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A controlled trial of the health benefits of regular walking on a golf course∗

      Abstract

      PURPOSE: To study the effects of regular walking during a golf game on various health and fitness indicators in middle-aged men.
      METHODS: Study subjects were 55 healthy male golfers aged 48 to 64 years who had been sedentary during the 7 months before the study, and 55 age-matched, similarly sedentary controls. During the 20-week study, those in the intervention group were encouraged to play golf two to three times a week; the controls were not. Measurements of body composition, cardiorespiratory performance, motor and musculoskeletal fitness, blood pressure, and serum lipid, glucose, and insulin levels were obtained at baseline and after the 20-week study.
      RESULTS: Walking during a golf game was a practical and safe form of physical activity with high adherence. It significantly increased aerobic performance and trunk muscle endurance, with a net difference (pretraining to posttraining change between the golfers and controls) of 36 seconds (95% confidence interval [CI]: 19 to 53 seconds, P < 0.001) for treadmill walking time and 13 seconds (95% CI: 2 to 24 seconds, P = 0.02) for static back extension. In addition, regular walking favorably affected body composition, including reductions in weight of 1.4 kg (95% CI: 0.6 to 2.1 kg, P < 0.001), in waist circumference of 2.2 cm (95% CI: 1.0 to 3.3 cm, P < 0.001), and in abdominal skin fold thickness of 2.2 cm (95% CI: 0.9 to 3.4 cm, P = 0.001). Golfers also had significantly greater increases in serum high-density lipoprotein (HDL) cholesterol levels and in the ratio of HDL cholesterol to total cholesterol.
      CONCLUSIONS: Regular walking had many positive effects on the health and fitness of sedentary middle-aged men. Walking during a golf game is characterized by high adherence and low risk of injury and is therefore a good form of health-enhancing physical activity.
      Regular exercise and related fitness enhances health (
      • Hakim A
      • Petrovitch H
      • Burchfiel C
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      Effects of walking on mortality among nonsmoking retired men.
      ,
      • Lee I
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      Exercise intensity and longevity in men the Harvard alumni health study.
      ,
      • Erikssen G
      • Liestol K
      • Bjornholt J
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      Changes in physical fitness and changes in mortality.
      ,
      • Shephard R.J
      What is the optimal type of physical activity to enhance health?.
      ,
      • Morris J.N
      • Hardman A.E
      Walking to health.
      ), including decreasing the risks of coronary heart disease (
      • Berlin J.A
      • Colditz G.A
      A meta-analysis of physical activity in the prevention of coronary heart disease.
      ,
      • Ekelund L.G
      • Haskell W.L
      • Johnson J.L
      • et al.
      Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men the Lipid Research Clinics Mortality Follow-up Study.
      ,
      • Leon A.S
      • Connet J
      • Jacobs D.R
      • Rauramaa R
      Leisure-time physical activity levels and risk of coronary heart disease and death the Multiple Risk Factor Intervention Trial.
      ), hypertension (

      Hagberg JM. Exercise, fitness and hypertension. In: Boughard C, Shephard RJ, Stephens T, et al, eds. Exercise, Fitness, and Health: A Consensus of Current Knowledge. Champaign, Ill: Human Kinetics; 1990:455–466.

