Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study

Nutritional biomarkers for objective dietary assessment

The accurate assessment of dietary exposure is important in investigating associations between diet and disease. Research in nutritional epidemiology, which has resulted in a large amount of information on associations between diet and chronic diseases in the last decade, relies on accurate assessment methods to identify these associations. However, most dietary assessment instruments rely to some extent on self-reporting, which is prone to systematic bias affected by factors such as age, gender, social desirability and approval. Nutritional biomarkers are not affected by these and therefore provide an additional, alternative method to estimate intake. However, there are also some limitations in their application: they are affected by inter-individual variations in metabolism and other physiological factors, and they are often limited to estimating intake of specific compounds and not entire foods. It is therefore important to validate nutritional biomarkers to determine specific strengths and limitations. In this perspective paper, criteria for the validation of nutritional markers and future developments are discussed.

Co-variations and clustering of chronic disease behavioral risk factors in China: China Chronic Disease and Risk Factor Surveillance, 2007

BACKGROUND

Chronic diseases have become the leading causes of mortality in China and related behavioral risk factors (BRFs) changed dramatically in past decades. We aimed to examine the prevalence, co-variations, clustering and the independent correlates of five BRFs at the national level.

METHODOLOGY/PRINCIPAL FINDINGS

We used data from the 2007 China Chronic Disease and Risk Factor Surveillance, in which multistage clustering sampling was adopted to collect a nationally representative sample of 49,247 Chinese aged 15 to 69 years. We estimated the prevalence and clustering (mean number of BRFs) of five BRFs: tobacco use, excessive alcohol drinking, insufficient intake of vegetable and fruit, physical inactivity, and overweight or obesity. We conducted binary logistic regression models to examine the co-variations among five BRFs with adjustment of demographic and socioeconomic factors, chronic conditions and other BRFs. Ordinal logistic regression was constructed to investigate the independent associations between each covariate and the clustering of BRFs within individuals. Overall, 57.0% of Chinese population had at least two BRFs and the mean number of BRFs is 1.80 (95% confidence interval: 1.78-1.83). Eight of the ten pairs of bivariate associations between the five BRFs were found statistically significant. Chinese with older age, being a male, living in rural areas, having lower education level and lower yearly household income experienced increased likelihood of having more BRFs.

CONCLUSIONS/SIGNIFICANCE

Current BRFs place the majority of Chinese aged 15 to 69 years at risk for the future development of chronic disease, which calls for urgent public health programs to reduce these risk factors. Prominent correlations between BRFs imply that a combined package of interventions targeting multiple BRFs might be appropriate. These interventions should target elder population, men, and rural residents, especially those with lower SES.

[Chronic inflammation and biomarkers. Is ageing an expression of chronic inflammation?]

Ageing shows a high interindividual and intraindividual variability. Subclinical and clinical cardiovascular diseases accelerate the ageing process in part and in total. This leads to the idea that ageing is a result of a chronic inflammation process and to the term "inflammageing". A variety of biomarkers (e.g. C-reactive protein, interleukin-6, tumor necrosis factor alpha, fibrinogen, albumin and serum amyloid A) are described in this context. Furthermore there is a relationship to changes in the immune system across the lifespan (immunosenescence), viral infections, the occurrence of markers of oxidative stress and genetic changes. At this point in time the role for determining ageing and its use as a prognostic tool seems to be impossible. Whether inflammageing is a valid model for describing the ageing process or is the consequence of other mechanisms needs further discussion.

Do lifestyle behaviours explain socioeconomic differences in all-cause mortality, and fatal and non-fatal cardiovascular events? Evidence from middle aged men in France and Northern Ireland in the PRIME Study

OBJECTIVE

To examine the contribution of lifestyle behaviours to the socioeconomic gradient in all-cause mortality, and fatal and non-fatal cardiovascular events.

METHOD

10,600 men aged 50-59 years examined in 1991-1994 in Northern Ireland (NI) and France and followed annually for deaths and cardiovascular events for 10 years. Baseline smoking habit, physical activity, and fruit, vegetable, and alcohol consumption were assessed.

RESULTS

All lifestyle behaviours showed marked socioeconomic gradients for most indicators in NI and France, with the exception of percentage of alcohol consumers in NI and frequency of alcohol consumption in NI and France. At 10 years, there were 544 deaths from any cause and 440 fatal and non-fatal cardiovascular events. After adjustment for country and age, socioeconomic gradients were further adjusted for lifestyle behaviours. For total mortality, the median residual contribution of lifestyle behaviours was 28% and for cardiovascular incidence, 41%. When cardiovascular risk factors were considered in conjunction with lifestyle behaviours these percentages increased to 38% and 67% respectively.

CONCLUSION

Lifestyle behaviours contribute to the gradient in mortality and cardiovascular incidence between socioeconomic groups, particularly for cardiovascular incidence, but a substantial proportion of these differentials was not explained by lifestyle behaviours and cardiovascular risk factors.

Cardiovascular risk factor screening satisfaction in the Heart of New Ulm Project

OBJECTIVE

Community-based cardiovascular disease (CVD) risk factor screening programs have been used successfully in rural health improvement initiatives. However, little is known about what consumers like or dislike about them, which is a barrier to the design of future process improvements. The objective of this study was to examine the degree to which health risks and participant characteristics predicted screening satisfaction.

DESIGN

This study utilized a cross-sectional survey design.

SETTING

Data was collected as part of the broader Heart of New Ulm Project, which is a community-based CVD prevention demonstration project based in rural Minnesota.

PARTICIPANTS

There were 126 randomly invited individuals from the CVD risk factor screenings, with 118 individuals who agreed to participate and had complete data available for analyses.

METHODS

A multivariate logistic regression analysis was used to examine the association between demographics, lifestyle, and biometric risk factors and screening satisfaction.

RESULTS

Twenty percent of respondents indicated some level of dissatisfaction with the screening process. Satisfied participants were more likely to be female (OR=4.15), not have an optimal lifestyle (OR=3.47), and have an intention to improve their lifestyle habits (OR=3.26). Age, education, and CVD risk level were not significant predictors in the final model.

CONCLUSION

Satisfaction was high in this screening program, with healthy males being least satisfied with their experience. This has implications for the design of future intervention efforts, as they may require specific programmatic features and more specialized, targeted marketing strategies to attract a broad spectrum of participants likely to benefit.

Combined impact of five lifestyle factors and subsequent risk of cancer: the Japan Public Health Center Study

OBJECTIVE

To evaluate whether 5 combined healthy lifestyle factors (not smoking, moderate drinking, eating minimum salt-preserved foods, being physically active, and having appropriate body mass index) are associated with reduced risk of cancer.

METHODS

Participants were enrolled in the Japan Public Health Center Study and responded to the 5-year follow-up questionnaire covering lifestyle factors in 1995-1999 at ages 45-74 years. During follow up through December 31, 2006, 3451 and 2125 cases of cancer were newly identified in men and women, respectively. For men and women, a factor-dependent risk reduction was observed for healthy lifestyles and cancer development. Compared to 0-1 healthy lifestyle factors, the adjusted RRs and 95% CIs for adherence to 2, 3, 4, and 5 healthy factors were 0.86 (0.78-0.95), 0.72 (0.65-0.80), 0.61 (0.54-0.69), and 0.57 (0.45-0.72), respectively, for men (P for trend<0.0001) and 0.86 (0.53-1.40), 0.73 (0.46-1.16), 0.68 (0.42-1.08), and 0.63 (0.39-1.01), respectively, for women (P for trend=0.0003). Risk was reduced 14% and 9% by each one healthy lifestyle for men and women, respectively. Risk reduction was more pronounced among elderly women.

CONCLUSION

These combined lifestyle factors have a considerable impact on preventing cancer.

