Published online before print September 18, 2003, doi: 10.1161/01.STR.0000091843.02517.9D
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(Stroke. 2003;34:2475.)
© 2003 American Heart Association, Inc.
Original Contributions |
Physical Activity and Stroke Risk
A Meta-Analysis
From the Department of Sports and Exercise Sciences, West Texas A&M University, Canyon (C.D.L.); Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis (A.R.F.); and Division of Epidemiology and Clinical Applications, The Cooper Institute, Dallas, Tex (S.N.B.).
Reprint requests to Dr Chong Do Lee, Department of Sports and Exercise Sciences, West Texas A&M University, Canyon, TX 79016. E-mail CLee{at}wtamu.edu
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Abstract |
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 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
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Background and Purpose— Whether physical activity reduces stroke risk remains controversial. We used a meta-analysis to examine the overall association between physical activity or cardiorespiratory fitness and stroke incidence or mortality.
Methods— We searched MEDLINE from 1966 to 2002 and identified 23 studies (18 cohort and 5 case-control) that met inclusion criteria. We estimated the overall relative risk (RR) of stroke incidence or mortality for highly and moderately active individuals versus individuals with low levels of activity using the general variance–based method.
Results— The meta-analysis documented that there was a reduction in stroke risk for active or fit individuals compared with inactive or unfit persons in cohort, case-control, and both study types combined. For cohort studies, highly active individuals had a 25% lower risk of stroke incidence or mortality (RR=0.75; 95% CI, 0.69 to 0.82) compared with low-active individuals. For case-control studies, highly active individuals had a 64% lower risk of stroke incidence (RR=0.36; 95% CI, 0.25 to 0.52) than their low-active counterparts. When we combined both the cohort and case-control studies, highly active individuals had a 27% lower risk of stroke incidence or mortality (RR=0.73; 95% CI, 0.67 to 0.79) than did low-active individuals. We observed similar results in moderately active individuals compared with inactive persons (RRs were 0.83 for cohort, 0.52 for case-control, and 0.80 for both combined). Furthermore, moderately and highly active individuals had lower risk of both ischemic and hemorrhagic strokes than low-active individuals.
Conclusions— We conclude that moderate and high levels of physical activity are associated with reduced risk of total, ischemic, and hemorrhagic strokes.
Key Words: incidence • meta-analysis • mortality • physical activity • stroke
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Introduction |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Stroke is a leading cause of death and long-term disability in the United States. Approximately one half million US adults suffer from stroke (first attack) each year, with 100 000 recurrent attacks.1 Of these, 160 000 are fatal.2 Since effective treatments for stroke are limited and many stroke survivors require lengthy rehabilitation and chronic care, primary prevention of stroke is imperative to avoid the burden of this disease.
Hypertension and cardiac disease are the primary risk factors for stroke.3,4 Physical activity may modify these risk factors for stroke and may have more direct effects to lower stroke risk as well. A systematic review reported that physical activity is inversely associated with incidence of hypertension and coronary heart disease.5 However, whether physical activity alters stroke risk was less clear, partly because there were fewer stroke events in some studies. Some investigators found an inverse association between physical activity and stroke risk.6–21 Other studies have shown a U-shaped association, no association, or a positive association between physical activity and stroke incidence or mortality.22–27 To
See Editorial Comment, page 2481
address stroke prevention strategies, it is important to investigate whether physical activity reduces stroke incidence or mortality. We therefore investigated the overall association between physical activity and stroke incidence or mortality from published studies between 1966 and 2002.