      ), noninsulin-dependent diabetes mellitus (
      • Helmrich S.P
      • Ragland D.R
      • Leung R.W
      • Paffenbarger Jr, R.S
      Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus.
      ), colon cancer (
      • Lee I.-M
      • Paffenbarger Jr, R.S
      • Hsieh C.-C
      Physical activity and risk of developing colorectal cancer among college alumni.
      ), and overall mortality (
      • Hakim A
      • Petrovitch H
      • Burchfiel C
      • et al.
      Effects of walking on mortality among nonsmoking retired men.
      ,
      • Lee I
      • Hsieh C
      • Paffenbarger R
      Exercise intensity and longevity in men the Harvard alumni health study.
      ,
      • Erikssen G
      • Liestol K
      • Bjornholt J
      • et al.
      Changes in physical fitness and changes in mortality.
      ,
      • Paffenbarger Jr, R.S
      • Hyde R.T
      • Wing A.L
      • et al.
      The association of changes in physical-activity level and other life-style characteristics with mortality among men.
      ,
      • Blair S.N
      • Kohl H.W
      • Barlow C.E
      • et al.
      Changes in physical fitness and all-cause mortality a prospective study of healthy and unhealthy men.
      ). In addition, regular exercise may prevent osteoporotic fractures by preventing both osteoporosis and falls (
      • Kannus P
      Preventing osteoporosis, falls, and fractures among elderly people. Promotion of lifelong physical activity is essential.
      ).
      Walking is a rhythmic, dynamic, and aerobic activity of large muscles that confers many benefits with minimal adverse effects (
      • Morris J.N
      • Hardman A.E
      Walking to health.
      ). Golf is a social and pleasurable form of activity that includes long bouts of low- to moderate-intensity walking and it can be enjoyed by all age groups and by both sexes. Although the amount of walking during a golf game depends on the golf course and the player’s skills, the estimated distance walked per round is about 7 km (
      • Palank E
      • Hargreaves E
      The benefits of walking the golf course.
      ). The intensity of walking during golf depends on the pace of the game, the softness and slopes of the terrain, and the weight of the clubs that a player carries or pulls (
      • Magnusson G
      Golf exercise for fitness and health.
      ).
      Despite the increasing popularity of golf, its health benefits have not been studied in a controlled manner. The hypothesis of this study was that regular walking on a golf course is a feasible and safe form of recreational physical activity that has favorable effects on the health and fitness of previously sedentary middle-aged men.

      Methods

      Subject selection

      Study subjects were recruited through announcements in the local newspaper and golf clubs. Golfers were advised to ask coworkers to act as control subjects. To be included, subjects and controls were required to be previously healthy 45- to 65-year-old men with no diseases or disabilities that precluded exercise training. Regular use of medication, smoking, or physical exercise more than once a week during the 7-month period before the study (October to April) were also exclusion criteria. Of the 123 volunteers (62 golfers and 61 controls), the baseline medical screening examination excluded 13 persons (7 golfers and 6 controls) because of a greater than allowed body mass index (>32 kg/m2), diastolic blood pressure (>105 mm Hg), or total serum cholesterol level (>8 mmol/L). Thus, 55 male golfers and their 55 age-matched (± 1 year) controls started the study.
      The study was approved by the ethics committee of the Urho Kaleva Kekkonen (UKK) Institute, and all study subjects gave informed consent. Measurements of body composition, cardiorespiratory fitness, motor and musculoskeletal fitness, blood pressure, and serum lipid, glucose, and insulin levels were obtained at baseline and after the 20-week study.

