alvina


173

ABSTRACT

Sedentary lifestyle gives rise to important health problems in the world, such as
cardiovascular disorders and hypertension. Hypertension is an important
modifiable risk factor for cardiovascular disease and is the most significant risk
factor for stroke. There is mounting evidence that physical activity is beneficial
for the elderly, and may have positive effects on chronic disorders, such as
hypertension. The purpose of the present study was to assess the effectiveness
of physical activity for reducing hypertension and the healthcare costs of
hypertension in the elderly. This cross-sectional study, conducted from August
to October 2009, involved 237 community-dwelling elderly in one district of
South Jakarta, comprising 86 males and 151 females aged 66.4 ± 6.3 years. Data
on background characteristics were collected using a validated questionnaire,
while physical activity was assessed using the short version of the International
Physical Activity Questionnaire. Results showed that 32.9% elderly was
physically active and 67.1 % less physically active. The overall prevalence of
hypertension was 18.6%, while there was no significant difference of
hypertension between male and female elderly (p=0.737). The risk for
hypertension in the physically active group was 0.40 times lower than that in the
less physically active group (OR = 0.40; 95% C.I. 0.16 – 0.97), leading to annual
healthcare cost savings in the physically active group of 60%. In conclusion,
physical activity reduces hypertension and the associated healthcare expenditure
among community-dwelling elderly.

Key words : Physical activity, hypertension, cost-effectiveness analysis, elderly

*Department of Anatomy
Pathology, Faculty of Medicine.
Trisakti University
**Department of Community
Medicine, Faculty of Medicine,
Trisakti University

Correspondence
Dr. Robert D. Gandasentana, dr,
MS
Department of Anatomy
Pathology,
Medical Faculty,
Trisakti University
Jalan Kyai Tapa  no. 260, Grogol
Jakarta Barat – 11440
Phone: 021-5672731 ext.2703
Email: robsentana@yahoo.com

Univ Med 2011;30:173-81

Physical activity reduced hypertension in
the elderly and cost-effective

September-December, 2011September-December, 2011September-December, 2011September-December, 2011September-December, 2011       Vol.30 - No.3      Vol.30 - No.3      Vol.30 - No.3      Vol.30 - No.3      Vol.30 - No.3

UNIVERSA MEDICINA

Robert D. Gandasentana* and Rina K. Kusumaratna**

INTRODUCTION

The aging individual is subject to a
reduction in musculoskeletal mass, which is
largely due to physical inactivity, as most elderly
are commonly unemployed or retired and

generally pay less attention to their physical
health. In addition, the elderly frequently suffer
f r o m  c h r o n i c  d i s e a s e s ,  p a r t i c u l a r l y
h y p e r t e n s i o n  a n d  o t h e r  c a r d i o v a s c u l a r
disorders. A World Health Organization (WHO)
report estimated that 80% of adults aged 65



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Gandasentana, Kusumaratna                                                                               Physical activity reduced hypertension in elderly

years and older has more than one chronic health
condition and that 50% has more than two
chronic health conditions.(1) Hypertension is an
independent and powerful prognostic indicator
for cardiovascular and renal disease, whereas
it is significantly associated with the increased
morbidity and mortality from cerebrovascular
disease, myocardial infarction, congestive heart
failure and renal insufficiency.(2,3) Arterial
hypertension is highly prevalent in the elderly,
and according to the National Health and
Nutrition Examination Survey III Study, its
prevalence rate for subjects >60 years old (white
non-Spanish speaking Americans) is estimated
to be >60%. (4) H y p e r t e n s i o n  p r e v a l e n c e
increases with advancing age and is higher in
men than in women until the age of 55 years,
but is slightly higher in postmenopausal
women.(5) Hypertension is the major risk factor
for stroke, heart failure, and coronary artery
disease in older adults, while all of these
disorders are important contributors to mortality
and functional disability. Hypertension is defined
as a systolic blood pressure of 140 mmHg or
greater and/or a diastolic blood pressure of 90
mmHg or greater. Isolated systolic hypertension
is defined as a systolic pressure of 140 mmHg
or greater with a diastolic pressure of less than
90 mmHg.(6) According to the most recent
National American Guidelines for Hypertension,
values of 120-139 mm Hg and 80-89 mmHg,
for systolic and diastolic blood pressure
respectively, are characterized as a precursor
stage of hypertension, since these values are
b e i n g  a s s o c i a t e d  w i t h  i n c r e a s e d  r i s k  o f
hypertension development compared to lower
values of arterial pressure.(7) Sedentary lifestyle
is a major risk factor for cardiovascular disease
and being physically active reduces risk by
40%.(8)

