Combined effect of health behaviours and risk of first ever stroke in 20,040 men and women over 11 years' follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): prospective population study

Assessing the Effectiveness of eHealth Interventions to Manage Multiple Lifestyle Risk Behaviors Among Older Adults: Systematic Review and Meta-Analysis

BACKGROUND

Developing adverse lifestyle behaviors increases the risk of a variety of chronic age-related diseases, including cardiovascular disease, obesity, and Alzheimer disease. There is limited evidence regarding the effectiveness of eHealth-based multiple health behavior change (MHBC) interventions to manage lifestyle risk behaviors.

OBJECTIVE

The purpose of this systematic evaluation was to assess the effectiveness of eHealth MHBC interventions in changing ≥2 major lifestyle risk behaviors in people aged ≥50 years.

METHODS

The literature search was conducted in 6 electronic databases-PubMed, Embase, Web of Science, Scopus, Cochrane Library, and SPORTDiscus-from inception to May 1, 2024. Eligible studies were randomized controlled trials of eHealth interventions targeting ≥2 of 6 behaviors of interest: alcohol use, smoking, diet, physical activity (PA), sedentary behavior, and sleep.

RESULTS

A total of 34 articles with 35 studies were included. eHealth-based MHBC interventions significantly increased smoking cessation rates (odds ratio 2.09, 95% CI 1.62-2.70; P<.001), fruit intake (standardized mean difference [SMD] 0.18, 95% CI 0.04-0.32; P=.01), vegetable intake (SMD 0.17, 95% CI 0.05-0.28; P=.003), self-reported total PA (SMD 0.22, 95% CI 0.02-0.43; P=.03), and objectively measured moderate to vigorous PA (SMD 0.25, 95% CI 0.09-0.41; P=.002); in addition, the interventions decreased fat intake (SMD -0.23, 95% CI -0.33 to -0.13; P<.001). No effects were observed for alcohol use, sedentary behavior, or sleep. A sensitivity analysis was conducted to test the robustness of the pooled results. Moreover, the certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework.

CONCLUSIONS

eHealth-based MHBC interventions may be a promising strategy to increase PA, improve diet, and reduce smoking among older adults. However, the effect sizes were small. Further high-quality, older adult-oriented research is needed to develop eHealth interventions that can change multiple behaviors.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42023444418; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023444418.

Lifestyle modification interventions for adults with intellectual disabilities: systematic review and meta-analysis at intervention and component levels

BACKGROUND

Adults with intellectual disabilities (IDs) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs.

METHODS

A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours and poor diet in adults (aged ≥ 18 years) with ID were included. Meta-analysis was conducted at the intervention level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie's 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Risk of Bias (ROB) Version 2 and Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I). The study involved a patient and public involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results and organising of dissemination events.

RESULTS

Our literature search identified 12 180 articles, of which 80 studies with 4805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only or multiple behaviours generated positive effects on various outcomes while some interventions led to no change or worsened outcomes, which could be attributed to the presence of a single core-component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared with treatment-as-usual and each other. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss [mean difference (MD) = -3.61, 95% credible interval (CrI) -9.68 to 1.95] and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the component network meta-analysis for which additional components were identified. Most studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation.

CONCLUSION

Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires and abilities of people with ID.

Lifestyle behaviors and risk of cardiovascular disease and prognosis among individuals with cardiovascular disease: a systematic review and meta-analysis of 71 prospective cohort studies

BACKGROUND

Healthy lifestyle behaviors (LBs) have been widely recommended for the prevention and management of cardiovascular disease (CVD). Despite a large number of studies exploring the association between combined LBs and CVD, a notable gap exists in integration of relevant literatures. We conducted a systematic review and meta-analysis of prospective cohort studies to analyze the correlation between combined LBs and the occurrence of CVD, as well as to estimate the risk of various health complications in individuals already diagnosed with CVD.

METHODS

Articles published up to February 10, 2023 were sourced through PubMed, EMBASE and Web of Science. Eligible prospective cohort studies that reported the relations of combined LBs with pre-determined outcomes were included. Summary relative risks (RRs) and 95% confidence intervals (CIs) were estimated using either a fixed or random-effects model. Subgroup analysis, meta-regression, publication bias, and sensitivity analysis were as well performed.

RESULTS

In the general population, individuals with the healthiest combination of LBs exhibited a significant risk reduction of 58% for CVD and 55% for CVD mortality. For individuals diagnosed with CVD, adherence to the healthiest combination of LBs corresponded to a significant risk reduction of 62% for CVD recurrence and 67% for all-cause mortality, when compared to those with the least-healthy combination of LBs. In the analysis of dose-response relationship, for each increment of 1 healthy LB, there was a corresponding decrease in risk of 17% for CVD and 19% for CVD mortality within the general population. Similarly, among individuals diagnosed with CVD, each additional healthy LB was associated with a risk reduction of 27% for CVD recurrence and 27% for all-cause mortality.

CONCLUSIONS

Adopting healthy LBs is associated with substantial risk reduction in CVD, CVD mortality, and adverse outcomes among individuals diagnosed with CVD. Rather than focusing solely on individual healthy LB, it is advisable to advocate for the adoption of multiple LBs for the prevention and management of CVD.

TRIAL REGISTRATION

PROSPERO: CRD42023431731.

