Journal of Gerontology: MEDICAL SCIENCES Copyright 2006 by The Gerontological Society of America

2006, Vol. 61A, No. 1, 97–102

Associations of Changes in Exercise Level

With Subsequent Disability Among Seniors:
A 16-Year Longitudinal Study
David R. Berk, Helen B. Hubert, and James F. Fries

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Department of Medicine, Stanford University School of Medicine, California.

Background. The effect of changes in physical exercise on progression of musculoskeletal disability in seniors has
rarely been studied.

Methods. We studied a prospective cohort annually from 1984 to 2000 using the Health Assessment Questionnaire
Disability Index (HAQ-DI). The cohort included 549 participants, 73% men, with average end-of-study age of 74 years.
At baseline and at the end of the study, participants were classified as ‘‘High’’ or ‘‘Low’’ vigorous exercisers using a cut-
point of 60 min/wk. Four groups were formed: ‘‘Sedentary’’ (LowfiLow; N ¼ 71), ‘‘Exercise Increasers’’ (LowfiHigh;
N ¼ 27), ‘‘Exercise Decreasers’’ (HighfiLow; N ¼ 73), and ‘‘Exercisers’’ (HighfiHigh; N ¼ 378). The primary de-
pendent variable was change in HAQ-DI score (scored 0–3) from 1984 to 2000. Multivariate statistical adjustments using
analysis of covariance included age, gender, and changes in three risk factors, body mass index, smoking status, and
number of comorbid conditions. Participants also prospectively provided reasons for exercise changes.

Results. At baseline, Sedentary and Increasers averaged little exercise (16 and 22 exercise min/wk), whereas
Exercisers and Decreasers averaged over 10 times more (285 and 212 exercise min/wk; p , .001). All groups had low
initial HAQ-DI scores, ranging from 0.03 to 0.08. Increasers and Exercisers achieved the smallest increments in HAQ-DI
score (0.17 and 0.11) over 16 years, whereas Decreasers and Sedentary fared more poorly (increments 0.27 and 0.37).
Changes in HAQ-DI score for Increasers compared to Sedentary were significantly more favorable ( p , .05) even after
multivariate statistical adjustment.

Conclusions. Inactive participants who increased exercise achieved excellent end-of-study values with increments in
disability similar to those participants who were more active throughout. These results suggest a beneficial effect of
exercise, even when begun later in life, on postponement of disability.

W ITH aging of the population, the number of seniors

with disability will likely continue to grow. However,
the disability associated with aging is not an inevitable con-
stant (1). The Compression of Morbidity hypothesis suggests
that adopting healthy lifestyles may postpone disability onset
until the few years immediately preceding death, reducing
lifetime disability (2). Longitudinal comparison of cumu-
lative disability among seniors in three health-risk strata
supports this hypothesis (3). Moreover, mortality follow-
back analysis demonstrates lower end-of-life disability with
lower health risks (4). Recently, the rate of disability de-
velopment among seniors has declined faster than has
mortality, demonstrating that compression of morbidity is
possible nationally (1,3).
A 13-year longitudinal study of runners initially aged 50–
72 years demonstrated that vigorous exercise in seniors is
associated with disability-free life and disability postpone-
ment of 8–12 years (5). Over time, however, initially active
seniors may become sedentary, and initially sedentary se-
niors may become active. To make informed recommenda-
tions about lifestyle modifications at older age, studying
the impact of changes in health risk factors among seniors
is important. Moreover, examining reasons for exercise
changes should inform targeted interventions.
Examining changes in lifestyle risks rather than baseline
risks has important advantages. Associations of outcomes
with baseline risk status may be related to self-selection bias,
whereas associations of outcomes with risk status changes
more likely suggest a causal relationship. Statistical adjust-
ment procedures seldom remove all self-selection bias, and
unobserved factors still may be causally related to outcomes.
Although many studies have examined associations be-
tween changes in physical activity and mortality (6–18),
fewer have examined older populations (6,16,17,19). Fur-
thermore, data are limited regarding the effect of changes in
exercise and other risk factors on disability or health-related
quality of life (10,13,19), particularly in seniors (19).
A 16-year longitudinal analysis was performed using data
from a comparative study of vigorous exercisers and pop-
ulation controls (5). We hypothesized that (i) among par-
ticipants originally self-selecting for inactivity, those who
increased exercise would have slower disability progres-
sion; and (ii) among participants originally self-selecting
for exercise, those who decreased activity would have
more rapid disability progression, associated with in-
creased comorbidity.
PARTICIPANTS AND METHODS
Study Sample
In 1984, participants were recruited from the Fifty-Plus
Runner’s Association including predominantly Californians