Impact of lifestyle-related factors on all-cause and cause-specific mortality in patients with type 2 diabetes: the Taichung Diabetes Study

OBJECTIVE

To examine whether combined lifestyle behaviors have an impact on all-cause and cause-specific mortality in patients aged 30-94 years with type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

Participants included 5,686 patients >30 years old with T2DM who were enrolled in a Diabetes Care Management Program at a medical center in central Taiwan before 2007. Lifestyle behaviors consisted of smoking, alcohol drinking, physical inactivity, and carbohydrate intake. The main outcomes were all-cause and cause-specific mortality. Cox proportional hazards models were used to examine the association between combined lifestyle behaviors and mortality.

RESULTS

The mortality rate among men was 24.10 per 1,000 person-years, and that among women was 17.25 per 1,000 person-years. After adjusting for the traditional risk factors, we found that combined lifestyle behavior was independently associated with all-cause mortality and mortality due to diabetes, cardiovascular disease, and cancer. Patients with three or more points were at a 3.50-fold greater risk of all-cause mortality (95% CI 2.06-5.96) and a 4.94-fold (1.62-15.06), 4.24-fold (1.20-14.95), and 1.31-fold (0.39-4.41) greater risk of diabetes-specific, CVD-specific, and cancer-specific mortality, respectively, compared with patients with zero points. Among these associations, the combined lifestyle behavior was not significantly associated with cancer mortality.

CONCLUSIONS

Combined lifestyle behavior is a strong predictor of all-cause and cause-specific mortality in patients with T2DM.

The benefits of dispositional mindfulness in physical health: a longitudinal study of female college students

OBJECTIVE

This article examines the relationship between dispositional mindfulness, health behaviors (eg, sleep, eating, and exercise), and physical health.

PARTICIPANTS

Participants included 441 college women.

METHODS

Women completed self-report surveys at the beginning and end of a 10-week academic quarter. The study was conducted over 5 academic quarters from fall 2008 to fall 2010.

RESULTS

Findings indicated that higher levels of dispositional mindfulness were related to healthier eating practices, better quality of sleep, and better physical health. Dispositional mindfulness contributed to better physical health even after controlling for traditional health habits. Finally, bidirectional mediational relationships were found between healthy eating and dispositional mindfulness as well as between sleep quality and dispositional mindfulness when physical health was the outcome variable.

CONCLUSIONS

Findings suggest that incorporating mindfulness training into programming on college campuses may be beneficial, as results indicate that dispositional mindfulness is related to positive physical health among college students.

Impact of individual and combined health behaviors on all causes of premature mortality among middle aged men in Korea: the Seoul Male Cohort Study

OBJECTIVES

The aim of this study was to evaluate and quantify the risk of both individual and combined health behaviors on premature mortality in middle aged men in Korea.

METHODS

In total, 14 533 male subjects 40 to 59 years of age were recruited. At enrollment, subjects completed a baseline questionnaire, which included information about socio-demographic factors, past medical history, and life style. During the follow-up period from 1993 to 2008, we identified 990 all-cause premature deaths using national death certificates. A Cox proportional hazard regression model was used to estimate the hazard ratio (HR) of each health risk behavior, which included smoking, drinking, physical inactivity, and lack of sleep hours. Using the Cox model, each health behavior was assigned a risk score proportional to its regression coefficient value. Health risk scores were calculated for each patient and the HR of all-cause premature mortality was calculated according to risk score.

RESULTS

Current smoking and drinking, high body mass index, less sleep hours, and less education were significantly associated with all-cause premature mortality, while regular exercise was associated with a reduced risk. When combined by health risk score, there was a strong trend for increased mortality risk with increased score (p-trend < 0.01). When compared with the 1-9 score group, HRs of the 10-19 and 20-28 score groups were 2.58 (95% confidence intervals [CIs], 2.19 to 3.03) and 7.09 (95% CIs, 5.21 to 9.66), respectively.

CONCLUSIONS

Modifiable risk factors, such as smoking, drinking, and regular exercise, have considerable impact on premature mortality and should be assessed in combination.

Combined lifestyle factors and cardiovascular disease mortality in Chinese men and women: the Singapore Chinese health study

BACKGROUND

Lifestyle factors directly influence cardiovascular disease (CVD) risk, yet little research has examined the association of combined lifestyle factors with CVD mortality, especially in Asian populations.

METHODS AND RESULTS

We examined the association of 6 combined lifestyle factors (dietary pattern, physical activity, alcohol intake, usual sleep, smoking status, and body mass index) with CVD mortality in 50 466 (44 056 without a history of diabetes mellitus, CVD, or cancer and 6410 with diabetes mellitus or history of clinical CVD) Chinese men and women in Singapore who were 45 to 74 years of age during enrollment in the Singapore Chinese Health Study in 1993 to 1998 and followed up through 2009. Each lifestyle factor was independently associated with CVD mortality. When combined, there was a strong, monotonic decrease in age- and sex-standardized CVD mortality rates with an increasing number of protective lifestyle factors. Relative to participants with no protective lifestyle factors, the hazard ratios of CVD mortality for 1, 2, 3, 4, and 5 to 6 protective lifestyle factors were 0.60 (95% confidence interval, 0.45-0.84), 0.50 (95% confidence interval, 0.38-0.67), 0.40 (95% confidence interval, 0.30-0.53), 0.32 (95% confidence interval, 0.24-0.43), and 0.24 (95% confidence interval, 0.17-0.34), respectively, among those without a history of diabetes mellitus, CVD, or cancer (P for trend <0.0001). A parallel graded inverse association was observed in participants with a history of CVD or diabetes mellitus at baseline. Results were consistent for coronary heart disease and cerebrovascular disease mortality.

CONCLUSION

An increasing number of protective lifestyle factors is associated with a marked decreased risk of coronary heart disease, cerebrovascular disease, and overall CVD mortality in Chinese men and women.

[Frailty: a phenotype under review]

A person's biological condition in old age partly depends on previous lifestyles. Consequently, the relationship between physical activity and obesity is emerging as an important risk factor for frailty, especially due to the resulting chronic inflammatory state. This inflammation not only leads to sarcopenia, which is basic to the development of frailty, but also affects the vascular and central nervous systems. Therefore, we believe that these two systems should be included in the frailty phenotype. Under these premises, and using the data from the Toledo Study for Healthy Aging, we propose that the frailty phenotype be extended and recommend the use of a scale to evaluate the frailty trait.

Combined impact of lifestyle factors on cancer mortality in men

PURPOSE

The impact of lifestyle factors on cancer mortality in the U.S. population has not been thoroughly explored. We examined the combined effects of cardiorespiratory fitness, never smoking, and normal waist girth on total cancer mortality in men.

METHODS

We followed a total of 24,731 men ages 20-82 years who participated in the Aerobics Center Longitudinal Study. A low-risk profile was defined as never smoking, moderate or high fitness, and normal waist girth, and they were further categorized as having 0, 1, 2, or 3 combined low-risk factors.

RESULTS

Over an average of 14.5 years of follow-up, there were a total of 384 cancer deaths. After adjustment for age, examination year, and multiple risk factors, men who were physically fit, never smoked, and had a normal waist girth had a 62% lower risk of total cancer mortality (95% confidence interval [CI], 45%-73%) compared with men with no low-risk factors. Men with all 3 low-risk factors had a 12-year (95% CI, 8.6-14.6) longer life expectancy compared with men with no low-risk factors. Approximately 37% (95% CI, 17%-52%) of total cancer deaths might have been avoided if the men had maintained all 3 low-risk factors.

CONCLUSIONS

Being physically fit, never smoking, and maintaining a normal waist girth is associated with lower risk of total cancer mortality in men.