Trends in Unhealthy Lifestyle Factors among Adults with Stroke in the United States between 1999 and 2018

BACKGROUND: Unhealthy lifestyle factors are risk factors for stroke, and they play a key role in stroke secondary prevention. A better understanding of these factors may aid with improvements in public health policy. OBJECTIVE: Our objective was to comprehensively understand the trends in unhealthy lifestyle factors in people who have previously had a stroke in the US. METHODS: Utilizing data from the biannual United States National Health and Nutrition Examination Surveys (NHANESs) between 1999 and 2018, we collated data on unhealthy lifestyle factors (smoking, alcohol drinking, depression, unhealthy diet, high BMI, physical inactivity, and sedentary behavior) in adults with a history of stroke. The Joinpoint Regression model was used to calculate the annual percentage change (APC) and average annual percentage change (AAPC) to identify trends. Logistic regression modeling was used to identify the influence of sociodemographic factors (age, sex, race/ethnicity, marital status, employment status, family income, and highest education level). RESULTS: The analysis included 2017 respondents with a history of stroke. Current alcohol drinking (39.3% (95% confidence interval: 29.8, 48.7) to 57.4% (45.7, 69.0) p = 0.008) and obesity (39.2% (28.3, 50.2) to 49.4% (38.9, 59.8) p = 0.029) increased significantly from 1999 to 2018. The prevalence of smoking and depression remained generally stable. The proportion of respondents with an unhealthy diet decreased from 1999 (44.5% (32.4, 56.5)) to 2011 (29.0% (17.5, 40.4) p = 0.019), but then returned to its original prevalence in 2018 (42.0% (31.4, 52.7)). From 2007 to 2018, the proportion of respondents who were physically inactive decreased significantly, from 70.4% (64.4, 76.3) to 55.1% (46.1, 64.2; p = 0.017). After a gradual increase in sedentary activity from 2007 to 2012, this declined from 2013 to 2018, with no statistical significance. We found stroke survivors who were widowed, divorced, separated, or unemployed were at a higher risk of having unhealthy lifestyles than those who were employed or had other marital statuses. CONCLUSIONS: A modest reduction in the prevalence of physical inactivity was observed in Americans with a history of stroke between 1999 and 2018. The prevalences of smoking, drinking, depression, poor diet, obesity, and sedentary behavior were stable or increasing.

Effects of Face-to-Face and eHealth Blended Interventions on Physical Activity, Diet, and Weight-Related Outcomes among Adults: A Systematic Review and Meta-Analysis

An increasing number of studies are blending face-to-face interventions and electronic health (eHealth) interventions to jointly promote physical activity (PA) and diet among people. However, a comprehensive summary of these studies is lacking. This study aimed to synthesize the characteristics of blended interventions and meta-analyze the effectiveness of blended interventions in promoting PA, diet, and weight-related outcomes among adults. Following the PRISMA guidelines, PubMed, SPORTDiscus, PsycINFO, Embase, and Web of Science were systematically searched to identify eligible articles according to a series of inclusion criteria. The search was limited to English language literature and publication dates between January 2002 and July 2022. Effect sizes were calculated as standardized mean difference (SMD) for three intervention outcomes (physical activity, healthy diet, and weight-related). Random effect models were used to calculate the effect sizes. A sensitivity analysis and publication bias tests were conducted. Of the 1561 identified studies, 17 were eligible for the systematic review. Studies varied in participants, intervention characteristics, and outcome measures. A total of 14 studies were included in the meta-analyses. There was evidence of no significant publication bias. The meta-analyses indicated that the blended intervention could lead to a significant increase in walking steps (p < 0.001), total PA level (p = 0.01), and diet quality (p = 0.044), a significant decrease in energy intake (p = 0.004), weight (p < 0.001), BMI (p < 0.001), and waist circumferences (p = 0.008), but had no influence on more moderate-to-vigorous physical activity (MVPA) or fruit and vegetable intake among adults, compared with a control group. The study findings showed that blended interventions achieve preliminary success in promoting PA, diet, and weight-related outcomes among adults. Future studies could improve the blended intervention design to achieve better intervention effectiveness.

Does the Structure Matter? An External Validation and Health Economic Results Comparison of Event Simulation Approaches in Severe Obesity

OBJECTIVES

As obesity-associated events impact long-term survival, health economic (HE) modelling is commonly applied, but modelling approaches are diverse. This research aimed to compare the events simulation and the HE outcomes produced by different obesity modelling approaches.

METHODS

An external validation, using the Swedish obesity subjects (SOS) study, of three main structural event modelling approaches was performed: (1) continuous body mass index (BMI) approach; (2) risk equation approach; and (3) categorical BMI-related approach. Outcomes evaluated were mortality, cardiovascular events, and type 2 diabetes (T2D) for both the surgery and the control arms. Concordance between modelling results and the SOS study were investigated by different state-of-the-art measurements, and categorized by the grade of deviation observed (grades 1-4 expressing mild, moderate, severe, and very severe deviations). Furthermore, the costs per quality-adjusted life-year (QALY) gained of surgery versus controls were compared.

RESULTS

Overall and by study arm, the risk equation approach presented the lowest average grade of deviation (overall grade 2.50; control arm 2.25; surgery arm 2.75), followed by the continuous BMI approach (overall 3.25; control 3.50; surgery 3.00) and by the categorial BMI approach (overall 3.63; control 3.50; surgery 3.75). Considering different confidence interval limits, the costs per QALY gained were fairly comparable between all structural approaches (ranging from £2,055 to £6,206 simulating a lifetime horizon).

CONCLUSION

None of the structural approaches provided perfect external event validation, although the risk equation approach showed the lowest overall deviations. The economic outcomes resulting from the three approaches were fairly comparable.