97
98 BERK ET AL.
(runners), and a Stanford, California community-based
sample originally recruited as controls for the Lipid Re-
search Clinics Study (controls) (20). Initially, 1311 runners
club and 2181 Stanford community members were invited
to participate. Baseline questionnaires and consent forms
were sent to the 654 runners club and 568 community mem-
bers who expressed interest and satisfied the inclusion
criteria of age
50 years, high school education, and
English as primary language; 538 runners and 423 controls
(N ¼ 961) consented.
Participants annually completed a mailed questionnaire
assessing self-reported sociodemographic characteristics,
health risk factors (including body mass index (BMI), smok-
ing status, and exercise), medical conditions, and health care
utilization. They also completed the Health Assessment Ques-
tionnaire assessing disability (HAQ-DI). Details of sample
selection and data collection are described elsewhere (21).
Assessment of Disability
The HAQ-DI contains 21 questions covering eight
physical function domains, including rising, dressing and/
or grooming, hygiene, eating, walking, reach, grip, and
activities and/or chores. Each dimension is scored 0–3, with
0 ¼ no difficulty, 1 ¼ some difficulty, 2 ¼ much difficulty,
and 3 ¼ inability to perform. The HAQ-DI score (scored
0–3) is the average of scores across domains. A score of
0.125 is minimal disability, equal to some difficulty in one
domain; a score of 0.375 represents inability in one domain
or lesser difficulty in two or three domains. Thus, small
differences in HAQ-DI score describe significant differences
in functioning. The HAQ-DI is a widely used, rigorously
validated index of disability (22,23).
Formation of Exercise Groups
Vigorous exercise was assessed as minutes per week
(min/wk) for specific types of activities. Examples of vig-
orous exercise that were queried included running, swim-
ming, cycling, dancing, brisk walking, and racket sports.
Participants reported whether and why they made sub-
stantial changes (increase, decrease, stop, or start) in any
type of exercise.
We studied 549 participants followed from 1984 to 2000
(completers), including 335 runners and 214 controls. Indi-
viduals were classified as ‘‘High’’ or ‘‘Low’’ exercisers at
baseline and at end of study according to whether they
averaged more than 60 min/wk of vigorous exercise in
1984–1986 and 1998–2000; 3-year periods were used to
reduce year-to-year variability. Four groups were formed
based on exercise during these two periods: ‘‘Sedentary’’
(LowfiLow; N ¼ 71): 60 exercise min/wk during both
periods; ‘‘Exercise Increasers’’ (LowfiHigh; N ¼ 27): 60
exercise min/wk at baseline, but .60 min/wk at end of
study; ‘‘Exercise Decreasers’’ (HighfiLow; N ¼ 73): .60
exercise min/wk at baseline, but 60 min/wk at end of
study; and ‘‘Exercisers’’ (HighfiHigh; N ¼ 378): .60
exercise min/wk during both periods.
Of the remaining 412 participants who discontinued
participation, 106 died and 306 represented attrition. Overall
attrition rates were only 2% per year. Dropout rates were
similar among baseline Low and High exercisers. However,
baseline Low exercisers were more likely than were High
exercisers to die during follow-up (1.3% vs 0.5% annually,
p , .001). For both groups, those participants who died or
dropped out were significantly older than were the com-
pleters, and had higher baseline disability. Among baseline
Low exercisers, those who died or dropped out had more
comorbid conditions (0.25 vs 0.05 for completers, p , .01).
However, there were no significant differences between
withdrawals and completers in baseline exercise minutes
for either group.
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Statistical Analysis
Differences between those participants who remained in
their exercise group and those who changed were tested using
analysis of variance to contrast variable means and Kruskal–
Wallis chi-square tests to compare proportions. Adjusted
change in HAQ-DI score was estimated using analysis of
covariance controlling for age, gender, changes in BMI
and smoking status (yes/no) from 1984 to 2000, and change
in number of comorbid conditions from 1989 to 2000.
Comorbid conditions that were considered include cardio-
vascular conditions, pulmonary conditions, cancer, gas-
trointestinal conditions, diabetes, neurologic conditions,
musculoskeletal conditions, and other. Not all factors thought
to influence disability, such as cognitive function, could be
included in our analysis due to lack of data in early study
years. Other possible covariables such as dietary factors were
also not included for the same reasons. Interaction terms were
not tested due to small numbers in several groups. Statistical
significance was considered (p , .05) using a two-tailed test.
RESULTS
Table 1 describes participants at baseline and end of
study. Compared to Sedentary, Increasers were more likely
to be men and to be slightly more educated. Compared
to Exercisers, Decreasers were more likely to be women,
smokers, slightly older, and have a higher BMI. Comor-
bidity data were similar at baseline across groups. However,
by 2000, Decreasers averaged more comorbid conditions
than Exercisers (1.4 vs 1.1, p , .05). Decreasers compared
to Exercisers, and Sedentary compared to Increasers more
often had arthritic, neurological, and cardiovascular comor-
bidities. The Sedentary cohort had the most pulmonary
comorbidities.
At baseline, Sedentary and Increasers (the original sed-
entary groups) averaged well below the 60 exercise min/
wk cutoff (16 and 22 min/wk), whereas Exercisers and
Decreasers (the original exercising groups) averaged well
above this cutoff (285 and 212 min/wk). The baseline
difference between Exercisers and Decreasers, however,
was significant ( p , .001). At end of study, exercise
minutes were 22 for Sedentary compared to 134 for
Increasers (p , .01), and 261 for Exercisers compared to
24 for Decreasers ( p , .001).
By end of study, Decreasers increased BMI more than did
Exercisers (1.6 vs 1.1, p , .05; Table 2). The percentage of
smokers remained low. The increase in number of co-
morbidities ranged from 1.0 to 1.4 and showed no statistically
significant difference between Decreasers and Exercisers.
 EXERCISE EFFECTS ON DISABILITY 99