Multiple health behaviors and serum hepatic enzymes among US adults with obesity

INTRODUCTION

This study was to examine the cumulative number and clustering patterns of low-risk health behaviors (i.e., not currently smoking, not excessive drinking, and physically active) associated with elevation of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyltransferase (GGT) among adults with obesity in the United States.

METHODS

We estimated the age-adjusted prevalence of elevated ALT, AST, and GGT from 4547 adults with obesity aged ≥ 20 years who participated in the 2005-2008 National Health and Nutrition Examination Survey. The associations between the cumulative number or clustering patterns of low-risk health behaviors and measures of serum ALT, AST, and GGT were assessed using multivariate regression models.

RESULTS

Adult men who reported having three low-risk health behaviors were 62%, 39%, and 48% less likely to have elevated serum ALT, AST, and GGT, respectively; adult women were 56% and 73% less likely to have elevated serum AST and GGT, respectively, when compared to their respective counterparts who reported having none of the low-risk health behaviors.

CONCLUSIONS

The findings of this study indicate that, among adults with obesity, having multiple low-risk health behaviors is associated with decreased likelihoods of elevated hepatic enzymes, including ALT in men, AST and GGT in both men and women.

Lifestyle and quality of life in colorectal cancer survivors

PURPOSE

As cancer survival rates improve, there is growing interest in the role of lifestyle in longer-term health and quality of life (QoL). This study examined the prevalence of health-related behaviours, and the associations between health behaviours and QoL, in colorectal cancer survivors.

METHODS

Patients diagnosed with colorectal cancer within the last 5 years identified from five London (UK) hospitals (N = 495) completed a survey that included measures of fruit and vegetable (F&V) intake, physical activity, smoking status and alcohol consumption. The EORTC-QLQ-C30 questionnaire was used to index QoL.

RESULTS

The majority of respondents were overweight/obese (58%), not physically active (<5 bouts of moderate activity per week; 82%) and ate fewer than five portions of F&V a day (57%). Few were smokers (6%) or heavy drinkers (weekly alcohol units >21 for men and >14 for women; 8%). Physical activity showed the strongest association with functional QoL and was also associated with lower fatigue, pain and insomnia (P < 0.05). F&V intake was associated with higher global QoL and physical, role and cognitive function (P < 0.05). Using a total health behaviour score (calculated by assigning one point for each of the following behaviours: not smoking, consuming ≥5 portions of F&V a day, being physically active and having moderate alcohol consumption), there was a linear relationship with global QoL, physical function and fatigue (P < 0.05).

CONCLUSION

A high proportion of colorectal cancer survivors in the UK have suboptimal health behaviours, and this is associated with poorer QoL.

The clustering of health behaviours in Ireland and their relationship with mental health, self-rated health and quality of life

Background

Health behaviours do not occur in isolation. Rather they cluster together. It is important to examine patterns of health behaviours to inform a more holistic approach to health in both health promotion and illness prevention strategies. Examination of patterns is also important because of the increased risk of mortality, morbidity and synergistic effects of health behaviours. This study examines the clustering of health behaviours in a nationally representative sample of Irish adults and explores the association of these clusters with mental health, self-rated health and quality of life.

Methods

TwoStep Cluster analysis using SPSS was carried out on the SLÁN 2007 data (national Survey of Lifestyle, Attitudes and Nutrition, n = 10,364; response rate =62%; food frequency n = 9,223; cluster analysis n = 7,350). Patterns of smoking, drinking alcohol, physical activity and diet were considered. Associations with positive and negative mental health, quality of life and self-rated health were assessed.

Results

Six health behaviour clusters were identified: Former Smokers, 21.3% (n = 1,564), Temperate, 14.6% (n = 1,075), Physically Inactive, 17.8% (n = 1,310), Healthy Lifestyle, 9.3% (n = 681), Multiple Risk Factor, 17% (n = 1248), and Mixed Lifestyle, 20% (n = 1,472). Cluster profiles varied with men aged 18-29 years, in the lower social classes most likely to adopt unhealthy behaviour patterns. In contrast, women from the higher social classes and aged 65 years and over were most likely to be in the Healthy Lifestyle cluster. Having healthier patterns of behaviour was associated with positive lower levels of psychological distress and higher levels of energy vitality.

Conclusion

The current study identifies discernible patterns of lifestyle behaviours in the Irish population which are similar to those of our European counterparts. Healthier clusters (Former Smokers, Temperate and Healthy Lifestyle) reported higher levels of energy vitality, lower levels of psychological distress, better self-rated health and better quality of life. In contrast, those in the Multiple Risk Factor cluster had the lowest levels of energy and vitality and the highest levels of psychological distress. Identification of these discernible patterns because of their relationship with mortality, morbidity and longevity is important for identifying national and international health behaviour patterns.

The impact of a Mediterranean diet and healthy lifestyle on premature mortality in men and women

BACKGROUND

The Mediterranean diet has been associated with reduced mortality; few studies have investigated the combined impact of the Mediterranean diet with other modifiable lifestyle factors.

OBJECTIVES

The objectives were to investigate the association between adherence to the Mediterranean diet and total mortality and to estimate the overall impact of a combined healthy lifestyle on premature death.

DESIGN

In 1986 a cohort of 120,852 men and women aged 55-69 y provided information on dietary and other lifestyle habits. A mortality follow-up until 1996 was established by linkage to the Dutch Central Bureau of Genealogy. A combined lifestyle score was constructed by allocating one point per the following healthy lifestyle factors: adhering to the Mediterranean diet, nonsmoking, normal weight [BMI (in kg/m(2)): 18.5 to <25], and regular physical activity. The lifestyle score ranged from 0 to 4 points (least healthy to healthiest). The multivariate case-cohort analysis was based on 9691 deaths and 3576 subcohort members.

RESULTS

Adherence to the Mediterranean diet was significantly related to lower mortality in women but not significantly in men. The healthy lifestyle score was strongly inversely related to mortality in women and men. When the least-healthy to the healthiest lifestyle scores were compared, HRs of 4.07 (95% CI: 2.59, 6.40; P-trend <0.001) and 2.61 (95% CI: 1.79, 3.80; P-trend <0.001) were shown in women and men, respectively. For the same comparison, the mortality rate advancement period ("aging effect") was 15.1 y (95% CI: 9.9, 20.2 y) in women and 8.4 y (95% CI: 5.0, 11.8 y) in men.

CONCLUSION

This study suggests that adherence to 4 modifiable healthy lifestyle factors can substantially reduce premature mortality in women and men.

Lifestyle behaviours and quality-adjusted life years in middle and older age

OBJECTIVE

to examine the relationship between combined lifestyle behaviours and quality-adjusted life years (QALYs) in a general population.

METHODS

a population-based study was conducted in 13,358 men and women who participated in the European Prospective Investigation into Cancer (EPIC)-Norfolk (baseline 1993-97). A score of 1 was given to each of non-smoking, physically not inactive, moderate alcohol consumption (1-14 units) and consumption of at least five portions of fruit and vegetables (vitamin C level ≥50 µmol/l). Short-Form Six-Dimension (SF-6D) health utility index scores were derived from the SF-36. QALYs were estimated up to follow-up (July 2007).

RESULTS

a total of 13,358 men and women were eligible to be included in the study (aged 40-79 years at baseline). A total of 12,921 people were alive at follow-up (117, 784 person-years). Mean follow-up period was ∼11.5 years. 437 (4.4% of men and 2.4% of women) died. The death rate was 6.5 times higher in people with health behaviour score 0 compared with those who scored 4 (8.4 versus 1.3%). People with higher scores had significantly higher QALYs.

CONCLUSION

our findings support the view that modifiable lifestyle factors are an important component in health improvement.

Association between a healthy lifestyle and general obesity and abdominal obesity in an elderly population at high cardiovascular risk

BACKGROUND

Diet, smoking and physical activity are important modifiable lifestyle factors that can influence body weight and fat accumulation. We assessed the relationship between lifestyle and obesity risk in a baseline analysis of the PREDIMED study, a randomized dietary primary prevention trial conducted in Spain.