      Measurements

      Body weight and height were measured in light clothing without shoes. Body mass index was calculated by dividing weight (kg) by the square of height (m). We measured waist circumference halfway between the lowest rib and the iliac crest, hip circumference at the level of the greater trochanters, and upper-arm circumference at the midpoint of the humerus. Thickness of fat tissue was measured on the right iliac crest as well as on the triceps muscle at the midpoint of the right humerus.
      Blood pressure at rest was measured in triplicate in the supine position on 2 separate days. The same trained nurse made all measurements using a mercury sphygmomanometer. The means of the six readings of the systolic and diastolic blood pressures were used.
      Maximal aerobic performance was determined during an uphill walk on a treadmill (Telineyhtymä Oy, Kotka, Finland). The test protocol was designed for golfers according to the heart rate and metabolic responses reported during a golf game (
      • Murase Y
      • Kamei S
      • Hoshikawa T
      Heart rate and metabolic responses to participation in golf.
      ). In each test, the subjects were familiarized with the treadmill by walking for 4 minutes at 2 km/h (0% inclination) without gripping the handrails. After the warm-up, the mouthpiece, nose clip, and head harness were fitted. Standard instructions for obtaining the subject’s rating of perceived exertion using the original (6- to 20-point) Borg scale (
      • Borg G
      Perceived exertion as an indicator of somatic stress.
      ) were also given. The subjects performed the following 3-minute stages: stage I (3 metabolic equivalents [METs], 4.3 km/h, 0% inclination), stage II (4 METs, 4.3 km/h, 3% inclination), stage III (5 METs, 5.5 km/h, 3% inclination), stage IV (6 METs, 6.0 km/h, 3% inclination), and stage V (7 METs, 6.0 km/h, 4% inclination). One MET approximates the resting metabolic rate that corresponds with an oxygen consumption of about 3.5 mL per kg per minute (
      • Shephard R.J
      What is the optimal type of physical activity to enhance health?.
      ). After stage V, the mouth piece and nose clip were removed and subjects continued with the 1 MET per minute protocol until fatigued. The maximal oxygen consumption was calculated from the four directly measured submaximal (stages II to V) rates of consumption and heart-rate pairs using linear regression analysis, with extrapolation of the regression line to the measured maximal heart rate, defined as the highest heart rate obtained during the exercise test. Walking time to exhaustion (treadmill time) was the time at which the test was terminated by the subject.
      During the exercise test, a metabolic analyzer (Metabolic Measurement Cart 2900Z; Sensor Medics Corp., Anaheim, California) was used to collect and analyze expired air. Metabolic data were collected every 20 seconds. The gas analyzers were calibrated immediately before each test using standard calibration gases. An electrocardiogram (ECG; Case 12; Marquette Electronics Inc., Milwaukee, Wisconsin) was monitored continuously. A fingertip blood sample was taken for lactate analysis after the levels of 4 and 7 METs and immediately after cessation of exercise. All tests were supervised by the study physician.
      Static balance (one-leg standing for the assessment of static postural control) was measured first, followed by dynamic balance (timed backward tandem-walk test over a 6-m course), flexibility (trunk side-bending), shoulder-neck mobility, upper-body strength (modified pushups), and trunk muscular endurance (static back extension). The reliability and feasibility of these measurements have been reported (
      • Suni J
      • Oja P
      • Laukkanen R
      • et al.
      Health-related fitness test battery for adults. Aspects of reliability.
      ,
      • Suni J
      • Oja P
      • Miilunpalo S
      • et al.
      Health-related fitness test battery for adults associations with perceived health, mobility, and back function and symptoms.
      ,
      • Nelson M.E
      • Fiatarone M.A
      • Morganti C.M
      • et al.
      Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures.
      ,
      • Suni J
      • Miilunpalo S
      • Asikainen T
      • et al.
      Safety and feasibility of a health related fitness test battery for adults.
      ).
      Blood samples were taken after a 12-hour overnight fast. Subjects were told to refrain from physical exercise and alcohol consumption for 48 hours before sampling. Samples for serum lipid levels were taken twice (separated by a 1-week interval), and the mean values were used. Serum cholesterol and triglyceride levels were analyzed from frozen samples by enzymatic methods (CHOD-PAP for cholesterol and GPO-PAP for triglycerides; Boehringer Mannheim, Mannheim, Germany). High-density lipoprotein (HDL) cholesterol levels were determined by dextran sulfate precipitation. Lactate determinations were done by enzymatic method with deproteinization (Lactate MPR1; Boehringer Mannheim, Mannheim, Germany) using a Shimadzu CL-720 spectrophotometer (Shimadzu Corporation, Kyoto, Japan).