Table 1. Participant Characteristics at Baseline and End of Study Table 2. Changes in Participant Characteristics From Baseline
Exercise Groups Exercise Groups
Sedentary Increasers Decreasers Exercisers Sedentary Increasers Decreasers Exercisers
Participant LowfiLow LowfiHigh HighfiLow HighfiHigh LowfiLow LowfiHigh HighfiLow HighfiHigh
Characteristics (N ¼ 71) (N ¼ 27) (N ¼ 73) (N ¼ 378) Change in: (N ¼ 71) (N ¼ 27) (N ¼ 73) (N ¼ 378)
Mean age, 1984, y 59.8 (0.7) 59.6 (1.1) 59.2 (0.8) 57.5 (0.3)* Exercise min/wk,
Mean age, 2000, y 75.6 (0.7) 75.5 (1.1) 75.2 (0.8) 73.4 (0.3)* 1984–2000,
Men, % 49.3 85.2y 63.0 78.0y mean 5.1 (6.4) 112.0 (17.2)* 185.3 (20.1) 23.7 (11.4)y
Education, mean y 15.9 (0.3) 17.0 (0.4)* 16.5 (0.3) 16.8 (0.1) BMI, 1984–2000,

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Exercise min/wk, mean kg/m2 0.9 (0.3) 0.4 (0.4) 1.6 (0.3) 1.1 (0.1)*
1984, mean 15.9 (4.3) 21.5 (7.0) 212.2 (19.5) 285.2 (9.4)z No. of comorbid
Exercise min/wk, conditions,
1984, median 0.0 0.0 160.0 240.0 1989–2000,
Exercise min/wk, mean 1.4 (0.1) 1.2 (0.2) 1.3 (0.1) 1.0 (0.1)
2000, mean 21.5 (4.3) 133.5 (17.5)y 24.2 (4.5) 261.1 (10.7)z % Smokers,
Exercise min/wk, 1984–2000 5.6 7.4 8.2 0.5y
2000, median 0.0 140.0 0.0 220.0
Note: Standard errors are shown in parentheses.
BMI, 1984,
y Values of p for testing differences between Sedentary versus Increasers and
mean kg/m2 24.4 (0.4) 24.9 (0.4) 23.8 (0.4) 22.9 (0.1)
Exercisers versus Decreasers:
BMI, 2000,
*p , .05.
mean kg/m2 25.2 (0.5) 25.4 (0.5) 25.5 (0.6) 24.0 (0.1)z y
p , .001.
% Smokers, 1984 12.7 7.4 12.3 1.1z
BMI ¼ body mass index.
% Smokers, 2000 7.0 0.0 4.1 1.6
No. of comorbid
conditions,
1989, mean 0.06 (0.03) 0.00 (0.00) 0.08 (0.03) 0.06 (0.01) difficulty in 1 of 8 domains of function evaluated by the
No. of comorbid HAQ-DI. However, the baseline HAQ-DI score in De-
conditions, creasers already was significantly higher than in Exercisers
2000, mean 1.5 (0.1) 1.2 (0.2) 1.4 (0.1) 1.1 (0.1)*
(0.08 vs 0.03). Sedentary recorded the greatest change and
Note: Standard errors are shown in parentheses. poorest end-of-study HAQ-DI scores, increasing 0.37
Values of p used for testing differences between Sedentary versus Increasers disability units to 0.42, equivalent to more than some
and Exercisers versus Decreasers:
difficulty in 3 domains of daily function or inability to
*p , .05.
y
p , .01. perform 1 domain evaluated by the HAQ-DI. Decreasers
z
p , .001. showed poor end-of-study scores, increasing 0.28 to 0.36