METHODS

7000 subjects at high cardiovascular risk were assessed cross-sectionally. A healthy lifestyle pattern (HLP) was determined using a score including: adherence to the Mediterranean diet, moderate alcohol consumption, expending ≥200 kcal/day in leisure-time physical activity, and non-smoking.

RESULTS

Inverse linear trends were observed between the HLP-score and body-mass-index (BMI) or waist circumference (p<0.001). The BMI and waist circumference of participants with a HLP-score=4 were, respectively, 1.3 kg/m(2) (95% CI: 0.9 to 1.7) and 4.3 cm (3.1 to 5.4) lower than those of subjects with an HLP≤1. The odds ratios of general obesity and abdominal obesity for an HLP score of 4 compared to an HPL score≤1 were 0.50 (0.42 to 0.60) and 0.51 (0.41 to 0.62), respectively.

CONCLUSION

A combination of four healthy lifestyle behaviors was associated with a lower prevalence of general obesity and abdominal obesity in Mediterranean elderly subjects at high cardiovascular risk.

Low-risk lifestyle behaviors and all-cause mortality: findings from the National Health and Nutrition Examination Survey III Mortality Study

OBJECTIVES

We examined the relationship between 4 low-risk behaviors-never smoked, healthy diet, adequate physical activity, and moderate alcohol consumption-and mortality in a representative sample of people in the United States.

METHODS

We used data from 16958 participants aged 17 years and older in the National Health and Nutrition Examination Survey III Mortality Study from 1988 to 2006.

RESULTS

The number of low-risk behaviors was inversely related to the risk for mortality. Compared with participants who had no low-risk behaviors, those who had all 4 experienced reduced all-cause mortality (adjusted hazard ratio [AHR]=0.37; 95% confidence interval [CI]=0.28, 0.49), mortality from malignant neoplasms (AHR=0.34; 95% CI=0.20, 0.56), major cardiovascular disease (AHR=0.35; 95% CI=0.24, 0.50), and other causes (AHR=0.43; 95% CI=0.25, 0.74). The rate advancement periods, representing the equivalent risk from a certain number of years of chronological age, for participants who had all 4 high-risk behaviors compared with those who had none were 11.1 years for all-cause mortality, 14.4 years for malignant neoplasms, 9.9 years for major cardiovascular disease, and 10.6 years for other causes.

CONCLUSIONS

Low-risk lifestyle factors exert a powerful and beneficial effect on mortality.

The pre-adoption demographic and health profiles of men participating in a programme of men's health delivered in English Premier League football clubs

OBJECTIVES

To investigate the pre-adoption demographic and health profiles of men participating in a programme of men's health delivered in English Premier League (EPL) football clubs.

STUDY DESIGN

A series of match day and programmed health promotion interventions held in EPL clubs (n = 16), including awareness-raising activity days for supporters, weekly healthy lifestyle classes, and outreach activities targeted in local communities. Interventions were delivered at football stadia, club training venues and community facilities. Interventions were run by health trainers who received specific training in men's health and behavioural change activities.

METHODS

Participants completed self-report measures for demographics and lifestyle behaviours, including physical activity, consumption of fruit and vegetables, smoking, height, weight, consumption of alcohol and perception of health. Measurement occurred before the interventions. Data were independently analysed and used to assess adoption of the interventions and pre-intervention health profiles of participants.

RESULTS

Nine hundred and forty-six men adopted the interventions, but the mode of engagement led to variations in the sample size. Demographics showed that 89% (n = 783/875) were aged 18-44 years and 78% (n = 685/878) were White British. In a subsample, the percentages of men failing to meet health guidelines were as follows: physical activity, 79% (n = 351/440); consumption of fruit and vegetables, 82% (n = 315/380); smoking, 28% (n = 103/373); high body weight, 67% (n = 245/358); and high alcohol consumption, 40% (n = 112/279). Sixty-nine percent of men (n = 242/348) considered that they had no health problems, but 67% (n = 208/310) presented with three or more risk factors for coronary heart disease. Over 40% (n = 125/307) reported never going to see their general practitioner.

CONCLUSION

A national programme of men's health promotion interventions delivered in EPL football clubs was effective in reaching target audiences. Interventions were predominantly adopted by men not meeting health guidelines.

Sociodemographic, health and lifestyle predictors of poor diets

OBJECTIVE

Poor-quality diet, regarded as an important contributor to health inequalities, is linked to adverse health outcomes. We investigated sociodemographic and lifestyle predictors of poor-quality diet in a population sample.

DESIGN

A cross-sectional analysis of the Survey of Lifestyle, Attitudes and Nutrition (SLÁN). Diet was assessed using an FFQ (n 9223, response rate = 89%), from which a dietary score (the DASH (Dietary Approaches to Stop Hypertension) score) was constructed.

SETTING

General population of the Republic of Ireland.

SUBJECTS

The SLÁN survey is a two-stage clustered sample of 10,364 individuals aged 18 years.

RESULTS

Adjusting for age and gender, a number of sociodemographic, lifestyle and health-related variables were associated with poor-quality diet: social class, education, marital status, social support, food poverty (FP), smoking status, alcohol consumption, underweight and self-perceived general health. These associations persisted when adjusted for age, gender and social class. They were not significantly altered in the multivariate analysis, although the association with social support was attenuated and that with FP was borderline significant (OR = 1·2, 95% CI 1·03, 1·45). A classical U-shaped relationship between alcohol consumption and dietary quality was observed. Dietary quality was associated with social class, educational attainment, FP and related core determinants of health.

CONCLUSIONS

The extent to which social inequalities in health can be explained by socially determined differences in dietary intake is probably underestimated. The use of composite dietary quality scores such as the DASH score to address the issue of confounding by diet in the relationship between alcohol consumption and health merits further study.

A Review of Lifetime Risk Factors for Mortality

This review was undertaken for the Faculty and Institute of Actuaries as part of their programme to encourage research collaborations between health researchers and actuaries in order to understand better the factors influencing mortality and longevity. The authors presented their findings in a number of linked sessions at the Edinburgh conference (Joining Forces on Mortality and Longevity) in October 2009 and contributed to this overview. The purpose is to review evidence for the impact on adult mortality of characteristics of the individual's lifetime socioeconomic or psychosocial environment or phenotype at the behavioural; multi-system (e.g. cognitive and physical function); or body system level (e.g. vascular and metabolic traits) that may be common risk factors for a number of major causes of death. This review shows there is growing evidence from large studies and systematic reviews that these individual characteristics, measured in pre-adult as well as the adult life, are associated with later mortality risk. The relative contribution of lifetime environment, genetic factors and chance, whether these contributions change with age, and the underlying social and biological pathways are still to be clarified. This review identifies areas where further life course research is warranted.

Association between area-level socioeconomic deprivation and a cluster of behavioural risk factors: cross-sectional, population-based study

BACKGROUND

The Commission on Social Determinants of Health has urged governments across the world to promote health equity by reducing the gap between the most and least deprived individuals in society. Some of this gap can be bridged by promoting healthy lifestyles through targeted Public Health policy and interventions.

METHODS

Cross-sectional analyses of data on behavioural risk factors, individual socioeconomic factors and neighbourhood deprivation score collected from 26 290 adults aged over 16 years who participated in the 2008 East of England Lifestyle Survey.

RESULTS

After adjustment for individual socioeconomic factors, across quintiles of increasing neighbourhood deprivation, participants were more likely to smoke and less likely to consume five portions of fruit and vegetables on five or more days of the week (least deprived versus most deprived quintile: odds ratios for not smoking 0.45 (0.41-0.50); and fruit and vegetable consumption 0.70 (0.64-0.76), P-trend <0.0001). Greater neighbourhood deprivation and lower occupational social class were independently associated with a lower summary healthy lifestyle score (both P-trend <0.0001).