      Training prescription

      At the beginning of the intervention, the golfers were instructed to play an 18-hole round of golf twice a week and to walk rather than ride a cart, throughout the 20-week golfing season in Finland from May to September. The control subjects were instructed to continue their sedentary lifestyle, but to do their normal summer season activities such as gardening and home repair. Both groups kept a physical activity diary during the study. The golfers were advised to monitor their heart rate and energy expenditure (Polar Smart Edge; Polar Electro Oy, Kempele, Finland) during golf, and to use a pedometer (Fitty-3; Kasper & Richter, Uttenreuth, Germany) to count the number of steps they took, and, based on stride length, to estimate the distance walked. Additionally, the heart rate of each golfer was recorded continuously during one round of golf in midseason to determine the intensity of exercise (Polar PE 3000 Sport Tester; Polar Electro Oy, Kempele, Finland).
      The training group recorded all possible golf-related injuries, defined as any traumatic or overuse injury occurring during a golf game or practice that made the player unable to participate in the following session of golf. The injury rate was expressed as the number of injuries per 1,000 hours of golf.
      Current dietary intake was estimated on the basis of complete 3-day (including 1 weekend day) food diaries at the beginning and end of the study. Subjects were given oral and written instructions for calculating their food intake with household measures. Food composition data were calculated with MicroNutrica software (Social Insurance Institution, Helsinki, Finland) (

      Rastas M, Seppänen R, Knuts L-R, et al, eds. Nutrient Composition of Foods. Helsinki: Publications of the Social Insurance Institution, Finland; 1993.

      ).

      Statistical analysis

      Based on the assumption of a 5% absolute mean difference in the between-group change in maximal oxygen consumption, at an alpha of 0.01, a power of 80%, and a standard deviation (SD) of change of 7.5%, we estimated that a sample size of 53 subjects per group was needed.
      Continuous results are presented as means ± SD. An analysis of covariance, with baseline values as covariates, was used to estimate the training effects, defined as the difference between the training and control group at the follow-up, adjusted for baseline values. We also estimated 95% confidence intervals (CI) for these differences.

      Results

      Subjects assigned to the golfing intervention and control subjects had generally similar characteristics at baseline (Table 1). Two golfers and 2 controls did not complete the study. One golfer developed ventricular tachycardia during exercise testing, and the other golfer had worsening of previous osteoarthritis of the knee during the intervention. One of the controls became seriously ill during the trial, and the other moved from the city.
      Table 1Baseline Characteristics of the Study Subjects
      HDL = high-density lipoprotein; LDL = low-density lipoprotein; MET = metabolic equivalent.
      CharacteristicTraining Group (n = 55)Control Group (n = 55)P Value
      Mean ± SD
      Age (years)55 ± 455 ± 40.96
      Weight (kg)83 ± 1084 ± 110.67
      Body mass index (kg/m2)26 ± 327 ± 30.16
      Systolic blood pressure (mm Hg)128 ± 13129 ± 120.90
      Diastolic blood pressure (mm Hg)82 ± 880 ± 70.18
      Serum cholesterol (mmol/L)5.9 ± 0.95.6 ± 1.00.07
      Serum triglycerides (mmol/L)1.7 ± 1.41.6 ± .090.98
      LDL cholesterol (mmol/L)3.9 ± 0.93.7 ± 0.90.11
      HDL cholesterol (mmol/L)1.3 ± 0.31.2 ± 0.30.20
      HDL/cholesterol (%)23 ± 723 ± 60.88
      Treadmill time (min)21.8 ± 1.521.3 ± 1.20.04
      Oxygen consumption at 7 MET (L/min)
      Submaximal level; 7 METs is an oxygen consumption of about 24.5 mL/kg/min.
      1.85 ± 0.231.87 ± 0.260.56
      Heart rate at 7 METs (beats/min)128 ± 12132 ± 140.11
      Serum lactate at 7 METs (mmol/L)1.85 ± 0.672.22 ± 0.840.01
      Maximal heart rate177 ± 10177 ± 120.97
      Maximal oxygen consumption (L/min)3.0 ± 0.63.0 ± 0.70.93
      Submaximal level; 7 METs is an oxygen consumption of about 24.5 mL/kg/min.
      legend HDL = high-density lipoprotein; LDL = low-density lipoprotein; MET = metabolic equivalent.
      Reported training compliance was very good. The golfers played a mean average of 2.5 ± 1.1 rounds of golf per week, corresponding to 10 ± 4 hours per week, during the 20-week study. Heart rates during golf varied from 50 to 160 beats per minute (Figure 1). The mean heart rate during golf was 104 ± 16 beats per minute, corresponding to 59% ± 8% of the measured maximal heart rate and 46% ± 8% of the maximal oxygen consumption. There was a modest trend for heart rates to increase during the round of golf (Figure 1). The mean distance walked during one round of golf was 8,212 ± 447 m, corresponding with an energy expenditure of 1,759 ± 176 kcal. Participation in other summer activities did not differ between the golfers and the controls. Physical activity diaries disclosed that neither group engaged in other forms of strenuous activity.
      Figure thumbnail GR1
      Figure 1Effects of a 4-hour golf game in 38 middle-aged male golfers on heart rate, as a percent of maximal heart rate.