Several studies support the important role of
physical activity for both primary and secondary
prevention of cardiovascular diseases,(9) and
according to epidemiological evidence there exist
positive associations between regular physical
activity and health benefits. (10) The WHO

recommends at least 30 minutes of regular,
moderate-intensity physical activity on most days
of the week to reduce the risk of diseases.(10)

To change physical activity behavior and
promote regular physical exercise among
community-dwelling elderly, there is a need for
cost-effectiveness analyses using standardized
methods to determine the costs and benefits of
participation in physical activity.(11)

Outside of Indonesia, a large number of
interventions have been conducted to promote
physical activity, ranging from individual
counseling by general practitioners to mass-
media campaigns. The cost-effectiveness of
several interventions have been evaluated using
v a r i o u s  m e t h o d o l o g i e s .  C o b i a c  e t  a l . (8)

performed cost-effectiveness analyses on six
intervention programs, and concluded that all six
could lead to substantial improvement in
population health at a cost saving to the health
sector.

Cobiac and colleagues modelled the costs
a n d  h e a l t h  o u t c o m e s  a s s o c i a t e d  w i t h
interventions to improve physical activity in the
population, and identify specific interventions
that are likely to be cost-saving. Rubinstein et
al. (12) used generalized cost-effectiveness
(GCE) analysis, a WHO-designed methodology,
to evaluate a CVD reduction intervention
package in Buenos Aires.

D e s p i t e  t h e  h i g h  p r e v a l e n c e  o f
hypertension in older adults, it should not be
considered a normal consequence of aging.
Primary hypertension is the result of multiple
c o n d i t i o n s ,  s u c h  a s  g e n e t i c ,  n u t r i t i o n a l ,
psychosocial, and life style factors. One of the
life style factors leading to hypertension is
obesity, which is usually related to a sedentary
life style and inadequate physical activity.
Therefore one way to prevent hypertension or
at least decrease the risk of hypertension is to
perform habitual physical activity (exercise),
including work-related activity and activities of
daily living.

In general, cost-effectiveness analysis has
been used by governments and international



175

organizations for analyzing the efficiency of
alternative programs, including healthcare
intervention programs, such as promotion of
physical activity among population groups.

H o w e v e r,  t h e  p r i n c i p l e s  o f  c o s t -
effectiveness analysis are presumably universal,
and may therefore be applied at the level of the
individual, especially where large healthcare
expenditures are to be borne by the individual
concerned. This is particularly true for most of
the middle- to low-income groups of Indonesian
elderly, as many, if not all, of them have no health
insurance cover, apart from free but extremely
restricted health insurance for the poorest,
provided by the provincial governments.

In view of the foregoing, the aim of the
p r e s e n t  s t u d y  w a s  t o  c o n d u c t  a  c o s t
effectiveness analysis of physical activity in
relation to primary hypertension in community-
dwelling elderly, in order to provide evidence of
the economic benefits of physical activity in
hypertensive individuals.

METHODS

Research design
The study was an observational cross-

s e c t i o n a l  s t u d y  t o  d e t e r m i n e  t h e  c o s t -
effectiveness of physical activity among
community-dwelling elderly with hypertension,
conducted from August to October 2009.