CONCLUSIONS

Public health interventions aimed at reducing health inequalities by targeting behavioural risk factors may focus in particular on reducing smoking and increasing fruit and vegetable consumption in more deprived communities.

Nutritional strategies for successful aging

With increasing life expectancy in developed and developing countries, maintaining health and function in old age has become an important goal, including avoidance or optimal control of chronic diseases; maintenance or retarding the decline of physical and cognitive function; optimizing psychological health; and maintaining independent functioning in tasks related to self-care and societal interaction. This article discusses all of those, as well as other components of successful aging such as social network and socioeconomic status.

Following cancer prevention guidelines reduces risk of cancer, cardiovascular disease, and all-cause mortality

BACKGROUND

Few studies have evaluated the combined impact of following recommended lifestyle behaviors on cancer, cardiovascular disease (CVD) and all-cause mortality, and most included tobacco avoidance. Because 80% of Americans are never or former smokers, it is important to consider the impact of other recommended behaviors.

METHODS

In 1992 and 1993, 111,966 nonsmoking men and women in the Cancer Prevention Study-II Nutrition Cohort completed diet and lifestyle questionnaires. A score ranging from 0 to 8 points was computed to reflect adherence to the American Cancer Society cancer prevention guidelines on body mass index, physical activity, diet, and alcohol consumption, with 8 points representing optimal adherence. Multivariable-adjusted relative risks (RR) of death and 95% CI were computed by Cox proportional hazard regression.

RESULTS

During 14 years of follow-up, 10,369 men and 6,613 women died. The RR of all-cause mortality was lower for participants with high (7, 8) versus low (0-2) scores (men, RR = 0.58, 95% CI: 0.53-0.62; women, RR = 0.58, 95% CI: 0.52-0.64). Inverse associations were found with CVD mortality (men, RR = 0.52, 95% CI: 0.45-0.59; women, RR = 0.42, 95% CI: 0.35-0.51) and cancer mortality (men, RR = 0.70, 95% CI: 0.61-0.80; women, RR = 0.76, 95% CI: 0.65-0.89). Similar associations, albeit not all statistically significant, were observed for never and former smokers.

CONCLUSION

Adherence to cancer prevention guidelines for obesity, diet, physical activity, and alcohol consumption is associated with lower risk of death from cancer, CVD, and all causes in nonsmokers.

IMPACT

Beyond tobacco avoidance, following other cancer prevention guidelines may substantially lower risk of premature mortality in older adults.

Combined influence of lifestyle risk factors on body fat in Spanish adolescents--the Avena study

OBJECTIVE

To examine the combined influence of four lifestyle risk factors related to physical activity, television viewing, sleep duration, and meal frequency on body fat (BF) in adolescents.

METHOD

This cross-sectional study comprised 1,310 Spanish adolescents (age 13-18.5 years). Lifestyle variables were self-reported and BF indicators (weight, height, six skinfold thicknesses, waist circumference) measured during the years 2000-2002. Lifestyle risk factors were: physically inactive, ≥ 3 h/day watching television, <8 h/day sleep duration, and <5 meals a day. The number of lifestyle risk factors was calculated for each participant, ranging from 0 to 4.

RESULTS

The number of lifestyle risk factors was positively associated with sum of six skinfolds, %BF, waist circumference, and waist-height ratio (all p < 0.001). The odds ratios (95% confidence interval) of overweight (including obesity) for groups with 1, 2, and 3-4 lifestyle risk factors compared with those with 0 were 2.86 (1.77-4.62), 3.61 (2.16-6.04), and 5.81 (3.07-10.99), respectively (p for trend <0.001). All the observations were independent of age, gender, race, socioeconomic status, and fat free mass.

CONCLUSION

The combined influence of four lifestyle risk factors is positively associated with BF and an approximately sixfold risk of overweight in adolescents.

Effects of body size and sociodemographic characteristics on differences between self-reported and measured anthropometric data in middle-aged men and women: the EPIC-Norfolk study

BACKGROUND/OBJECTIVES

To investigate the effects of body size and sociodemographic characteristics on differences between self-reported (SR) and measured anthropometric data in men and women.

SUBJECTS/METHODS

This study comprises 9933 men and 11,856 women aged 39-79 years at baseline survey (1993-1997) in the EPIC-Norfolk study (Norfolk arm of the European Investigation into Cancer and Nutrition Study). The effects of sex, measured height, weight, age group, educational level and social class on differences between SR and measured weight, height, body mass index (BMI), waist, hip and waist-to-hip ratio (WHR) were examined.

RESULTS

There were systematic differences between SR and measured anthropometric measurements by sex, measured height, weight and sociodemographic characteristics. Height was overestimated in both sexes while weight, waist, hip, and consequently, BMI and WHR were underestimated. Being male, shorter, heavier, older, and having no educational qualifications and manual occupation were independently associated with overreporting of height, and underreporting of weight was associated independently with being female, shorter, heavier, younger age, and higher education level and social class. Underreporting of waist circumference was strongly associated with being female and higher measured waist circumference, while underreporting of hip circumference was associated with being male and higher measured hip circumference. Furthermore, there was substantial degree of misclassification of BMI and waist circumference categories for both general and central obesity associated with SR data.

CONCLUSIONS

These findings suggest that errors in SR anthropometric data, especially waist and hip circumference are influenced by actual body size as well as sociodemographic characteristics. These systematic differences may influence associations between SR anthropometric measures and health outcomes in epidemiological studies.

Poor health behaviour and reduced quality of life of people treated with psychotropic drugs

BACKGROUND

Recent literature reports a reduced l\ife expectancy in patients with severe mental illness. We have investigated health behaviour, quality of life, and sociodemographic variables of people with psychopharmacological treatment using data from the most recent Austrian Health Survey.

METHODS

Quality of life (the World Health Organization quality of life, abbreviated version) questionnaires and items from the European Health Interview Survey were used in assessing health status and health behaviour of 15,474 people living in Austria. From this sample, 882 individuals (5.7%) under psychopharmacological treatment were compared with respondents without mental illness.

RESULTS

We found significant differences in health behaviour (reduced physical activity, more smoking) and sociodemographic data (age, gender, education, income) between people treated for mental illness and respondents without psychopharmacological treatment. Correspondingly, more somatic illness and reduced quality of life were found in the former group.

CONCLUSION

These data stress the necessity of health intervention and antipoverty programmes taking social and somatic issues for people with moderate mental health problems into account.

Health behaviours, socioeconomic status, and mortality: further analyses of the British Whitehall II and the French GAZEL prospective cohorts

BACKGROUND

Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistent findings of epidemiologic research. However, research on social inequalities in health has yet to provide a comprehensive understanding of the mechanisms underlying this association. In recent analysis, we showed health behaviours, assessed longitudinally over the follow-up, to explain a major proportion of the association of socioeconomic status (SES) with mortality in the British Whitehall II study. However, whether health behaviours are equally important mediators of the SES-mortality association in different cultural settings remains unknown. In the present paper, we examine this issue in Whitehall II and another prospective European cohort, the French GAZEL study.

METHODS AND FINDINGS

We included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study. Over the follow-up (mean 19.5 y in Whitehall II and 16.5 y in GAZEL), health behaviours (smoking, alcohol consumption, diet, and physical activity), were assessed longitudinally. Occupation (in the main analysis), education, and income (supplementary analysis) were the markers of SES. The socioeconomic gradient in smoking was greater (p<0.001) in Whitehall II (odds ratio [OR] = 3.68, 95% confidence interval [CI] 3.11-4.36) than in GAZEL (OR = 1.33, 95% CI 1.18-1.49); this was also true for unhealthy diet (OR = 7.42, 95% CI 5.19-10.60 in Whitehall II and OR = 1.31, 95% CI 1.15-1.49 in GAZEL, p<0.001). Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 (95% CI 1.28-2.05) in Whitehall II and 1.94 in GAZEL (95% CI 1.58-2.39) for lowest versus highest occupational position. Health behaviours attenuated the association of SES with mortality by 75% (95% CI 44%-149%) in Whitehall II but only by 19% (95% CI 13%-29%) in GAZEL. Analysis using education and income yielded similar results.