      Effects on body composition, fitness, and serum lipid levels

      Consistent and favorable changes in the body composition of the golfers were observed during the 20-week study (Figure 2). The mean weight of the golfers decreased by 1.4 kg (95% CI: 0.6 to 2.1 kg, P < 0.001) more than in the control subjects. Similar between-group differences were also seen for body mass index (−0.4 kg/m2, 95% CI: −0.2 to −0.7 kg/m2, P < 0.001), waist circumference (−2.2 cm, 95% CI: −1.0 to −3.3 cm, P < 0.001), waist-to-hip ratio (−1.3%, 95% CI: −0.5 to −2.1%, P = 0.002), abdominal skin fold thickness (−2.2 cm, 95% CI: −0.9 to −3.4 cm, P = 0.001), and triceps skin fold thickness (−0.7 cm, 95% CI: −0.3 to −1.1 cm, P = 0.001). Adjusted mean daily energy intake of the controls was 171 kcal (95% CI: 15 to 327 kcal, P = 0.03) lower than that of the golfers at the end of the study. Golfers’ energy intake did not change significantly during the intervention (P = 0.38).
      Figure thumbnail GR2
      Figure 2Percentage changes in the body composition of the 51 golfers and 52 controls who completed the 20-week study in whom measurements of body composition were available. Bars represent 95% confidence intervals. All the between-group differences were statistically significant (P < 0.01).
      The maximum heart rates during the baseline and follow-up treadmill tests were similar in both groups (Table 1, Table 2). During the 20-week study, mean treadmill time increased slightly in the golfers and decreased slightly in the control subjects; the difference in the between-group change in mean treadmill time was 36 seconds (95% CI: 19 to 53 seconds, P < 0.001). Similar benefits were also seen for the submaximal measurements of aerobic fitness, but not for maximum oxygen consumption (Table 2).
      Table 2Follow-up (20 weeks) Values and Training Effects on Cardiorespiratory Fitness
      MeasurementValues at Follow-upTraining Effects
      Posttraining difference between training and control groups, adjusted for baseline values.
      Training Group (n = 53)Control Group (n = 53)Adjusted Mean Difference (95% Confidence Interval)P Value
      Mean ± SD
      Treadmill time (min)22.0 ± 1.521.0 ± 1.30.6 (0.3 to 0.9)<0.001
      Oxygen consumption at 7 METs (L/min)
      Submaximal level; 7 METs is an oxygen consumption of about 24.5 mL/kg per minute.
      1.77 ± 0.261.86 ± 0.30−0.08 (−0.16 to 0.00)0.05
      Heart rate at 7 METs (beats/min)125 ± 12132 ± 14−4.6 (−7.9 to −1.3)0.01
      Serum lactate at 7 METs (mmol/L)1.58 ± 0.642.19 ± 0.78−0.33 (−0.50 to −0.15)<0.001
      Maximal heart rate177 ± 9176 ± 121 (−1 to 3)0.38
      Maximum oxygen consumption (L/min)2.97 ± 0.682.85 ± 0.610.13 (−0.07 to 0.32)0.20
      Posttraining difference between training and control groups, adjusted for baseline values.
      Submaximal level; 7 METs is an oxygen consumption of about 24.5 mL/kg per minute.
      Mean blood pressure was similar in both groups at baseline (Table 1), as well as at the end of the study (golfers 127 ± 12/82 ± 7 mm Hg; controls 128 ± 11/82 ± 8 mm Hg; P = 0.63 for systolic blood pressure and P = 0.80 for diastolic blood pressure). In a posthoc analysis of the study subjects (26 golfers and 26 controls) with the highest blood pressures, there was a trend toward a benefit of the intervention in reducing the diastolic blood pressure (between-group differences of −3 mm Hg, 95% CI: 0 to −5 mm Hg, P = 0.03).
      After the 20-week study, the golfers had statistically greater increases in HDL cholesterol levels and the ratio of HDL cholesterol to total cholesterol (Table 3).
      Table 3Follow-up Values (20 weeks) and Training Effects on Serum Lipid Levels
      HDL = high-density lipoprotein; LDL = low-density lipoprotein.
      MeasurementValues at Follow-upTraining Effects
      Posttraining difference between training and control groups adjusted for baseline values.
      Training Group (n = 53)Control Group (n = 53)Adjusted Mean Difference (95% Confidence Interval)P Value
      Mean ± SD
      Cholesterol (mmol/L)5.7 ± 0.85.6 ± 0.9−0.07 (−0.25 to 0.10)0.41
      Triglycerides (mmol/L)1.4 ± 0.71.6 ± 0.7−0.14 (−0.31 to 0.04)0.12
      LDL cholesterol (mmol/L)3.7 ± 0.73.6 ± 0.8−0.12 (−0.28 to 0.03)0.12
      HDL cholesterol (mmol/L)1.4 ± 0.41.3 ± 0.30.05 (0.00 to 0.10)0.05
      HDL/cholesterol (%)24 ± 723 ± 71.2 (0.2 to 2.2)0.02
      Posttraining difference between training and control groups adjusted for baseline values.
      legend HDL = high-density lipoprotein; LDL = low-density lipoprotein.