Study subjects
The population under study comprised

community-dwelling elderly residing in the
vicinity of a primary community health center in
South Jakarta. Inclusion criteria were: age 60
years and older, male or female gender, mobile
and independent, able to verbally communicate,
and apparently healthy. The participants’ health
status was determined by self-reported medical
history and by physical examination during
recruitment, and cross-checked with their
medical record at the heath center. The sample
size was determined to be around 229 subjects,
based on a power of 95% and expected dropout

of 20%. The subjects were recruited from a
district in South Jakarta with a relatively high
number of elderly persons of low to medium
socioeconomic status among the permanent
residents, as indicated by official data from
the District Health Office (Sudinkes). Cluster
random sampling was used to determine the
participating villages in the district and the
numbers of hamlets (RW) and RT required to
yield the calculated sample size. In Indonesia,
RTs are the smallest administrative units
comprising around 20 households, similar to
neighborhood associations. The study sample
consisted of community dwelling elderly selected
from each RT in five villages by proportionate
simple random sampling. The subjects meeting
the inclusion and exclusion criteria gave written
informed consent, confirmed by signature for the
literate and by thumbprint for the illiterate.

Physical activity assessment
Physical activity among the participants

was evaluated by a modification of the Short
F o r m a t  I n t e r n a t i o n a l  P h y s i c a l  A c t i v i t y
Questionnaire (SF-IPAQ), recommended by the
WHO to measure physical activity among adults
from 15–69 years.(13) As a consequence, this
study could assess only the physical activity
status of elderly aged 60–69 years. The 9-item
short form assesses time spent on different
activities. The short form of IPAQ records four
types of physical activity: vigorous activity such
as aerobics; moderate-intensity activity such
as leisure cycling; walking; and sitting. The
IPAQ-SF contains questions on the frequency
(number of days per week), duration (total time
spent in physical activity per day), and intensity
of physical activity over the previous week
( l i g h t ,  m o d e r a t e ,  a n d  v i g o r o u s ) .  A f t e r
assessment of physical activity, the subjects
were assigned to two groups, i.e. one group
with moderate to high levels of physical activity,
and one group with low levels of physical
activity, designated in the present study as the
physically active group and the less physically
active group, respectively.

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Gandasentana, Kusumaratna                                                                               Physical activity reduced hypertension in elderly

Blood pressure measurement
Tw o  s i t t i n g  b l o o d  p r e s s u r e  ( B P )

measurements were taken for all subjects and
the mean value was used to determine BP status:
hypertensive (systolic BP >140 mm Hg, diastolic
BP >90 mm Hg, or not.

Body mass index
Height was measured with microtoise with

a precision of 0.1 cm. Weight was measured
with Sage portable scales with a precision of
0.1 kg. Body mass index (BMI) was calculated
as the weight (kg) divided by the square of the
height (m2). For Asian populations, BMI is
classified into the following categories:
underweight (<18.5 kg/m2), normal (18.5–22.9
kg/m2), overweight (23.0–27.5 kg/m2), and
obese (> 27.6 kg/m2).(14)

Cost-effectiveness analysis
C o s t - e f f e c t i v e n e s s  a n a l y s i s  ( C E A )

generally considers the costs and effects of
adding new interventions to current practice or
the cost of replacing an existing intervention with
another targeting the same condition. The CEA
in this study indicated that for hypertensive
patients attending a health center (Puskesmas),
t h e  h e a l t h  c a r e  e x p e n d i t u r e  i n c l u d i n g
medications was approximately Rp. 12,000 at
the time of the study. Patients with hypertension
are usually advised to visit their physician once
weekly for follow-up, until their BP is adequately
controlled, with a systolic BP of <140 mmHg
and a diastolic BP of <90 mmHg.(15) Therefore
the annual healthcare costs for regular follow-
up at a health center is approximately Rp.
624,000.

Ethical clearance
Ethical clearance was issued by the

R e s e a r c h  E t h i c s  C o m m i t t e e ,  F a c u l t y  o f
Medicine, Trisakti University.