CONCLUSIONS

Health behaviours were strong predictors of mortality in both cohorts but their association with SES was remarkably different. Thus, health behaviours are likely to be major contributors of socioeconomic differences in health only in contexts with a marked social characterisation of health behaviours. Please see later in the article for the Editors' Summary.

Role modeling, risk, and resilience in California adolescents

PURPOSE

To examine the relationship between role model presence, type of role model, and various health-risk and health-protective behaviors among California adolescents.

METHODS

We used cross-sectional data on 4,010 multiethnic adolescents aged 12-17 years from the 2003 California Health Interview Survey, a population-based random-digit dial telephone survey of more than 40,000 California households. The survey, conducted every other year since 2001, collects extensive demographic, health, and health-related information.

RESULTS

Fifty-nine percent of adolescents identified a role model. Affluent teens were more likely to have a role model than lower income teens. Role models were generally of the same ethnicity and gender as the teens; ethnic congruence was higher among African Americans and whites than Latinos and Asians; gender congruence was higher among males. Type of role model was significantly associated with health-related behaviors. Identification of a teacher was strongly associated with positive health behaviors. Correlations with health-promoting behaviors were generally smaller in magnitude but consistently positive among family member and athlete role models. Peer or entertainer role models were associated with health-risk behaviors.

CONCLUSION

Not only role model presence but also the type of role model is an important predictor of adolescent health-related behaviors. Our findings have implications for designing youth targeted interventions and policies involving role models.

Crossing a border for a low-cost, high-risk environment: smoking status and excessive drinking among young adults in Tijuana

This study examines the drinking and smoking behavior of 2,311 college-age adults traveling from San Diego, California, to Tijuana, Mexico (December 2006 to December 2008). We describe this Border sample's drinking history and smoking status and estimate multivariate models of evening drinking participation and, conditional on drinking, blood alcohol concentration. Noting limitations, we present implications for identifying young adults at high risk for alcohol and tobacco use, particularly females, and lay the foundation for further research examining young adults? alcohol and tobacco use in reduced price scenarios.

Redox-modulatory vitamins and minerals that prospectively predict mortality in older British people: the National Diet and Nutrition Survey of people aged 65 years and over

The predictive power, for total, vascular, cancer and respiratory mortality, of selected redox-modulatory (vitamin and mineral nutrient) indices measured at baseline, was studied in the British National Diet and Nutrition Survey (community-living subset) of people aged 65 years and over. Mortality status and its primary and underlying causes were recorded for 1054 (mean age 76·6 (sd 7·4) years and 49·0 % female) participants, from the baseline survey in 1994–5 until September 2008. During this interval, 74 % of the male and 62 % of the female participants died. Total mortality was significantly predicted by baseline plasma concentrations (per sd) of vitamin C (hazard ratio (HR) 0·81; 95 % CI 0·74, 0·88), α-carotene (HR 0·90; 95 % CI 0·81, 0·99), Se (HR 0·76; 95 % CI 0·69, 0·84), Zn (HR 0·79; 95 % CI 0·72, 0·87), Cu (HR 1·27; 95 % CI 1·14, 1·42) and Fe (HR 0·81; 95 % CI 0·74, 0·89). Total mortality was also significantly predicted by baseline dietary intakes (per sd) of food energy (HR 0·86; 95 % CI 0·79, 0·94), vitamin C (HR 0·88; 95 % CI 0·80, 0·94), carotenoids (HR 0·89; 95 % CI 0·83, 0·96), Zn (HR 0·89; 95 % CI 0·82, 0·96) and Cu (HR 0·91; 95 % CI 0·84, 1·00). Prediction patterns and significance for primary vascular, cancer and respiratory mortality differed in certain respects, but not fundamentally. Model adjustment for known disease or mortality risk predictors resulted in loss of significance for some of the indices; however, plasma Se and Zn, and food energy remained significant predictors. We conclude that total and primary vascular, cancer and respiratory mortality in older British people of both sexes is predicted by several biochemical indices of redox-modulatory nutrients, some of which may reflect the respondents' acute-phase status at baseline, whereas others may reflect the healthiness of their lifestyle.

Is prevention a fantasy, or the future of medicine? A panoramic view of recent data, status, and direction in cardiovascular prevention

Americans are under assault by a fierce epidemic of obesity, diabetes, and cardiovascular disease, of their own doing. Lowered death rates from heart disease and reduced rates of smoking are seriously threatened by the inexorable rise in overweight and obesity. Latest data indicate that 32% of children are overweight or obese, and fewer than 17% exercise sufficiently. Over 68% of adults are overweight, 35% are obese, nearly 40% fulfill criteria for the metabolic syndrome, 8–13% have diabetes, 34% have hypertension, 36% have prehypertension, 29% have prediabetes, 15% of the population with either diabetes, hypertension, or dyslipidemia are undiagnosed, 59% engage in no vigorous activity, and fewer than 5% of the US population qualifies for the American Heart Association (AHA) definition of ideal cardiovascular health. Health, nutrition, and exercise illiteracy is prevalent, while misinformation and unrealistic expectations are the norm. Half of American adults have at least one cardiovascular risk factor. Up to 65% do not have their conventional risk biomarkers under control. Of those patients with multiple risk factors, fewer than 10% have all of them adequately controlled. Even when patients are treated according to evidence-based protocols, about 70% of cardiac events remain unaddressed. Undertreatment is also common. Poor patient adherence, probably well below 50%, adds further difficulty in reducing cardiovascular risk. Available data indicate that only a modest fraction of the total cardiovascular risk burden in the population is actually now being eliminated. A fresh view of these issues, a change in current philosophy, leading to new and different, multimechanistic methods of prevention may be needed. Adherence to published guidelines will improve substantially outcomes in both primary and secondary prevention. Primordial prevention, which does not allow risk values to appear in a population, affords more complete protection than subsequent partial reversal of elevated risk factors or biomarkers. Current evidence supports recent calls for massive educational programs supporting primordial prevention, individual responsibility and pride in achieving population-wide ideal cardiovascular health through lifestyle modification. Environmental and social changes will be necessary, along with major supportive adjustments in the food industry and the assistance of the media. Cooperation is critical to the success of such an initiative.

Conventional and behavioral risk factors explain differences in sub-clinical vascular disease between black and Caucasian South Africans: the SABPA study

OBJECTIVES

There is an emerging burden of cardiovascular disease among urban black Africans in South Africa, which has been largely explained by the transition from traditional African lifestyles to more westernized behavior. We examined the role of health behaviors in explaining the excess burden of sub clinical vascular disease seen in black Africans compared to Caucasians.

METHODS

This was a cross-sectional study, comprising of urban African teachers (n=192 black, 206 Caucasian) working for one of the four Kenneth Kaunda Education districts in the North West Province, South Africa. Conventional cardiovascular risk factors, 24 h ambulatory blood pressure and objectively measured physical activity (Actical® accelerometers), smoking (confirmed by serum cotinine), and alcohol (serum gamma glutamyl transferase) were assessed. The main outcome was a marker of sub-clinical vascular disease, mean carotid intima media thickness (mCIMT), measured using high resolution ultrasound.