      Musculoskeletal performance and injuries

      There were no significant differences in the changes in static or dynamic balance, flexibility, shoulder-neck mobility, and upper-body strength tests between the two groups. However, the mean maximum static back-extension time improved among the golfers (from 93 to 101 seconds), whereas in controls this time decreased from 91 to 89 seconds; the net difference was 13 seconds (95% CI: 2 to 24 seconds, P = 0.02).
      During the 20-week study period, the golfers sustained 4 injuries (0.3 per 1,000 playing-hours). One injury was due to an acute trauma to the elbow, and the remaining 3 consisted of 2 overuse injuries of the back and 1 of the hip.

      Discussion

      We explored the effects of regular walking on a golf course on several indicators of health and fitness in middle-aged men and observed favorable effects on body composition, cardiorespiratory performance, trunk muscle endurance, and HDL cholesterol levels. Walking during a golf game was found to be a practical and safe form of physical activity for these previously sedentary men. The major strengths of the study were the very good compliance with the intervention and the low drop-out rate (only 4 of 110 subjects). The selected outcome measures were validated and reliable, and the measurements were done by trained and experienced personnel.
      The study also had some limitations. First, randomization could not be done because of the nature of the intervention: it was not possible to randomly assign some of the regular golf players to “no golf” for an entire season. However, the golfers and control subjects were age and sex matched, had similar health and socioeconomic backgrounds, and had similarly sedentary lifestyles during the 7 months before the intervention. Second, the golf season in Finland is shorter than in many other countries, making our follow-up time relatively short (20 weeks). Thus, our results may underestimate the health effects of walking during golf for middle-aged men who play a similar amount of golf for longer periods of time.
      Several recent studies suggest that the fitness and health of sedentary adults can be improved through adoption of low levels of leisure activity, because the largest health gains are achieved when someone progresses from the lowest to a slightly greater level of physical activity or physical fitness (
      • Erikssen G
      • Liestol K
      • Bjornholt J
      • et al.
      Changes in physical fitness and changes in mortality.
      ,
      • Shephard R.J
      What is the optimal type of physical activity to enhance health?.
      ,
      • Ekelund L.G
      • Haskell W.L
      • Johnson J.L
      • et al.
      Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men the Lipid Research Clinics Mortality Follow-up Study.
      ,
      • Leon A.S
      • Connet J
      • Jacobs D.R
      • Rauramaa R
      Leisure-time physical activity levels and risk of coronary heart disease and death the Multiple Risk Factor Intervention Trial.
      ,
      • Blair S.N
      • Kohl H.W
      • Barlow C.E
      • et al.
      Changes in physical fitness and all-cause mortality a prospective study of healthy and unhealthy men.
      ,
      • Blair S.N
      • Connelly J.C
      How much physical activity should we do? The case for moderate amounts and intensities of physical activity.
      ). Golf is a low- to moderate-intensity exercise that can be engaged in regularly and thus fulfills criteria for health-enhancing physical activity (

