Physical activity, the Framingham risk score and risk of coronary heart disease in men and women of the EPIC-Norfolk study



      Test the hypothesis that considering leisure-time and work-related physical activity habits in addition to the Framingham risk score (FRS) would result into better classification of coronary heart disease (CHD) risk than FRS alone.


      Prospective, population-based study of 9564 men and 12165 women aged 45–79 years followed for an average of 11.4 years. A modified FRS which takes into account physical activity (evaluated using a validated lifestyle questionnaire taking into account leisure-time and work-related physical activity) was computed.


      During follow-up, 2191 CHD events occurred. Among 3369 men who were classified as intermediate risk (event rate of 12.4%) according to the FRS, 413 were reclassified into the low-risk category and 279 were reclassified into the high-risk category after modification of the FRS. After reclassification of these men, CHD event rate was of 5.3% and 18.6%, respectively for men classified at low and high CHD risk. Among 4766 women initially classified as intermediate risk (event rate of 8.4%), 1282 were reclassified into the low-risk category whereas 1071 women were reclassified into the high-risk category. After reclassification of these women, CHD event rate was of 6.8% and 12.2%, respectively for women classified at low and high CHD risk.


      Results of the present study suggest that asking simple questions about leisure-time and work-related physical activity which can be rapidly obtained by any physician at no cost could be helpful in the estimation of patients’ CHD risk.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wilson P.W.
        • D’Agostino R.B.
        • Levy D.
        • et al.
        Prediction of coronary heart disease using risk factor categories.
        Circulation. 1998; 97: 1837-1847
      1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106(25):3143-3421.

        • Rodriguez B.L.
        • Curb J.D.
        • Burchfiel C.M.
        • et al.
        Physical activity and 23-year incidence of coronary heart disease morbidity and mortality among middle-aged men. The Honolulu Heart Program.
        Circulation. 1994; 89: 2540-2544
        • Haapanen N.
        • Miilunpalo S.
        • Vuori I.
        • Oja P.
        • Pasanen M.
        Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged men and women.
        Int J Epidemiol. 1997; 26: 739-747
        • Manson J.E.
        • Greenland P.
        • LaCroix A.Z.
        • et al.
        Walking compared with vigorous exercise for the prevention of cardiovascular events in women.
        N Engl J Med. 2002; 347: 716-725
        • Lee I.M.
        • Sesso H.D.
        • Paffenbarger Jr., R.S.
        Physical activity and coronary heart disease risk in men: does the duration of exercise episodes predict risk?.
        Circulation. 2000; 102: 981-986
        • Hu G.
        • Tuomilehto J.
        • Borodulin K.
        • Jousilahti P.
        The joint associations of occupational, commuting, and leisure-time physical activity, and the Framingham risk score on the 10-year risk of coronary heart disease.
        Eur Heart J. 2007; 28: 492-498
        • Day N.
        • Oakes S.
        • Luben R.
        • et al.
        EPIC-Norfolk: study design and characteristics of the cohort. European Prospective Investigation of Cancer.
        Br J Cancer. 1999; 80: 95-103
        • Friedewald W.T.
        • Levy R.I.
        • Fredrickson D.S.
        Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge.
        Clin Chem. 1972; 18: 499-502
        • Boekholdt S.M.
        • Peters R.J.
        • Day N.E.
        • et al.
        Macrophage migration inhibitory factor and the risk of myocardial infarction or death due to coronary artery disease in adults without prior myocardial infarction or stroke: the EPIC-Norfolk Prospective Population study.
        Am J Med. 2004; 117: 390-397
        • Ainsworth B.E.
        • Haskell W.L.
        • Whitt M.C.
        • et al.
        Compendium of physical activities: an update of activity codes and MET intensities.
        Med Sci Sports Exerc. 2000; 32: S498-504
        • Wareham N.J.
        • Jakes R.W.
        • Rennie K.L.
        • et al.
        Validity and repeatability of the EPIC-Norfolk Physical Activity Questionnaire.
        Int J Epidemiol. 2002; 31: 168-174
        • Hu F.B.
        • Willett W.C.
        • Li T.
        • et al.
        Adiposity as compared with physical activity in predicting mortality among women.
        N Engl J Med. 2004; 351: 2694-2703
        • Mora S.
        • Cook N.
        • Buring J.E.
        • Ridker P.M.
        • Lee I.M.
        Physical activity and reduced risk of cardiovascular events: potential mediating mechanisms.
        Circulation. 2007; 116: 2110-2118
        • Ekelund U.
        • Griffin S.J.
        • Wareham N.J.
        Physical activity and metabolic risk in individuals with a family history of type 2 diabetes.
        Diabetes Care. 2007; 30: 337-342
        • Molenaar E.A.
        • Massaro J.M.
        • Jacques P.F.
        • et al.
        Association of lifestyle factors with abdominal subcutaneous and visceral adiposity: the Framingham Heart Study.
        Diabetes Care. 2008; 32: 505-510
        • Colbert L.H.
        • Visser M.
        • Simonsick E.M.
        • et al.
        Physical activity, exercise, and inflammatory markers in older adults: findings from the Health, Aging and Body Composition Study.
        J Am Geriatr Soc. 2004; 52: 1098-1104
        • Wannamethee S.G.
        • Lowe G.D.
        • Whincup P.H.
        • et al.
        Physical activity and hemostatic and inflammatory variables in elderly men.
        Circulation. 2002; 105: 1785-1790
        • Zethelius B.
        • Berglund L.
        • Sundstrom J.
        • et al.
        Use of multiple biomarkers to improve the prediction of death from cardiovascular causes.
        N Engl J Med. 2008; 358: 2107-2116
        • Ridker P.M.
        • Paynter N.P.
        • Rifai N.
        • Gaziano J.M.
        • Cook N.R.
        C-reactive protein and parental history improve global cardiovascular risk prediction: the Reynolds Risk Score for men.
        Circulation. 2008; 118: 2243-2251
        • Preis S.R.
        • Hwang S.J.
        • Fox C.S.
        • et al.
        Eligibility of individuals with subclinical coronary artery calcium and intermediate coronary heart disease risk for reclassification (from the Framingham Heart Study).
        Am J Cardiol. 2009; 103: 1710-1715
        • Bernstein M.
        • Sloutskis D.
        • Kumanyika S.
        • et al.
        Data-based approach for developing a physical activity frequency questionnaire.
        Am J Epidemiol. 1998; 147: 147-154
        • Knowler W.C.
        • Barrett-Connor E.
        • Fowler S.E.
        • et al.
        Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • Tuomilehto J.
        • Lindstrom J.
        • Eriksson J.G.
        • et al.
        Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.
        N Engl J Med. 2001; 344: 1343-1350