Molecular mechanisms underlying some major common risk factors of stroke

Ischemic and hemorrhagic strokes are the most common known cerebrovascular disease which can be induced by modifiable and non-modifiable risk factors. Age and race are the most common non-modifiable risk factors of stroke. However, hypertension, diabetes, obesity, dyslipidemia, physical inactivity, and cardiovascular disorders are major modifiable risk factors. Understanding the molecular mechanism mediating each of these risk factors is expected to contribute significantly to reducing the risk of stroke, preventing neural damage, enhancing rehabilitation, and designing suitable treatments. Abnormalities in the structure of the blood-brain barrier and blood vessels, thrombosis, vasoconstriction, atherosclerosis, reduced cerebral blood flow, neural oxidative stress, inflammation, and apoptosis, impaired synaptic transmission, excitotoxicity, altered expression/activities of many channels and signaling proteins are the most knows mechanisms responsible for stroke induction. However, the molecular role of risk factors in each of these mechanisms is not well understood and requires a lot of search and reading. This review was designed to provide the reader with a single source of information that discusses the current update of the prevalence, pathophysiology, and all possible molecular mechanisms underlying some major risk factors of stroke namely, hypertension, diabetes mellitus, dyslipidemia, and lipid fraction, and physical inactivity. This provides a full resource for understanding the molecular effect of each of these risk factors in stroke.

Digital multiple health behaviour change intervention targeting online help seekers: protocol for the COACH randomised factorial trial

INTRODUCTION

Unhealthy lifestyle behaviours continue to be highly prevalent, including alcohol consumption, unhealthy diets, insufficient physical activity and smoking. There is a lack of effective interventions which have a large enough reach into the community to improve public health. Additionally, the common co-occurrence of multiple unhealthy behaviours demands investigation of efforts which address more than single behaviours.

METHODS AND ANALYSIS

The effects of six components of a novel digital multiple health behaviour change intervention on alcohol consumption, diet, physical activity and smoking (coprimary outcomes) will be estimated in a factorial randomised trial. The components are designed to facilitate behaviour change, for example, through goal setting or increasing motivation, and are either present or absent depending on allocation (ie, six factors with two levels each). The study population will be those seeking help online, recruited through search engines, social media and lifestyle-related websites. Included will be those who are at least 18 years of age and have at least one unhealthy behaviour. An adaptive design will be used to periodically make decisions to continue or stop recruitment, with simulations suggesting a final sample size between 1500 and 2500 participants. Multilevel regression models will be used to analyse behavioural outcomes collected at 2 months and 4 months postrandomisation.

ETHICS AND DISSEMINATION

Approved by the Swedish Ethical Review Authority on 2021-08-11 (Dnr 2021-02855). Since participation is likely motivated by gaining access to novel support, the main concern is demotivation and opportunity cost if the intervention is found to only exert small effects. Recruitment began on 19 October 2021, with an anticipated recruitment period of 12 months.

TRIAL REGISTRATION NUMBER

ISRCTN16420548.

Residential Characteristics as Factors Related to Healthy Behavior Practices-Decision Tree Model Analysis Using a Community Health Survey from Korea

In this study, we sought to identify relevant factors in healthy behavior practices, including not only individual-level variables but also regional and physical environments. Data from the Korea Community Health Survey (KCHS) of Gyeongsangnam-do in 2018 were used, with data from 16,519 of the 17,947 individuals (excluding 1428 individuals who had missing values) who participated in the survey. Healthy behavior practices were defined as meeting the criteria for all three modifiable healthy behaviors (non-smoking, moderate alcohol consumption, regular walking). A decision tree analysis was performed. In men, healthy behavior practices were lower in the unemployed population, in those aged 40−50 years, living in rural residential areas, and with stress. For women who lived in areas with small populations (<100,000 population), healthy behavior practices were below-average. Men and women who had below-average healthy behavior practices reported poor access to places for exercise and fair or poor self-rated health statuses. It is necessary to implement a health behavior practice intervention that considers not only individual characteristics but also access to local exercise facilities and residential area characteristics (urban, rural). Since age is an important variable in healthy behaviors for both men and women, customized programs that consider age should be provided.

Risk Factors for Locomotive Crew Members Depending on Their Place of Work

PURPOSE

The purpose of this study is to examine the prevalence of workplace exposure, behavior, and individual health conditions, along with resulting medical activity among locomotive crew members depending on their place of work.

PATIENTS AND METHODS

Participants included 5585 train drivers and 3723 train drivers' assistants (7% of the total train operators in the Russian Federation). Measured height and weight were used to calculate body mass index (BMI), and waist circumference, pulse rate, and blood pressure were also measured. The risk assessment was conducted using the STEPS tool. The level of commitment to a Healthy Lifestyle was assessed based on World Health Organization recommendations. Occupational risk factors were surveyed. Morbidity was analyzed over the past year.

RESULTS

The lowest frequency of work exposure risk factors was found for employees of the Trans-Baikal railway; the highest was among Krasnoyarsk, North, and South-East. The participants from the Far East and October Railways had the lowest self-reported frequency of behavioral risk factors. The participants from the Eastern Siberian, October, and Southern Urals railways had the lowest occurrence of individual health conditions. The participants from the East Siberian, Far East, Kuibyshev, and Sverdlovsk railways were the least likely to visit their doctor, take temporary disability leave, or be hospitalized. The total assessed Healthy Lifestyle commitment index was higher for participants from the Far Eastern and Southern Urals railways. The participants from the Moscow and October railways were the least committed to a Healthy Lifestyle.