Statistical analysis
The background characteristics were

analyzed using descriptive statistics, after

c h e c k i n g  f o r  n o r m a l  d i s t r i b u t i o n  b y  t h e
Kolmogorov-Smirnov test of normality. Cost-
effectiveness of physical activity was analyzed
using the odds ratio as a measure of the risk of
hypertension among the physically active
s u b j e c t s  a s  c o m p a r e d  w i t h  t h e  r i s k  o f
hypertension in the less physically active
subjects. The level of significance was set at
p<0.05.
.
RESULTS

Background characteristics of the elderly
A total of 237 elderly people aged 60–69

years from eight hamlets in the five sub-districts
participated in the present study. The socio-
economic status of the subjects consisted of
education, history of employment, income
sources, health services, history of occupation
as well as their housing status. Regarding the
distribution of socio-economic status of the study
subjects, among the 237 elderly there were 138
(58.2%) in the age range of 60-64 years and 99
(41.8%) in the age range of 65-69 years. Overall
mean age was 63.9 ± 2.6 years. With regard to
gender, the subjects comprised 86 (36.3%) males
and 151 (63.7%) females. The majority (77.2%)
of the elderly had been educated and most of
them in their youth had received their formal
education at religious elementary schools. With
regard to marital status, approximately half of
them (55.7%) was widowed or unmarried. A
total of 60.8% of the elderly did not have regular
income for supporting their daily life and most
of the income came from their children. Only
13.5% of the elderly had insurance and for
access to health services, most of them had the
Kartu Miskin (health services card for the
poor). Around 80.6% of the elderly lived in their
own house (Table 1). The prevalence of
hypertension was 18.6%, while 32.9% was
physical active (Table 2).

There was no significant difference in the
prevalence of hypertension between males and
females. Similar results were obtained for
nutritional status and smoking habits. The results



177

indicated that for elderly with adequate physical
activity, the risk of hypertension was 0.4 times
lower, as compared with the less physically
active elderly (O.R.=0.4; 95% Confidence
Interval 0.16 – 0.97) (Table 3).

Cost-effectiveness of physical activity
Cost-effectiveness analysis was used to

evaluate the impact of physical activity on
h y p e r t e n s i o n ,  b y  a s s e s s i n g  t h e  r i s k  o f
hypertension in the physically active group as
compared to the risk of hypertension in the less
physically active group.

T h e  p r e v a l e n c e  o f  e l d e r l y  w i t h
hypertension was 10.3% in the physically
active group and 22.0 % in the less physically
active group. These data indicate that there
w e r e  s i g n i f i c a n t l y  m o r e  e l d e r l y  w i t h
hypertension in the less physically active group
than in the physically active group (p=0.027).
The risk for hypertension in the physically active
group was 0.40 times lower than that of the
less physically active group as shown in Table
3. This signifies that the risk of suffering from
h y p e r t e n s i o n  a m o n g  e l d e r l y  w h o  w e r e
physically active was significantly lower than
in elderly who were less physically active.

From Table 4 it is apparent that the cost of
a patient in the health center is Rp.12,000 per
ambulatory visit, amounting to 52 x Rp.12,000 =
Rp.624,000 per year. In subjects who are
physically active, the risk of hypertension was
0.40 lower, such that the total cost per year
amounts to Rp.249,600, yielding a 60% reduction
in healthcare expenditure, compared to subjects
who are less physical active.

DISCUSSION

For the 237 subjects of the present study,
the prevalence of hypertension was 18.6%. A
study in Costa Rica on elderly aged 60 to 80
years (mean age = 76 years) yielded differing
results, the prevalence of hypertension being
65.0%.(16) This may have been due to the higher

Variables n (%) 
Age   

 60-64 138 (58.2) 
 65-69  99 (41.8) 

Gender   
 Male  86 (36.3) 
 Female  151 (63.7) 

Education   
 Illiterate  54 (22.8) 
 Educated 183 (77.2) 

Marital status   
 Married 105 (44.3) 
 Widowed/unmarried 132 (55.7) 

Income sources   
 Regular 93 (39.2) 
 Non-regular 144 (60.8) 

Health services   
 Insurance 32 (13.5) 
 Non-insurance 205 (86.5) 