RESULTS

Compared with Caucasians, the black Africans demonstrated higher mCIMT (age and sex adjusted β=0.044, 95% CI, 0.024-0.064 mm). The blacks also had higher 24h systolic and diastolic blood pressure, triglycerides, adiposity, and C-reactive protein. In addition, blacks were less physically active (790.0 kcal/d vs 947.3 kcal/d, p<0.001), more likely to smoke (25% vs 16.3%, p=0.002), and demonstrated higher alcohol abuse (gamma glutamyl transferase, 66.6 μ/L vs 27.2 μ/L, p<0.001) compared with Caucasians. The difference in mCIMT between blacks and Caucasians was attenuated by 34% when conventional risk factors were added to the model and a further 18% when health behaviors were included.

CONCLUSION

There is an excess burden of sub clinical vascular disease seen in black Africans compared to Caucasians, which can be largely explained by health behaviors and conventional risk factors.

Effect of positive health factors and all-cause mortality in men

PURPOSE

Although several health-related factors are independently associated with diverse health outcomes, their combined affect on mortality has not been fully described.

METHODS

We examined the combined effect of several positive health factors, including having normal weight (body mass index = 18.5-24.9 kg.m), not smoking (not current smoker), consuming a moderate alcohol intake (1-14 drinks per week), being physically active (moderate to high level), and having a higher cardiorespiratory fitness (top two-thirds), on all-cause mortality in 38,110 men aged 20-84 yr from the Aerobics Center Longitudinal Study.

RESULTS

There were 2642 deaths during an average of 16 yr of follow-up. Compared with men with zero positive health factors, the multivariable-adjusted hazard ratios (HR) of all-cause mortality with one, two, three, four, and five positive health factors were 0.78 (95% confidence interval (CI) = 0.64-0.95), 0.61 (95% CI = 0.50-0.73), 0.54 (95% CI = 0.44-0.65), 0.43 (95% CI = 0.35-0.52), and 0.39 (95% CI = 0.31-0.48), respectively (P for trend <0.001). The combination of five positive health factors accounted for 29% (95% CI = 14%-40%) of population-attributable risk for all-cause mortality.

CONCLUSIONS

Our findings suggest that targeting more of these modifiable health factors may provide substantial health benefits in middle-aged men.

Environmental and lifestyle factors associated with perceived facial age in Chinese women

Perceived facial age has been proposed as a biomarker of ageing with 'looking young for one's age' linked to physical and cognitive functioning and to increased survival for Caucasians. We have investigated the environmental and lifestyle factors associated with perceived facial ageing in Chinese women. Facial photographs were collected from 250 Chinese women, aged 25-70 years in Shanghai, China. Perceived facial age was determined and related to chronological age for each participant. Lifestyle and health information was collected by questionnaire. Bivariate analyses (controlling for chronological age) identified and quantified lifestyle variables associated with perceived facial age. Independent predictors of perceived age were identified by multivariate modelling. Factors which significantly associated with looking younger for one's chronological age included greater years of education (p<0.001), fewer household members (p=0.027), menopausal status (p=0.020), frequency of visiting one's doctor (p=0.013), working indoors (p<0.001), spending less time in the sun (p=0.015), moderate levels of physical activity (p=0.004), higher frequency of teeth cleaning (p<0.001) and more frequent use of facial care products: cleanser (p<0.001); moisturiser (p=0.016) or night cream (p=0.016). Overall, 36.5% of the variation in the difference between perceived and chronological age could be explained by a combination of chronological age and 6 independent lifestyle variables. We have thus identified and quantified a number of factors associated with younger appearance in Chinese women. Presentation of these factors in the context of facial appearance could provide significant motivation for the adoption of a range of healthy behaviours at the level of both individuals and populations.

Impact of lifestyle in middle-aged women on mortality: evidence from the Royal College of General Practitioners' Oral Contraception Study

BACKGROUND

Although many individuals have multiple lifestyle risk factors, few studies have investigated the impact of lifestyle risk factor combinations among women.

AIM

To investigate the relationship between individual and combinations of lifestyle risk factors in middle-aged women with subsequent mortality, and to estimate the associated population attributable risks.

DESIGN OF STUDY

Prospective cohort study.

SETTING

Royal College of General Practitioners' (RCGP) Oral Contraception Study, UK.

METHOD

In 1994-1995, women remaining under follow-up in the RCGP Oral Contraception Study were sent a lifestyle survey, from which modifiable risk factors were identified: pack-years smoked, physical inactivity, never drinking versus consuming at least 7 units of alcohol weekly, and being underweight, overweight, or obese. The cohort was followed to December 2006 or death. Population attributable risks were calculated.

RESULTS

Of 10 059 women studied, 896 died. Pack-years smoked (11-20 years: adjusted hazard ratio [HR] = 1.82, 95% confidence interval [CI] = 1.46 to 2.27; >20 years: adjusted HR = 2.34, 95% CI = 2.00 to 2.74); never drinking alcohol (adjusted HR = 1.66, 95% CI = 1.34 to 2.05); being underweight (adjusted = HR 1.66, 95% CI = 1.03 to 2.68); and physical inactivity (<15 hours/week: adjusted HR = 1.73, 95% CI = 1.46 to 2.04) were significantly associated with mortality compared with their respective reference group. Women with multiple lifestyle risk factors had higher mortality risks than those reporting one factor. The population attributable risk of the combination of smoking, physical inactivity, body mass index outside normal range, and alcohol (never drinking or excess intake) was 59% (95% CI = 31% to 78%).

CONCLUSION

Assuming a causal relationship between lifestyle and mortality, avoidance of four lifestyle risk factors would have prevented 60% of the deaths. The importance of avoiding smoking and undertaking physical inactivity during midlife should continue to be emphasised.

Trends in low-risk lifestyle factors among adults in the United States: findings from the Behavioral Risk Factor Surveillance System 1996-2007

OBJECTIVE

Our objective was to examine recent trends in low-risk lifestyle factors for chronic diseases (not currently smoking, any exercise during the past 30 days, consuming fruits and vegetables ≥5 times per day, and body mass index <25kg/m(2)) among U.S. adults.

METHODS

We used data from 1,580,220 adults aged ≥18 years who participated in one of seven Behavioral Risk Factor Surveillance System surveys conducted from 1996 to 2007.

RESULTS

The age-adjusted percentage of adults meeting all four low-risk lifestyle factors was 8.5% in 1996 and 7.7% in 2007 (p for linear trend <0.001). Significant decreasing trends were noted for men, women, whites, Hispanics, and most age groups. The percentages of participants who were not currently smoking, who had done any exercise during the past 30 days, who reported consuming fruits and vegetables ≥5 times per day, and who had a body mass index <25kg/m(2) were 70.9%, 76.2%, 47.9% and 24.3%, respectively, in 1996 and 77.1%, 80.0%, 37.8%, and 24.5%, respectively, in 2007. Women and whites were more likely than their counterparts to meet all four criteria.

CONCLUSIONS

From 1996 to 2007, the percentage of U.S. adults meeting all four low-risk lifestyle factors decreased slightly.

Are there modifiable risk factors which will reduce the excess mortality in schizophrenia?

The 2009 World Health Organization report on global health risks identifies hypertension, smoking, raised glucose, physical inactivity, obesity and dyslipidaemia, in that order, as being the top six modifiable global mortality risk factors. Patients with schizophrenia have high levels of all these risk factors. There are a small number of studies showing that interventions can improve these, but prospective long-term studies are not available to show their impact on mortality. A number of studies are now supporting the view that patients with schizophrenia may be dying prematurely as they are not gaining access to or receiving the same medical care as the general population. The literature now suggests that low cardiorespiratory fitness and muscle strength are among the strongest predictors of all-cause mortality in the general population. Smoking is still one of the largest risk factors for premature all-cause mortality. The literature supports the thesis that lifestyle intervention programmes addressing exercise, smoking cessation and compliance with medication are likely to have significant impact on mortality in schizophrenia. It will be important to ensure that all patients with schizophrenia have advocates to ensure appropriate treatment and avoid prejudice, and to establish fitness standards in schizophrenia.