CONCLUSIONS

Significant differences exist between risk factors and Healthy Lifestyle commitment between railways. Future research should examine changes due to a new corporate health program introduced in 2020.

Sex Differences in Physical Activity and Incident Stroke: A Systematic Review

PURPOSE

Physical inactivity, a modifiable risk factor for cardiovascular disease, is independently associated with stroke. Though some prior data have suggested sex differences in levels of physical activity, whether there are sex differences in the role of physical activity in primary stroke prevention is largely unknown. This systematic review identifies and describes recent findings on sex differences in the association between physical activity and incident (first-ever) stroke. This review also describes the current evidence on the strength of the association between physical activity and a reduced stroke risk in women in particular.

METHODS

Using a prespecified strategy, PubMed/MEDLINE and Cochrane Central were searched to identify observational studies or trials published from 2000 to 2020 and reporting sex differences in physical activity and incident stroke. To be included, among other criteria, studies had to include sex-specific effect estimates from women, men, or both. Titles, abstracts, and full-text articles were screened to identify studies meeting the inclusion criteria, and adjusted sex-specific estimates of the association between physical activity and incident stroke for total stroke (ischemic plus hemorrhagic) or ischemic stroke were abstracted.

FINDINGS

Thirty-seven studies met the inclusion criteria. Of 17 studies that included data on total incident stroke (ischemic and hemorrhagic combined) in both women and men, 7 (41%) showed similar associations between physical activity and incident stroke between women and men, 6 (35%) suggested a significant effect in women but not in men, and 3 (18%) showed a significant effect in men but not in women. Of 10 studies that included data on ischemic stroke in women and men, 5 (50%) suggested similar effects in women and men, 4 (40%) suggested a significant effect in women but not in men, and 1 (10%) showed an effect in men but not women. In women specifically, the majority of included studies demonstrated a reduced risk for incident stroke with physical activity, with relative risk reductions ranging from 11% to 72%, though most estimates fell between 20% and 40%.

IMPLICATIONS

The majority of studies indicated a clear association between physical activity and a reduction in stroke risk. Studies were split as to the potential for sex differences in this association. Future prospective investigations should identify strategies for the use of increased physical activity for primary stroke prevention, with sex-specific considerations as warranted. The data on sex-specific dose-response relationship between physical activity and stroke risk are inconclusive and warrant more research.

The Lifestyle-Related Cardiovascular Risk Is Modified by Sleep Patterns

OBJECTIVE

To prospectively assess whether sleep patterns modified lifestyle-associated cardiovascular disease (CVD) risk.

PATIENTS AND METHODS

This study included 393,690 participants without CVD at baseline measurements between March 13, 2006, and October 1, 2010, from UK Biobank. A lifestyle score was calculated on the basis of the 4 lifestyle factors (smoking, alcohol consumption, physical activity, and diet), and sleep patterns were constructed based on sleep duration, chronotype, insomnia, snoring, and daytime dozing.

RESULTS

During a median follow-up of 8.93 years, we observed 10,218 incident CVD events, including 6595 myocardial infarctions (MIs) and 3906 strokes. We found that sleep patterns significantly modified the relations of the lifestyle score with incident CVD (P for interaction =.007) and MI (P for interaction =.004). Among participants with a poor sleep pattern, unfavorable lifestyle (per score increase) was associated with 25% (95% CI, 13% to 39%) and 29% (95% CI, 13% to 47%) increased risks for CVD and MI, while among participants with a healthy sleep pattern, unfavorable lifestyle was associated with 18% (95% CI, 15% to 21%) and 17% (95% CI, 13% to 21%) increased risks for CVD and MI.

CONCLUSION

Our results indicate that adherence to a healthy sleep pattern may attenuate the CVD risk associated with an unfavorable lifestyle.

Digitally characterizing the dynamics of multiple health behavior change

OBJECTIVE

We applied the ORBIT model to digitally define dynamic treatment pathways whereby intervention improves multiple risk behaviors. We hypothesized that effective intervention improves the frequency and consistency of targeted health behaviors and that both correlate with automaticity (habit) and self-efficacy (self-regulation).

METHOD

Study 1: Via location scale mixed modeling we compared effects when hybrid mobile intervention did versus did not target each behavior in the Make Better Choices 1 (MBC1) trial (n = 204). Participants had all of four risk behaviors: low moderate-vigorous physical activity (MVPA) and fruit and vegetable consumption (FV), and high saturated fat (FAT) and sedentary leisure screen time (SED). Models estimated the mean (location), between-subjects variance, and within-subject variance (scale).

RESULTS

Treatment by time interactions showed that location increased for MVPA and FV (Bs = 1.68, .61; ps < .001) and decreased for SED and FAT (Bs = -2.01, -.07; ps < .05) more when treatments targeted the behavior. Within-subject variance modeling revealed group by time interactions for scale (taus = -.19, -.75, -.17, -.11; ps < .001), indicating that all behaviors grew more consistent when targeted.

METHOD

Study 2: In the MBC2 trial (n = 212) we examined correlations between location, scale, self-efficacy, and automaticity for the three targeted behaviors.

RESULTS

For SED, higher scale (less consistency) but not location correlated with lower self-efficacy (r = -.22, p = .014) and automaticity (r = -.23, p = .013). For FV and MVPA, higher location, but not scale, correlated with higher self-efficacy (rs = .38, .34, ps < .001) and greater automaticity (rs = .46, .42, ps < .001).