History of occupation   
 Enterpreneur   25 (10.5) 
 Laborer 19 (8.0) 
 Goverment employee 19 (8.0) 
 Merchant 35 (14.8) 
 Unemployed 139 (58.6) 

Housing status   
 Own 191 (80.6) 
 Not own  46 (19.4) 

 

Table 1. Socio-economic and demographic
profile of the participants (n=273)

Variables n (/%) 
Nutritional status  
BMI* kg/m2 (Mean ± SD) 21.80 ± 4.04 

 Underweight 55 (23.2) 
 Normal 95 (40.1) 
 Overweight 87 (36.7) 

Health status  
 Chronic 186 (78.1) 
 Non-chronic  

Hypertension 
 Yes  
 No  

Physical activity 
 Active 
 Les active  

51 (21.5) 
 

44 (18.6) 
193 (81.4) 

 
78 (32.9) 

159 (67.1) 

 

Table 2. Nutritional, health status, and physical
activity of the elderly (n=273)

*BMI = Body Mass Index

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Gandasentana, Kusumaratna                                                                               Physical activity reduced hypertension in elderly

age of the subjects, whereas the elderly in our
study were relatively younger, with a mean age
of 63.9 years.

O u r  s t u d y  s h o w e d  t h a t  t h e  r i s k  f o r
hypertension in the physically active group was
0.40 times lower than that of the less physically
active group as shown in Table 3. Similar results
were obtained in a prospective study of 27,055
apparently healthy women, where vigorous
physical activity (1500 Kcal/week) led to a
reduction in the incidence of hypertension (R.R.
= 0.62;95% C.I. (0.51–0.74;p< 0.001).(17) A
study in Australia showed similar results, in that
the prevalence of poor physical activity was
higher among the hypertensive elderly.(18)

Many epidemiologic observational studies
have reported a consistent inverse association
between physical activity and the risk of incident
cardiovascular diseases.(19) Even at an advanced
age, becoming more active still confers a
reduction in coronary heart disease mortality.(20)

The cardio-protective effect of physical activity
may be related to its beneficial effects on body
weight, blood pressure, serum cholesterol and
glucose tolerance.(21)

Cobiac et al.(8) analysed cost-effectiveness
of six physical activity intervention programs in
community-dwelling frail elderly taken from a
larger number of meta-analyses. Their analysis
indicated that these interventions would be cost-

Hypertension 
Risk factors 

Yes (n= 44,/%) No (n=193,/%) 
p 

Gender 
Male 
Female 

Age (years) 
60 – 64 
65 – 69 
> 70 

Smoking 
Yes 
No 

Nutritional status  
Underweight 
Normal 
Overweight 

Physical activity 
Active 

 Less active 

 
15 (17.4) 
29 (19.2) 

 
25 (18.1) 
18 (18.9) 
1 (25.0) 

 
8 (17.0) 

36 (18.9) 
 

9 (16.4) 
24 (18.0) 
11 (22.4) 

 
8 (10.3) 

35 (22.0) 

 
71 (82.6) 

122 (80.8) 
 

113 (81.9) 
77 (81.1) 
3 (75.0) 

 
39 (83.) 

154 (81.1) 
 

46 (83.6) 
109 (82.0) 
38 (77.6) 

 
70 (89.7) 

124 (78.0) 

 
0.737 

 
 

0.934 
 
 
 

0.761 
 
 

0.709 
 
 
 

0.027 
O.R.* = 0.40 

(95% C.I.=0.16-0.97) 

 

Table 3. Risk factors of hypertension in the elderly (n=237)

* O.R.=odds ratio C.I.= confidence interval

Cost per ambulatory visit Cost-effectiveness per year Reduction 
Iitervention 

HC* HC* HC* 

Physical activity 12,000,- 374,400,- 60.0% 

 

Table 4. Costs, effects and cost-effectiveness of physical activity on hypertension

* HC : health center



179

saving to the health sector, leading to substantial
improvements in health for the Australian
population. Although the studies analyzed by
Cobiac et al.(8) differed from the present study
in South Jakarta in several respects, one of them
being that their subjects were frail elderly, their
findings were similar to the results of cost-
effectiveness analysis of the present study
regarding the cost-savings of physical activity
in the elderly.