      Physical Activity, and Health. A Report of the Surgeon General. Atlanta, Ga: US Department of Health and Human Services; 1996.

      ). Current recommendations are for exercise that consumes about 3 to 5 METs (4.5 to 6.5 kcal/min, depending on age and fitness). In the present study, the energy expenditure of golf was about 4 METs. This led to the favorable effects on body composition and was sufficient to improve aerobic endurance and HDL cholesterol levels among healthy sedentary middle-aged men. Although previous studies suggest that vigorous exercise is required to gain sufficient stimulus to improve aerobic fitness, a more valuable physiologic goal for most people is greater endurance (
      • Shephard R.J
      What is the optimal type of physical activity to enhance health?.
      ,
      • Morris J.N
      • Hardman A.E
      Walking to health.
      ,
      • Blair S.N
      • Connelly J.C
      How much physical activity should we do? The case for moderate amounts and intensities of physical activity.
      ), so that submaximal levels of activity can be sustained without fatigue, uncomfortably rapid heart rate or breathing, or sore muscles.
      In previous studies, walking has not usually been reported to increase muscle strength (
      • Shephard R.J
      What is the optimal type of physical activity to enhance health?.
      ,
      • Morris J.N
      • Hardman A.E
      Walking to health.
      ), but it may have important functional gains in the elderly (
      • Frändin K
      • Grimby G
      • Mellström D
      • Svanborg A
      Walking habits and health-related factors in a 70-year-old population.
      ). We found that regular golf increases trunk muscle endurance, which in turn might reduce lower back problems (
      • Suni J
      • Oja P
      • Miilunpalo S
      • et al.
      Health-related fitness test battery for adults associations with perceived health, mobility, and back function and symptoms.
      ). In elderly golfers, walking may reduce the frequency of generalized weakness, thereby lessening the risk of falls and fractures (
      • Cummings S.R
      • Nevitt M.C
      • Browner W.S
      • et al.
      Risk factors for hip fracture in white women.
      ,
      • Dargen-Molina P
      • Favier F
      • Grandjean H
      • et al.
      Fall-related factors, and risk of hip fracture. The EPIDOS prospective study.
      ). Regular walking during golf may also maintain or improve neuromuscular coordination.
      The amount, rather than the intensity, of exercise might have more important effects on body adiposity and blood lipid levels (
      • Oja P
      • Mänttäri A
      • Heinonen A
      • et al.
      Physiological effects of walking and cycling to work.
      ,
      • Wood P.D
      • Haskell W.L
      • Blair S.N
      • et al.
      Increased exercise level and plasma lipoprotein alterations a one-year randomized controlled study in sedentary middle-aged men.
      ,
      • Ballor D.L
      • Keesey R.A
      A meta-analysis of the factors affecting exercise-induced changed in body mass, fat mass and fat-free mass in males and females.
      ,
      • Duncan J.J
      • Gordon N.F
      • Scott C.B
      Women walking for health and fitness how much is enough?.
      ). In the present study, golfers walked with a relatively low intensity (about half of maximal oxygen consumption) for 15 to 20 km per week, and significant benefits were seen for body composition. Measurements of skin fold thickness suggested that the weight loss seen in the golfing group was due to loss of fat tissue. Dattilo and Kris-Etherton (
      • Dattilo A.M
      • Kris-Etherton P.M
      Effects of weight reduction on blood lipids and lipoproteins a meta-analysis.
      ) estimated that a 1-kg reduction in weight leads to a 1% reduction in serum total and LDL cholesterol levels and a 1% rise in the serum HDL cholesterol level, consistent with what we observed. Our findings also support those from other studies that have found that walking improves HDL cholesterol levels (
      • Oja P
      • Mänttäri A
      • Heinonen A
      • et al.
      Physiological effects of walking and cycling to work.
      ,