BMI ¼ body mass index. units. Increasers achieved very good end-of-study scores,
increasing only 0.17 to 0.20 units. Exercisers demonstrated
the least change and the best end-of-study scores, increasing
The Sedentary group maintained exercise between 16 and 0.11 to 0.14 units. Disability for Decreasers approaches
23 min/wk during the baseline (1984–1986) and final (1998– that for Sedentary over time, whereas disability levels of
2000) periods (Figure 1). Exercisers maintained exercise Exercisers and Increasers remained relatively low through-
between 233 and 327 minutes throughout, whereas the exer-
cise minutes of the Decreasers declined more than 8-fold.
Activity change data indicated that among Decreasers,
75% of swimmers and 64% of runners diminished levels of
their specific exercise. Lack of time and/or interest and joint
pain were the most common reasons for declining activity
among Decreasers. Orthopedic problems and injuries were
more frequently reasons for decreasing running or walking
than for decreasing swimming or cycling. Runners also were
most likely to change forms of exercise (20% did so).
Increasers most frequently increased walking and cycling.
One third of those who initially cycled and 29% of those
who initially walked increased their exercise, whereas only
15% of runners in this group increased their overall exercise
min/wk. Doctors’ recommendations and personal desires
for better fitness most often motivated Increasers’ positive
change in exercise. Activities that Increasers most often
started were aerobics (19%), cycling (19%), and weight
lifting (11%). No Increasers started running.
Figure 1. Mean exercise over time. Exercisers maintained high levels of
Table 3 indicates that all groups averaged low HAQ-DI exercise throughout the 16 years, whereas Sedentary remained relatively inactive.
scores in 1984, ranging from 0.03 to 0.08 disability units on On average, Increasers achieved greater than a 6-fold increase in exercise min/
the 0–3 scale, well below a score of 0.125 that reflects some wk, whereas Decreasers experienced a greater than 8-fold decrease.
100 BERK ET AL.

Table 3. HAQ-DI Score (Standard Error) at Baseline, End of Study,

and Change Over Time
Exercise Groups
Sedentary Increasers Decreasers Exercisers
LowfiLow LowfiHigh HighfiLow HighfiHigh
HAQ-DI Score (N ¼ 71) (N ¼ 27) (N ¼ 73) (N ¼ 378)
Disability, 1984 0.05 (0.01) 0.03 (0.01) 0.08 (0.02) 0.03 (0.00)z
Disability, 2000 0.42 (0.07) 0.20 (0.07)y 0.36 (0.06) 0.14 (0.02)z
Change in disability,