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Materials and Methods |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Study Selection
We searched MEDLINE from January 1966 through July 2002, using the medical subject headings physical activity, exercise, leisure-time activity, stroke, and cardiovascular disease. We also searched the Surgeon General’s report on physical activity and health.28 We reviewed all relevant articles and identified 31 published epidemiological studies of physical activity and stroke, 23 of which (18 cohort and 5 case-control) met our inclusion criteria. Inclusion criteria were English language reports of any cohort or case-control study in which physical activity (leisure-time activity)6–27 or cardiorespiratory fitness29 was classified as low, moderate, or high6,8–10,12–21,23–27 or was classified as the least to the highest intensity7,11,22,26 of physical activity. We excluded 8 studies from the analysis. Four studies either classified or analyzed physical activity only as low versus other30–33; 2 studies analyzed physical activity on a continuous scale34,35; and 2 studies reported death rates or relative risks (RRs) without CIs, and therefore the variances of the RRs were inestimable.36,37
Data Extraction
All the data were independently abstracted by 1 investigator (C.D.L.). Measures of association reported within a single study separately for different ethnic groups, sexes, age groups, or outcome measures were analyzed as separate units. For instance, in the National Health and Nutrition Examination Survey (NHANES) I epidemiological follow-up study, we included 5 different data units: white women aged 45 to 64 years, white women aged 65 to 74 years, white men aged 45 to 74 years, white men aged 65 to 74 years, and blacks aged 45 to 74 years.13 For Honolulu Heart Study men, we used 2 data units with different age groups (aged 45 to 54 and 55 to 68 years).6 For the Framingham Study, we separated 2 data units (men and women).12 In the Established Populations for Epidemiologic Studies of the US Elderly, we included 3 data units: Boston (Mass) elderly, New Haven (Conn) elderly, and Iowa elderly.27 We obtained 23 studies that met inclusion criteria, yielding a total of 31 data units. The studies’ characteristics were recorded as follows: author’s name, publication year, study population (sample size, age, sex, and ethnicity), physical activity classification (low, moderate, high activity intensities), activity type (leisure-time only), follow-up years (cohort studies), outcome measure (stroke incidence or mortality), RR (or odds ratio) and CI, and covariates.
Statistical Analysis
The RR or odds ratio was used to estimate the risk ratio of stroke incidence or mortality for moderately or highly active individuals versus low-active individuals. We used the general variance–based fixed effects model to analyze the cohort and case-control studies separately and then combined both study types.38 We transformed each study’s RR to natural logarithms to stabilize the variances. The variance of the RR was estimated from the CI. The overall RR was estimated as follows: equation
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where wi is a weight for the study, which is the inverse of the variance for the study. We tested homogeneity of the association across studies using Woolf’s 
2 statistic.39 We also tested for publication bias using a funnel plot of the sample sizes versus RRs and with the Kendall 
rank correlation method. All statistical analyses were performed with the use of STATA statistical software (Stata Corporation).
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Results |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Eleven of the 18 cohort studies (Table 1) were from the United States, and 7 studies were from elsewhere, such as England, Norway, Iceland, Japan, Italy, or the Netherlands. One of the 5 case-control studies (Table 2) was from the United States (New York), and the other 4 were from England, Australia, and the Netherlands. A funnel plot (sample sizes versus RRs) and the Kendall
correlation coefficient (r=0.13) suggested that there was no publication bias in the sample of reports (P=0.30). Associations were homogeneous within cohort (P=0.80) and case-control (P=0.96) study groups and across all studies (P=0.81).
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Figure 1 shows the RRs (and 95% CIs) of stroke incidence or mortality for highly active individuals versus low-active individuals in the cohort studies. The CIs for the RRs of many studies included 1.0. The RRs were <1.0 in 14 studies, but 4 studies had RRs >1.0. Overall, highly active individuals had a 25% lower risk of stroke incidence or mortality in the cohort studies than did low-active individuals (RR=0.75; 95% CI, 0.69 to 0.82; P<0.001). For case-control studies, highly active individuals had a 64% lower risk of stroke incidence than did low-active individuals (RR=0.36; 95% CI, 0.25 to 0.52; P<0.001) (Figure 2). When the cohort and case-control studies were combined, highly active individuals had a 27% lower risk of stroke incidence or mortality than did low-active individuals (RR=0.73; 95% CI, 0.67 to 0.79; P<0.001) (Table 3). We observed similar results across subtypes of stroke on the basis of 6 ischemic and 3 hemorrhagic stroke studies. Highly active individuals had a 21% lower risk of incident ischemic stroke (RR=0.79; 95% CI, 0.69 to 0.91; P<0.001) and a 34% lower risk of incident hemorrhagic stroke (RR=0.66; 95% CI, 0.48 to 0.91; P<0.001) compared with low-active individuals (Figures 3 and 4
).