CONCLUSIONS

Location scale mixed modeling suggests that both habit and self-regulation changes probably accompany acquisition of complex diet and activity behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Comparison of four healthy lifestyle scores for predicting cardiovascular events in a national cohort study

The protective effect of different healthy lifestyle scores for the risk of cardiovascular disease (CVD) was reported, although the comparisons of performance were lacking. We compared the performance measures of CVDs from different healthy lifestyle scores among Taiwanese adults. We conducted a nationwide prospective cohort study of 6042 participants (median age 43 years, 50.2% women) in Taiwan's Hypertensive, Hyperglycemia and Hyperlipidemia Survey, of whom 2002 were free of CVD at baseline. The simple and weighted the Mediterranean diet related healthy lifestyle (MHL) scores were defined as a combination of normal body mass index, Mediterranean diet, adequate physical activity, non-smokers, regular healthy drinking, and each dichotomous lifestyle factor. The World Cancer Research Fund and American Institute for Cancer Research cancer prevention recommended lifestyle and Life's Simple 7 following the guideline definition. The incidence of CVD among the four healthy lifestyle scores, each divided into four subgroups, was estimated. During a median 14.3 years follow-up period, 520 cases developed CVD. In the multivariate-adjusted Cox proportional hazard models, adherence to the highest category compared with the lowest one was associated with a lower incidence of CVD events, based on the simple (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.2-0.94) and weighted MHL scores (HR 0.44, 95% CI 0.28-0.68). Additionally, age played a role as a significant effect modifier for the protective effect of the healthy lifestyle scores for CVD risk. Specifically, the performance measures by integrated discriminative improvement showed a significant increase after adding the simple MHL score (integrated discriminative improvement: 0.51, 95% CI 0.16-0.86, P = 0.002) and weighted MHL score (integrated discriminative improvement: 0.38, 95% CI 0.01-0.74, P = 0.021). We demonstrated that the healthy lifestyle scores with an inverse association with CVD and reduced CVD risk were more likely for young adults than for old adults. Further studies to study the mechanism of the role of lifestyle on CVD prevention are warranted.

Understanding the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities: protocol for a mixed-methods systematic review

BACKGROUND

Adults with learning disabilities have an increased disposition to unhealthy lifestyle behaviours which often occur simultaneously. Existing studies focus on complex interventions targeting unhealthy diet, physical inactivity, sedentary behaviour, smoking, and alcohol use to reduce health risks experienced. It is essential to understand how well these interventions work, what works, for whom, in what context and why. This study aims to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions for adults with learning disabilities.

METHODS

This is a mixed-methods systematic review consisting of a network meta-analysis (NMA) and realist synthesis. Electronic databases (ASSIA, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched from inception to 14 January 2021 with no language restriction. Additionally, trial registries, grey literature databases and references lists will be searched. Studies related to lifestyle modification interventions on the adult population (>18 years) with learning disabilities will be eligible for inclusion. Two independent researchers will screen studies, extract data and assess its quality and risk of bias using the Cochrane Collaboration's Risk of Bias Assessment Tool (RoB Version 2) and ROBINS-I. The strength of the body of evidence will be assessed based on the GRADE approach. The NMA will incorporate results from RCTs and quasi-experimental studies to estimate the effectiveness of various lifestyle interventions. Where appropriate, a component NMA (CNMA) will be used to estimate effectiveness. The realist synthesis will complement and explain the findings of NMA and CNMA by including additional qualitative and mixed-methods studies. Studies will be included based on their relevance to the programme theory and the rigour of their methods, as determined by quality appraisal tools appropriate to the study design. Results from both syntheses will be incorporated into a logic model.

DISCUSSION

The paucity of population-specific lifestyle interventions contributes to the challenges of behaviour change in adults with learning disabilities. This study will provide an evidence-base from which various stakeholders can develop effective interventions for adults with learning disabilities. The evidence will also help prioritise and inform research recommendations for future primary research so that people with learning disabilities live happier, healthier and longer lives.

TRIAL REGISTRATION

PROSPERO CRD 42020223290.

Use of AUDIT-C alcohol screening tool in NHS general dental practices in North London

Background The numerous health risks of excessive alcohol consumption are well documented. Individuals at risk of harm from alcohol consumption can be identified through alcohol screening tools; however, there is limited research regarding their use in general dental practices.Methods Data were collected as part of a feasibility trial evaluating delivery of brief alcohol advice in general dental practices in North London. Patient demographics and health-related behaviours were collected, and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool was used to assess alcohol consumption patterns.Results The analytical sample comprised 552 dental patients, of whom approximately half (46%) were drinking alcohol at hazardous levels. Males, younger adults, those who consumed red meat weekly and smokers all had significantly increased risks of excessive alcohol consumption. Smokers were more likely to consume excessive levels of alcohol irrespective of smoking frequency. Notable sex differences in alcohol consumption were identified, with males being more likely to consume alcohol frequently and in larger quantities than females.Conclusion The AUDIT-C tool can be used in general dental practice to screen for harmful levels of alcohol consumption. Clear associations exist between patient demographics, health behaviours and excessive alcohol consumption.

Identifying Patterns of Alcohol Use and Obesity-Related Factors Among Emerging Adults: A Behavioral Economic Analysis

BACKGROUND

Although heavy alcohol consumption and maladaptive eating behaviors have been shown to co-occur among college students, less is known about the co-occurrence of these behaviors in a more diverse community-dwelling, emerging adult sample. The purpose of this study was to: (i) identify classes of emerging adults by their reported alcohol consumption patterns, food addiction symptoms, and body mass index; and (ii) determine whether these classes differed on indices of behavioral economic reinforcer pathology (e.g., environmental reward deprivation, impulsivity, alcohol demand).