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1984–2000 0.37 (0.06) 0.17 (0.07)* 0.27 (0.05)
Change in disability,
1984–2000,
adjusteda 0.29 (0.06) 0.12 (0.08)* 0.20 (0.06)
Note: aAdjusted for age and gender in 1984, change in body mass index
and change in smoking status (yes/no) from 1984 through 2000, and change
in number of comorbid conditions from 1989 through 2000.
Values of p for testing differences between Sedentary versus Increasers and
Exercisers versus Decreasers:
*p , .05.
y levels of disability. The Sedentary group experienced the poorest end-of-study
p , .01.
z
p , .001.
§
p ¼ .06.
out (Figure 2). Final disability scores were more associated
with the current than with the initial exercise group. The
HAQ-DI score change from 1984 to 2000 differed
significantly between groups, with Sedentary worse than
Increasers and Exercisers better than Decreasers. Differ-
ences between groups regarding the HAQ-DI score change
from 1984 to 2000, our main outcome measure, persisted
after adjustments for age, gender, and changes in three risk
factors, BMI, smoking status, and number of comorbidities.
In fact, adjusted change in HAQ-DI score was the same for
Increasers and Exercisers.
DISCUSSION
Because those persons older than 65 years compose the
fastest growing segment of the population in many nations
(24), methods to maximize disability-free life now have
critical medical, social, and economic importance (1,25).
Despite medical advances, primary prevention and health
risk reduction will remain important approaches to health
improvement, especially with increasingly sedentary, over-
weight populations (26–29).
This longitudinal study supports the thesis that exercising
at high levels, even late in life, delays disability de-
velopment. Additionally, the results examining effects of
exercise change suggest that increasing exercise in seniors
may still have important health effects. Individuals with
high exercise levels throughout our study period (Exer-
cisers, HighfiHigh) had the smallest adjusted increase in
disability, consistent with a beneficial effect of exercise.
Those participants with little exercise throughout our study
period (Sedentary, LowfiLow) had the greatest adjusted
increase in disability, consistent with a negative effect of
more sedentary lifestyles.
This analysis focused on those individuals who initially
self-selected for inactivity, but later increased exercise.
These Increasers had little progression of disability, similar
0.11 (0.01)z
0.12 (0.06)§
Figure 2. Mean disability over time. At baseline, all groups had very low
Health Assessment Questionnaire Disability Index (HAQ-DI) score, increasing
0.37 to 0.42. Exercisers achieved the best end-of-study HAQ-DI score,
increasing only 0.11 to 0.14. Increasers achieved good end-of-study HAQ-DI
score, increasing 0.17 to 0.20. Decreasers experienced poor end-of-study
HAQ-DI score, increasing 0.28 to 0.36.
to Exercisers who initially self-selected for exercise and
exercised at high levels throughout (Exercisers, Highfi
High). Despite the small number of Increasers, comparisons
with Sedentary were statistically significant in both un-
adjusted and adjusted analyses. These findings are consis-
tent with a beneficial effect of vigorous exercise on
disability development, even when exercise starts later in
life. Through 74 years of age, continuation or increase in
vigorous activity from a sedentary level appears beneficial.
Although this analysis focused on those individuals who
increased exercise (Increasers, LowfiHigh), it is interesting
to explore why individuals who decreased exercise (De-
creasers, HighfiLow) had poor outcomes. Decreasers had
progression of disability almost as rapid as individuals who
were Sedentary throughout. Either disability developed
because exercise was discontinued, or some individuals
developed comorbid conditions that caused the exercise
decrease; the latter seems likely considering the higher level
of arthritic, neurological, and cardiovascular comorbidities
among Decreasers and their reported reasons for exercise
reduction. When change in number of comorbid conditions
was included in adjustments, the difference in change in
disability between Exercisers and Decreasers reached
borderline significance ( p ¼ .056), suggesting that the
development of comorbid conditions explained part but not
all of the difference in disability progression between the
two groups.
There are limitations to all observational studies.
Although analyses were adjusted for BMI and smoking
status changes, Increasers and Decreasers may have
changed in other ways that were not ascertained. Although
our approach was designed to diminish self-selection bias, it
is impossible to eliminate all such bias in nonrandomized
studies given that, in this case, groups were categorized by
self-selected changes in exercise. These analyses did not
 EXERCISE EFFECTS ON DISABILITY
capture individuals who attempted but could not maintain
increases in exercise. Accordingly, we considered covariates
differing between groups, including age, gender, and change
in BMI, smoking status, and number of comorbidities.
Validation studies in runners and nonrunners found no
evidence to suggest reporting biases in such data (21).