Association of adherence to lifestyle recommendations and risk of colorectal cancer: a prospective Danish cohort study

OBJECTIVES

To evaluate the association between a simple lifestyle index based on the recommendations for five lifestyle factors and the incidence of colorectal cancer, and to estimate the proportion of colorectal cancer cases attributable to lack of adherence to the recommendations.

DESIGN

Prospective cohort study.

SETTING

General population of Copenhagen and Aarhus, Denmark.

PARTICIPANTS

55 487 men and women aged 50-64 years at baseline (1993-7), not previously diagnosed with cancer.

MAIN OUTCOME MEASURE

Risk of colorectal cancer in relation to points achieved in the lifestyle index (based on physical activity, waist circumference, smoking, alcohol intake, and diet (dietary fibre, energy percentage from fat, red and processed meat, and fruits and vegetables)) modelled through Cox regression.

RESULTS

During a median follow-up of 9.9 years, 678 men and women had colorectal cancer diagnosed. After adjustment for potential confounders, each additional point achieved on the lifestyle index, corresponding to one additional recommendation that was met, was associated with a lower risk of colorectal cancer (incidence rate ratio 0.89 (95% confidence interval 0.82 to 0.96). In this population an estimated total of 13% (95% CI 4% to 22%) of the colorectal cancer cases were attributable to lack of adherence to merely one additional recommendation among all participants except the healthiest. If all participants had followed the five recommendations 23% (9% to 37%) of the colorectal cancer cases might have been prevented. Results were similar for colon and rectal cancer, but only statistically significant for colon cancer.

CONCLUSIONS

Adherence to the recommendations for physical activity, waist circumference, smoking, alcohol intake, and diet may reduce colorectal cancer risk considerably, and in this population 23% of the cases might be attributable to lack of adherence to the five lifestyle recommendations. The simple structure of the lifestyle index facilitates its use in public health practice.

Differential white blood cell count and type 2 diabetes: systematic review and meta-analysis of cross-sectional and prospective studies

OBJECTIVE

Biological evidence suggests that inflammation might induce type 2 diabetes (T2D), and epidemiological studies have shown an association between higher white blood cell count (WBC) and T2D. However, the association has not been systematically investigated.

RESEARCH DESIGN AND METHODS

Studies were identified through computer-based and manual searches. Previously unreported studies were sought through correspondence. 20 studies were identified (8,647 T2D cases and 85,040 non-cases). Estimates of the association of WBC with T2D were combined using random effects meta-analysis; sources of heterogeneity as well as presence of publication bias were explored.

RESULTS

The combined relative risk (RR) comparing the top to bottom tertile of the WBC count was 1.61 (95% CI: 1.45; 1.79, p = 1.5*10(-18)). Substantial heterogeneity was present (I(2) = 83%). For granulocytes the RR was 1.38 (95% CI: 1.17; 1.64, p = 1.5*10(-4)), for lymphocytes 1.26 (95% CI: 1.02; 1.56, p = 0.029), and for monocytes 0.93 (95% CI: 0.68; 1.28, p = 0.67) comparing top to bottom tertile. In cross-sectional studies, RR was 1.74 (95% CI: 1.49; 2.02, p = 7.7*10(-13)), while in cohort studies it was 1.48 (95% CI: 1.22; 1.79, p = 7.7*10(-5)). We assessed the impact of confounding in EPIC-Norfolk study and found that the age and sex adjusted HR of 2.19 (95% CI: 1.74; 2.75) was attenuated to 1.82 (95% CI: 1.45; 2.29) after further accounting for smoking, T2D family history, physical activity, education, BMI and waist circumference.

CONCLUSIONS

A raised WBC is associated with higher risk of T2D. The presence of publication bias and failure to control for all potential confounders in all studies means the observed association is likely an overestimate.

Promoting functional health in midlife and old age: long-term protective effects of control beliefs, social support, and physical exercise

Background

Previous studies have examined physical risk factors in relation to functional health, but less work has focused on the protective role of psychological and social factors. We examined the individual and joint protective contribution of control beliefs, social support and physical exercise to changes in functional health, beyond the influence of health status and physical risk factors in middle-aged and older adults. Given that functional health typically declines throughout adulthood, it is important to identify modifiable factors that can be implemented to maintain functioning, improve quality of life, and reduce disability.

Methodology/Principal Findings

We conducted a national longitudinal study, Midlife in the United States (MIDUS), with assessments in 1995–1996 and 2004–2006, and 3,626 community-residing adults, aged 32 to 84, were included in the analyses. Functional health (Physical Functioning subscale of the SF-36) and protective factors were measured at both occasions. While controlling for socio-demographic, health status, and physical risk factors (large waist circumference, smoking, and alcohol or drug problems), a composite of the three protective variables (control beliefs, social support, and physical exercise) at Time 1 was significantly related to functional health change. The more of these factors at Time 1, the better the health maintenance over 10 years. Among middle-aged and older adults, declines in health were significantly reduced with an increased number of protective factors.

Conclusion/Significance

Age-related declines in health were reduced among those with more protective factors up to a decade earlier in life. Modifiable psychological, social, and physical protective factors, individually and in the aggregate, are associated with maintenance of functional health, beyond the damaging effects of physical risk factors. The results are encouraging for the prospect of developing interventions to promote functional health and for reducing public health expenditures for physical disability in later life.

Combined impact of lifestyle-related factors on total and cause-specific mortality among Chinese women: prospective cohort study

BACKGROUND

Although cigarette smoking, excessive alcohol drinking, obesity, and several other well-studied unhealthy lifestyle-related factors each have been linked to the risk of multiple chronic diseases and premature death, little is known about the combined impact on mortality outcomes, in particular among Chinese and other non-Western populations. The objective of this study was to quantify the overall impact of lifestyle-related factors beyond that of active cigarette smoking and alcohol consumption on all-cause and cause-specific mortality in Chinese women.

METHODS AND FINDINGS

We used data from the Shanghai Women's Health Study, an ongoing population-based prospective cohort study in China. Participants included 71,243 women aged 40 to 70 years enrolled during 1996-2000 who never smoked or drank alcohol regularly. A healthy lifestyle score was created on the basis of five lifestyle-related factors shown to be independently associated with mortality outcomes (normal weight, lower waist-hip ratio, daily exercise, never exposed to spouse's smoking, higher daily fruit and vegetable intake). The score ranged from zero (least healthy) to five (most healthy) points. During an average follow-up of 9 years, 2,860 deaths occurred, including 775 from cardiovascular disease (CVD) and 1,351 from cancer. Adjusted hazard ratios for mortality decreased progressively with an increasing number of healthy lifestyle factors. Compared to women with a score of zero, hazard ratios (95% confidence intervals) for women with four to five factors were 0.57 (0.44-0.74) for total mortality, 0.29 (0.16-0.54) for CVD mortality, and 0.76 (0.54-1.06) for cancer mortality. The inverse association between the healthy lifestyle score and mortality was seen consistently regardless of chronic disease status at baseline. The population attributable risks for not having 4-5 healthy lifestyle factors were 33% for total deaths, 59% for CVD deaths, and 19% for cancer deaths.

CONCLUSIONS

In this first study, to our knowledge, to quantify the combined impact of lifestyle-related factors on mortality outcomes in Chinese women, a healthier lifestyle pattern-including being of normal weight, lower central adiposity, participation in physical activity, nonexposure to spousal smoking, and higher fruit and vegetable intake-was associated with reductions in total and cause-specific mortality among lifetime nonsmoking and nondrinking women, supporting the importance of overall lifestyle modification in disease prevention. Please see later in the article for the Editors' Summary.