METHOD

Emerging adult participants were recruited as part of a study on risky alcohol use (n = 602; 47% white, 41.5% Black; mean age = 22.63, SD = 1.03). Participants completed questionnaires on alcohol and food-related risk factors and underwent anthropometric assessment.

RESULTS

Latent profile analysis suggested a four-profile solution: a moderate alcohol severity, overweight profile (Profile 1; n = 424, 70.4%), a moderate alcohol severity, moderate food addiction + obese profile (Profile 2; n = 93, 15.4%), a high alcohol severity, high food addiction + obese profile (Profile 3; n = 44, 7.3%), and a high alcohol severity, overweight profile (Profile 4; n = 41, 6.8%). Individuals in Profile 1 reported significantly lower levels of environmental reward deprivation than either Profile 2 or 3, and participants in Profile 3 reported significantly higher environmental reward deprivation than those in Profile 4 (p < 0.001). Profile 4 demonstrated significantly higher alcohol demand intensity and Omax and lower demand elasticity than Profile 1, Profile 2, or Profile 3. Profile 4 also demonstrated significantly greater proportionate substance-related reinforcement than Profile 1 (p < 0.001) and Profile 2 (p = 0.004).

CONCLUSION

Maladaptive eating patterns and alcohol consumption may share common risk factors for reinforcer pathology including environmental reward deprivation, impulsivity, and elevated alcohol demand.

Multiple Health Risk Factors in Vocational Education Students: A Systematic Review

Health risk factors such as tobacco smoking, inadequate fruit intake, inadequate vegetable intake, risky alcohol consumption, physical inactivity, obesity, anxiety and depression often commence during adolescence and young adulthood. Vocational education institutions enrol many students in these age groups making them an important setting for addressing multiple health risk factors. This systematic review examined (i) co-occurrence of health risk factors, (ii) clustering of health risk factors, and (iii) socio-demographic characteristics associated with co-occurrence and/or clusters of health risks among vocational education students. MEDLINE, PsycINFO, EMBASE, CINAHL and Scopus were searched to identify eligible studies published by 30 June 2020. Two reviewers independently extracted data and assessed methodological quality using the National Heart, Lung and Blood Institute Quality Assessment Tool. Five studies assessed co-occurrence and three studies clustering of health risks. Co-occurrence of health risk factors ranged from 29–98% and clustering of alcohol use and tobacco smoking was commonly reported. The findings were mixed about whether gender and age were associated with co-occurrence or clustering of health risks. There is limited evidence examining co-occurrence and clustering of health risk factors in vocational education students. Comprehensive assessment of how all these health risks co-occur or cluster in vocational education students is required.

Combined healthy lifestyle factors are more beneficial in reducing cardiovascular disease in younger adults: a meta-analysis of prospective cohort studies

To determine the association between combined lifestyle factors, including healthy diet, moderate alcohol consumption, non-smoking, physical activity, and optimal weight, and cardiovascular disease (CVD) risk among younger and older adults. We conducted a literature search using PubMed, EMBASE, Cochrane Library, and EBSCO databases up to November 30, 2019 and performed dose-response analysis, subgroup analysis and meta-regression with odds ratios and 95% confidence intervals (CIs). Twenty cohort studies involving 1,090,261 participants with 46,288 cardiovascular events and mean follow-up duration of 12.33 years were included. Compared with the group with the lowest number of healthy lifestyle factors, the group with the highest number had lower CVD risk [pooled hazard ratio, 0.37 (95% CI 0.31-0.43)]. With age as an effect modifier, the lifetime risk of CVD was 0.31 (95% CI 0.24-0.41) at age 37.1-49.9 years, 0.36 (95% CI 0.30-0.45) at age 50.0-59.9 years and 0.49 (95% CI 0.38-0.63) at age 60.0-72.9 years. The hazard ratio of CVD significantly increased from 37.1 to 72.9 years of age [slope in multivariate meta-regression: 0.01 (95% CI < 0.001-0.03; p = 0.042)]. Younger adults have more cardiovascular benefits from combined healthy lifestyle factors.

Results of a Pilot Trial of a Lifestyle Intervention for Stroke Survivors: Healthy Eating and Lifestyle after Stroke

OBJECTIVES

Although healthy lifestyle practices mitigate recurrent stroke risk and mortality, few stroke survivors adhere to them, particularly among socioeconomically disadvantaged communities. We developed and pilot tested a occupational therapy-based lifestyle management intervention, Healthy Eating And Lifestyle after Stroke (HEALS), to improve stroke survivors' self-management skills relating to diet and physical activity and evaluated it in a diverse safety-net population.

MATERIALS AND METHODS

One hundred English- or Spanish-speaking participants with stroke or transient ischemic attack were randomized to a 6-week occupational therapist-led group lifestyle intervention vs. usual care. Each of the six 2-h group sessions included didactic presentations on diet and physical activity, peer exchange, personal exploration with goal setting, and direct experience through participation in a relevant activity. Primary outcomes at 6 months were change in body mass index, fruit/vegetable intake, and physical activity. Secondary outcomes included change in waist circumference, smoking, blood pressure, high-density lipoprotein, low-density lipoprotein, triglyceride, total cholesterol, glycosylated hemoglobin levels, quality of care, and perceptions of care. Effect sizes were determined in preparation for a larger randomized controlled trial powered to detect a difference in primary outcomes. A nested formative evaluation assessed facilitators and barriers to implementation, acceptance, and intervention adherence.