Although our cohort is a selective group that is socio-
economically homogeneous and not representative of most
elderly populations, it may provide advantages for examin-
ing health outcomes in relation to lifestyle modifications
such as exercise. A generally healthy, well-educated, highly
selected population may allow us to more easily isolate
the impact of other risk factors such as exercise without
the confounding effects of other factors such as socioeco-
nomic status.
Moreover, there may be biases that could result in under-
estimation of the magnitude of intergroup differences. For
example, baseline Low exercisers more frequently died
during follow-up than did baseline High exercisers. Many
deaths were undoubtedly among individuals who had greater
changes in disability prior to death. Their exclusion would
cause underestimation of accrued disability in Sedentary
individuals. Additionally, not all factors known to influence
disability, such as cognitive function, could be included in
adjustments due to incomplete available data.
The loss of participants who were not known to have died
also may introduce bias, although we feel that our attrition
rate is small for a study of its duration (overall attrition rate ¼
2% annually). Within both baseline High and Low exercise
groups, later withdrawals had higher baseline disability but
equivalent exercise levels compared to ongoing participants.
By identifying reasons for activity changes, these results
may help target efforts at exercise enhancement. Cycling
and aerobics were most frequently initiated. Cycling and
walking were most frequently increased. Runners were most
likely to change types of exercise. Thus, efforts to promote
starting, increasing, or maintaining vigorous exercise among
seniors might be most successful when emphasizing
walking, cycling, or aerobics.
Although most studies of older adults have used cross-
sectional (not longitudinal) designs (30–34), poor health,
fear of injury, and perceived decreased activity needs have
been cited as principal barriers to exercise (30,32). Envi-
ronmental factors (access to facilities, weather, lack of exer-
cise companion) and program-based factors (inconvenience,
expense, lack of time and/or interest) have been less fre-
quently reported (30,32). Seniors’ reasons for maintaining
or increasing activity include their desire for better health
and doctors’ recommendations (30,34). Prospective studies
examining what motivates seniors’ activity changes are
limited, but suggest similar interpretations (34).
Orthopedic problems and lack of time and/or interest
were the most common reasons for exercise declines in this
study, suggesting that injury prevention may promote exer-
cise maintenance. Few seniors who decreased vigorous
exercise reported changing their type of exercise. The poor
outcomes of decreasing exercise suggest the importance
of sustainable exercise forms, even after comorbidity and
chronic illness. For example, cycling and swimming rep-
resent low impact alternatives for runners with joint
101
difficulties. Weight training allows individuals to focus on
uninvolved muscles after injuries develop. Isometric exer-
cise isolates muscle groups and allows exercise without
movement. Indeed, exercise for elderly individuals with
joint disease or injuries is clearly beneficial (35).
Reports of loss of time or interest are greater here than
in other studies (30–33), but suggest that exercise should
be made more interesting and of greater priority for se-
niors. For example, a stationary bicycle by the television
may make exercise interesting. Exercise clubs or neighbor-
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hood walking groups can maintain seniors’ interest with
social components.
Doctors’ recommendations to maintain or improve health
most often motivated increases in exercise. However, young
adults more frequently exercise to improve physical appear-
ance (36). Given more medical visits in seniors, physi-
cians have more opportunity to educate and motivate
(33). Improving Medicare reimbursement for visits for ex-
ercise promotion would encourage more active roles for
physicians (37).
Our data suggest that increasing vigorous exercise de-
creases disability progression. More sophisticated analyses
of time order issues (individual exercise change before or
after disability) is beyond the scope of this report, and could
help clarify interpretation of associations described. These
findings strongly suggest, however, that addressing mod-
ifiable health risks even late in life may promote health-
ier aging.
ACKNOWLEDGMENTS
This study was supported by grant R01 AG15815 from the National
Institute on Aging to Stanford University.
We thank Miho Bennett, PhD, for technical assistance.
This study was presented in part in abstract form at the American College
of Rheumatology Annual Scientific Meeting, October 27, 2003; Orlando,
Florida.
Address correspondence to James F. Fries, MD, Professor of Medicine,
Immunology and Rheumatology, 1000 Welch Rd. #203, Stanford, CA
94305-5755. E-mail: jff@stanford.edu
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Received January 19, 2005
Accepted May 16, 2005
Decision Editor: Luigi Ferrucci, MD, PhD