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adjusted for age and some risk factors excluding high blood pressure;
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Table 3 also shows the RRs of stroke incidence or mortality for moderately active individuals versus low-active individuals. In cohort studies, moderately active individuals had a 17% lower risk of stroke incidence or mortality than did low-active individuals (RR=0.83; 95% CI, 0.76 to 0.89; P<0.001). For case-control studies, moderately active individuals had a 48% lower risk of stroke incidence compared with low-active individuals (RR=0.52; 95% CI=0.40 to 0.69; P<0.001). Overall, when the cohort and case-control studies were combined, moderately active individuals had a 20% lower risk of stroke incidence or mortality than did low-active individuals (RR=0.80; 95% CI, 0.74 to 0.86; P<0.001). Moderately active individuals also had a 9% lower risk of incident ischemic stroke (RR=0.91; 95% CI, 0.80 to 1.05; P<0.001) and a 15% lower risk of incident hemorrhagic stroke (RR=0.85; 95% CI, 0.64 to 1.13; P<0.001) than did low-active individuals (Figures 3 and 4
).
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Discussion |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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We investigated the association of physical activity with stroke risk by a meta-analysis of existing epidemiological studies. The value of meta-analysis is illustrated by the fact that most studies individually lacked precision, a problem alleviated by pooling. The major finding was that moderately or highly active individuals had lower risk of stroke incidence or mortality than did low-active individuals. Overall, moderately active individuals had a 20% lower risk and highly active individuals had a 27% lower risk of stroke incidence or mortality than the low-active individuals. Both ischemic and hemorrhagic strokes were lower in moderately and highly active individuals. Results appeared to be slightly stronger for case-control studies than for cohort studies, but there was no statistically significant evidence of heterogeneity by study type.
Our study indicates that physical activity probably reduces stroke risk. However, physical activity questionnaires tend to be imprecise and have large measurement error, and therefore the pooled estimates of RR may have underestimated the true RR. We recently showed a strong inverse relation between cardiorespiratory fitness, an objective marker of physical activity, and stroke mortality.29
There are several plausible ways by which physical activity might reduce stroke risk. Hypertension and atherosclerosis of cerebral vessels are major causes of stroke.3,4 Hypertension is a risk factor for both ischemic and hemorrhagic strokes, and there is a direct dose-response relationship between blood pressure and stroke risk.40 Physical activity lowers blood pressure and improves lipid profiles.41 Physical activity also improves endothelial function, which enhances vasodilation and vasomotor function in the vessels.42 In addition, physical activity can play an antithrombotic role by reducing blood viscosity,43 fibrinogen levels,44 and platelet aggregability45 and by enhancing fibrinolysis,46–48 all of which might reduce cardiac and cerebral events.
One limitation of our meta-analysis is that few studies were available to investigate the relation of physical activity to hemorrhagic stroke,6,11,26 although many studies have shown an inverse relationship between physical activity and ischemic stroke. More studies are needed to investigate the relation of physical activity to hemorrhagic stroke. Another limitation is that the definitions of low, moderate, and high activity varied widely among studies, making it impossible to be entirely specific about the amount and type of physical activity required to prevent stroke. The degree of control for confounding variables also varied from study to study. Most studies adjusted for some risk factors besides age; approximately one third adjusted for high blood pressure. If the causal pathway is that physical activity reduces stroke by lowering blood pressure, then not adjusting for blood pressure would be appropriate.
In conclusion, our meta-analysis documents that moderately or highly active individuals have a reduced risk of stroke incidence or mortality. Reduction of stroke risk is another reason to participate in regular and moderate- to high-intensity physical activity.
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Acknowledgments |
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This research was supported by National Institutes of Health training grant T32-HL07779, National Institutes of Health grant AG06945, and a Killgore Research Enhancement grant from West Texas A&M University.
Received March 31, 2003; revision received June 3, 2003; accepted June 24, 2003.
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N. M. Kaplan, S. S. Gidding, T. G. Pickering, and J. T. Wright Jr Task Force 5: Systemic hypertension J. Am. Coll. Cardiol., April 19, 2005; 45(8): 1346 - 1348. [Full Text] [PDF]
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