      Ward A, Morris DH, Porcari JP, et al. Effects of walking and/or low fat diet on total cholesterol and HDL cholesterol and risk ratio. Circulation. 1989;80(suppl II):509.

      ,
      • Tucker L.A
      • Friedman G.M
      Walking and serum cholesterol in adults.
      ). The effects of walking on total and LDL cholesterol levels are less consistent (
      • Palank E
      • Hargreaves E
      The benefits of walking the golf course.
      ,
      • Duncan J.J
      • Gordon N.F
      • Scott C.B
      Women walking for health and fitness how much is enough?.
      ,
      • Leon A.S
      • Conrad J
      • Hunninghake D.B
      • Serfass R
      Effects of a vigorous walking program on body composition, and carbohydrate and lipid metabolism of obese young men.
      ,
      • Kukkonen-Harjula K
      • Laukkanen R
      • Vuori I
      • et al.
      Effects of walking training on health-related fitness in healthy middle-aged adults—a randomized controlled study.
      ). Palank and Hargreaves (
      • Palank E
      • Hargreaves E
      The benefits of walking the golf course.
      ) studied the effect of a 4-month period of golf on 28 male golfers and 16 nongolfing controls and observed a significant decrease in the LDL cholesterol level and increase in the ratio of HDL cholesterol to total cholesterol among the golfers.
      Previous reports of the effects of walking on blood pressure have given inconsistent results and indicate that the largest benefits might be seen on hypertensive and overweight persons (
      • Paffenbarger R.S
      • Wing A.L
      • Hyde R.T
      • Jung D.L
      Physical activity and incidence of hypertension in college alumni.
      ,
      • Cononie C.C
      • Graves J.E
      • Pollock M.L
      • et al.
      Effect of exercise training on blood pressure in 70- to79-yr-old men and women.
      ). Our analysis of the study subjects with the highest blood pressures supports this hypothesis.
      The injury rate that we observed was extremely low (about 0.3 injuries per 1,000 playing-hours), especially as compared with many other activities (
      • Jørgensen U
      The epidemiology of sports injuries in Denmark a prospective individual injury registration.
      ,
      • de Loës M
      • Goldie I
      Incidence rate of injuries during sport activity and physical exercise in a rural Swedish municipality incidence rates in 17 sports.
      ). Jørgensen (
      • Jørgensen U
      The epidemiology of sports injuries in Denmark a prospective individual injury registration.
      ) reported about 4 injuries per 1,000 playing-hours in football, and about 3 per 1,000 playing-hours for volleyball, badminton, and tennis. Golf seems to be an almost risk-free form of exercise for middle-aged men.
      That the baseline measurements were similar in both groups gives evidence that the favorable health effects of a golf season may not persist during the subsequent 7 nongolfing months (October to April in Finland) if a sedentary lifestyle is resumed. For this reason, the UKK Institute and the Finnish Golf Association have started a national Health Enhancing Golf Program to keep Finnish golfers active during the off-season.
      In conclusion, we showed that regular walking has favorable effects on many health and fitness indicators of middle-aged men. Walking during golf is a safe form of exercise with high adherence and can be recommended as an appropriate form of health-enhancing physical activity.

      Acknowledgements

      We thank the study subjects, the personnel of the UKK Institute, and the Finnish Golf Association and its workgroup for the Health Enhancing Golf Program.

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