D, Verschuren WM. Cycling and sports, but not walking, are associated with 10-year cardiovascular disease incidence: the MORGEN Study.Eur J Cardiovasc Prev Rehabil. 2011; 18:41–47. doi: 10.1097/HJR.0b013e32833bfc87.CrossrefMedlineGoogle Scholar4. Schnohr P, Marott JL, Jensen JS, Jensen GB. Intensity versus duration of cycling, impact on all-cause and coronary heart disease mortality: the Copenhagen City Heart Study.Eur J Prev Cardiol. 2012; 19:73–80. doi: 10.1177/1741826710393196.CrossrefMedlineGoogle Scholar5. Sahlqvist S, Goodman A, Simmons RK, Khaw KT, Cavill N, Foster C, Luben R, Wareham NJ, Ogilvie D. 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A Systematic Literature Review and Reflections on Evidence, International Journal of Environmental Research and Public Health, 10.3390/ijerph16060937, 16:6, (937) November 1, 2016Vol 134, Issue 18 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.024651PMID: 27799259 Originally publishedNovember 1, 2016 Keywordsexercisephysical activityatherosclerosismyocardial infarctioncoronary diseasePDF download Advertisement
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