RESULTS

There were no significant changes in primary or secondary outcomes at 6 months. Effect sizes for all outcomes were small (< 0.2). Focus group participants recommended extending the intervention program duration with more sessions, additional information on stroke and vascular risk factors, an interdisciplinary approach, additional family involvement, and incentives. Providers recommended longer program duration, more training, fidelity checks to ensure standardized program delivery, and additional incentives for participants.

CONCLUSIONS

The HEALS intervention was feasible in a safety-net setting, but effect sizes were small. A longer-duration intervention, with intervener fidelity checks may be warranted.

TRIAL REGISTRATION

NCT01550822.

Pre-stroke adherence to a Mediterranean diet pattern is associated with lower acute ischemic stroke severity: a cross-sectional analysis of a prospective hospital-register study

Background

High adherence to a Mediterranean Diet is associated with reduced incidence and mortality of acute ischemic stroke (AIS) but may also be associated with severity. Our purpose was to investigate the association of adherence to a Mediterranean diet and severity in a prospective hospital register of AIS patients.

Methods

We included AIS patients admitted from February 2017 to July 2019. All were assessed by a neurologist with a standard stroke protocol, including NIHSS. Adherence to Mediterranean diet was prospectively measured by the 14-point Mediterranean Diet Adherence Screener (MEDAS) and defined as low (0–6 points) or high (7–14 points). Demographic and clinical characteristics were compared by group with univariate analysis. A Generalized Linear Model (GLM) was used to investigate the association of admission NIHSS as a continuous ordinal variable and an ordinal logistic regression (OLR) analysis to determine the independent association of the NIHSS quartiles with adherence to Mediterranean diet.

Results

Three hundred sixty-eight patients were included, mean age 68.3 (17.7), 158 (42.9%) females. The median NIHSS score was 3 (IQR 1–9) and the median MEDAS score was 6 (IQR 4.5–8). Patients with high MEDAS scores had significantly lower; admission NIHSS scores, sedentary lifestyle, body mass index, total and LDL cholesterol levels, but higher alcohol consumption. After adjustments, high adherence to Mediterranean diet remained independently associated with lower stroke severity both in the GLM (β coefficient = − 0.19, p = 0.01) and in the OLR model (OR for lower NIHSS quartiles 0.6 (95% CI 0.37–0.98, p = 0.04).

Conclusions

Higher pre-stroke adherence to a Mediterranean diet is independently associated with lower AIS severity.

Socioeconomic Inequalities in Clustering of Health-Compromising Behaviours among Indian Adolescents

Background

The simultaneous occurrence of health-compromising behaviors can accentuate the risk of noncommunicable diseases (NCDs). This study aimed to examine the existence and patterns of clustering of four NCD risk behaviors among adolescents and its association with social position. In addition, socioeconomic inequalities in the occurrence of clustering of NCD risk behaviors were also assessed.

Methods

A cross-sectional study was undertaken among 1218 adolescents (14-19 years old) in the city of New Delhi, India. An interviewer-administered questionnaire was used to assess health-compromising behaviors (tobacco and alcohol use, fruit/vegetable intake, and physical inactivity). Clustering was assessed using pairwise correlations, counts of clustering of health-compromising behaviors, comparison of observed/expected ratios, and hierarchical agglomerative cluster analysis. Multivariable logistic regressions were used to test the associations of clustering with social position (education and wealth). The relative and slope indices of inequalities in the presence of clustering of behaviors according to education and wealth were estimated.

Results

Three major clusters of health behaviors emerged: (a) physical inactivity + lower fruit and vegetable intake, (b) tobacco + alcohol use, and (c) lower fruit and vegetable intake + tobacco + alcohol use. Pronounced clustering of health-compromising behaviors was observed with lower educational attainment and wealth.

Conclusion

The presence of clustering of health-compromising behaviors was considerably higher among adolescents with lower educational attainment and wealth. The area of residence has an important influence on socioeconomic inequalities in clustering of NCD risk factors.

The Mobile Health Multiple Lifestyle Behavior Interventions Across the Lifespan (MoBILE) Research Program: Protocol for Development, Evaluation, and Implementation

BACKGROUND

Clustering of multiple lifestyle risk behaviors has been associated with a greater risk of noncommunicable diseases and mortality than one lifestyle risk behavior or no lifestyle risk behaviors. The National Board of Health and Welfare in Sweden reported in 2018 that it is important to provide additional support to individuals with multiple lifestyle risk behaviors, as risks from these behaviors are multiplicative rather than additive. However, the same report emphasized that there is a lack of knowledge regarding interventions that support changes to unhealthy lifestyle behaviors.

OBJECTIVE

The MoBILE (Mobile health Multiple lifestyle Behavior Interventions across the LifEspan) research program has brought together two Swedish research groups supported by international collaborators. Through this collaboration, we aim to design and evaluate a number of novel and tailored mobile health (mHealth) multiple lifestyle behavior interventions across the life span of different health care populations. In addition, the MoBILE research program will extend ongoing research to include mHealth interventions for migrant pregnant women and children.