The pragmatic, single-blind randomized
clinical trial conducted by McCarthy et al.,(22)

showed that a home-based exercise program
supplemented with an 8-week class-based
exercise program yielded significantly better
results even 12 months after cessation of the
intervention, while their economic evaluation
suggested that structured physical activity
programs are likely to be cost-effective. The
findings of the McCarthy study that elderly
conducting regular physical activity have cost-
savings in health care expenditure, therefore are
consistent with the results of abovementioned
study, although differing in study design.

The beneficial effect of regular exercise
in hypertension is not limited to reduction of blood
pressure only. It has also been shown to reduce
left ventricular hypertrophy,(23) and improve
exercise capacity and quality of life.(24) When
combined with dietary alterations, regular
exercise causes reduction of oxidative stress,
increases nitric oxide availability and improves
the overall metabolic profile. (25) Recently
published large prospective epidemiological
studies have reported physical inactivity as a
predictor of not only cardiovascular but also total
mortality in middle-aged men and women.(26,27)

This association is strong, and independent of
other major risk factors, and illustrates the
enormous preventive potential of regular
exercise, especially given the high prevalence
of a sedentary lifestyle in most communities. It
also implies that physical activity also has a
protective effect on noncardiovascular mortality,
although the beneficial mechanisms are not
clearly understood.

In general, blood pressure rises with age,
certainly up to the seventh decade. The rise is
more marked for systolic pressure and is more
pronounced in men. Hypertension needs life-long
medical control. Once the subject has been
diagnosed as suffering from hypertension, he or
s h e  i s  o b l i g e d  t o  t a k e  a n t i h y p e r t e n s i v e
medications for life, thus becoming a burden to
the family and society. Ideally, the hypertension
patient has to visit his or her physician for control
of the disorder at regular intervals of one week.

For the calculation of cost of healthcare in
health centers, the present study used the
standard healthcare costs as determined by the
Department of Health.(28) The cost savings for
the physically active subjects in comparison to
the less physically active subjects was 60%.

It is apparent that regular physical activity
in older persons results in healthcare cost savings
due to reduced risk of hypertension. The cost-
effectiveness measured in the present study is
seen from the viewpoint of the study subjects
(on a micro scale), as most did not have health
insurance and had to pay for health services out
of their own pocket.

Several limitations of the present study
should be taken into consideration. As physical
activity was assessed by self-report, it is possible
that more precise assessment of this factors may
have resulted in a different contribution of this
variable to the reduction in hypertension. We
also did not have information on other variables
that are favorably influenced by physical activity,
such as those related to heart rate or autonomic
balance, or insulin sensitivity, so we could not
evaluate their contributions to the inverse relation
between physical activity and hypertension risk.

CONCLUSIONS

The prevalence of hypertension in the
elderly was 18.6%, while 67.1 % of the subjects
w a s  l e s s  p h y s i c a l l y  a c t i v e .  T h e  r i s k  o f
hypertension among the elderly who were
physically active was 0.4 lower compared to
less physically active elderly. In the economic

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Gandasentana, Kusumaratna                                                                               Physical activity reduced hypertension in elderly

evaluation the physically active group had higher
annual healthcare cost savings of approximately
60%. Future randomized controlled studies will
be needed to confirm the potential beneficial
effect of physical activity on health status of
the elderly and the attendant reduction in
healthcare expenditure.

ACKNOWLEDGEMENT

We wish to express our gratitude to the
D e a n  a n d  Vi c e  D e a n s  o f  t h e  F a c u l t y  o f
Medicine, Trisakti University, for the funding of
this study, to the staff of Mampang Prapatan
District Health Center and Sudinkes of South
Jakarta for the use of the health facilities, and
also to the participants of this study.

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Univ Med                                                                                                Vol.30 No.3