METHODS

Each project within the MoBILE program will focus on a specific group: pregnant women, preschool children, high school and university students, and adults in primary and clinical care. All the projects will follow the same 4 phases: requirements, development, evaluation, and implementation. During the requirements phase, implementers and end users will aid the design of content and functionality of the interventions. In the development phase, findings from the first phase will be synthesized with expert domain knowledge and theoretical constructs to create interventions tailored to the target groups. The third phase, evaluation, will comprise randomized controlled trials conducted to estimate the effects of the interventions on multiple lifestyle risk behaviors (eg, alcohol, nutrition, physical activity, and smoking). The final phase will investigate how the interventions, if found effective, can be disseminated into different health care contexts.

RESULTS

The research program commenced in 2019, and the first results will be available in 2020. Projects involving pregnant women, preschool children, and high school and university students will be completed in the first 3 years, with the remaining projects being planned for the program's final 3 years.

CONCLUSIONS

The development of evidence-based digital tools is complex, as they should be guided by theoretical frameworks, and requires large interdisciplinary teams with competence in technology, behavioral science, and lifestyle-specific areas. Individual researchers or smaller research groups developing their own tools is not the way forward, as it means reinventing the wheel over and over again. The MoBILE research program therefore aims to join forces and learn from the past 10 years of mHealth research to maximize scientific outcomes, as well as the use of financial resources to expand the growing body of evidence for mHealth lifestyle behavior interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/14894.

Self-Reported Fatigue Predicts Incident Stroke in a General Population: EPIC-Norfolk Prospective Population-Based Study

Background and Purpose- Fatigue is a common symptom among stroke survivors and in general practice. However, the clinical significance of fatigue and its relationship to incident stroke is unclear. The aim of this study was to examine the relationship between self-reported fatigue and the incidence of stroke in a general population. Methods- This was a prospective, population-based study. The study population was 15 654 men and women aged 39 to 79 years recruited in 1993 to 1997 and followed till March 2016. Fatigue was assessed at 18 months after baseline using the vitality domain of the Short Form 36 questionnaire. Cox proportional hazard models were constructed to describe the prospective relationship between baseline fatigue and incident stroke adjusting for age, sex, systolic blood pressure, cholesterol, physical activity, smoking status, alcohol consumption, fruit and vegetable consumption, diabetes mellitus, body mass index, vitamin supplement use, education level, Townsend deprivation index, and occupational social class. Incident stroke was ascertained using death certificates and hospital record linkage data. Results- Through 249 248 person-years of follow-up, 1509 incident strokes occurred. Participants who reported the highest level of fatigue (quartile 4) were more likely to be women, to be multimorbid, and to perceive their health as fair or poor. We observed ≈50% relative risk increase in stroke risk (hazard ratio, 1.49 [95% CI, 1.29-1.71]) in those who reported the highest level of fatigue compared with those who reported the lowest level of fatigue (Q4 versus Q1). This relationship remained unaltered regardless of anemia status, the presence or absence of chronic bronchitis, thyroid dysfunction, or depression. Conclusions- Self-report fatigue assessed by the vitality domain of the Short Form 36 questionnaire predicts the risk of future stroke at the general population level. Identifying and addressing stroke risk factors in those who report fatigue in general practice may have substantial benefit at the population level.

Associations of Psychosocial Factors with Multiple Health Behaviors: A Population-Based Study of Middle-Aged Men and Women

Background: The health behaviors smoking, risky alcohol consumption, insufficient physical activity, and poor diet constitute the main contributors to non-communicable diseases. Clustering of risk behaviors is common and increases the risk of these diseases. Despite health benefits, it is difficult to change health behaviors. Psychosocial factors could play a role in health behavior change, with research showing relationships between unfavorable psychosocial factors and health risk behaviors. However, many studies only investigated one or two health behaviors at a time. The present study, therefore, aimed to investigate associations between a broad range of psychosocial factors and multiple health risk behaviors in a general middle-aged population in Sweden. Methods: A cross-sectional design was used to investigate a random sample from the general population in Sweden (n = 1007, 45–69 years, 50% women). Questionnaire data on health behaviors (smoking, alcohol consumption, physical activity, and fruit/vegetable intake) and psychosocial factors, with both psychological and social resources (social integration, emotional support, perceived control, self-esteem, sense of coherence and trust) and psychological risk factors (cynicism, vital exhaustion, hopelessness and depressiveness), were analyzed. Logistic and ordinal logistic regression were used to analyze associations between psychosocial factors and multiple (0–1, 2 or 3–4) health risk behaviors. Results: A total of 50% of the sample had two health risk behaviors and 18% had three health risk behaviors. After adjusting for age, sex, education, employment status, and immigrant status, eight out of 10 psychosocial factors (exceptions: social integration and self-esteem) showed significant odds ratios (ORs) in the expected directions; low levels of psychosocial resources and high levels of psychosocial risk factors were associated with multiple risk behaviors. The strongest associations with multiple risk behaviors were seen for vital exhaustion (adjusted (adj.) OR 1.28; confidence interval (CI) 1.11–1.46), depressiveness (adj. OR 1.32, CI 1.14–1.52), and trust (adj. OR 0.80, CI 0.70–0.91). When controlling for all psychosocial factors in the same model, only the association with trust remained statistically significant (adj. OR 0.89, CI 0.73–1.00, p = 0.050). Associations with individual health behaviors were fewer and scattered, with no psychosocial factor being related to all four behaviors. Conclusions: Examining associations between a broad range of psychosocial factors and multiple health risk behaviors revealed consistent and significant associations for almost all psychosocial factors. These associations were stronger compared to associations to single health risk behaviors. Our findings support the relevance of considering psychosocial aspects in interventions aimed at health behavior change, especially for people with multiple health risk behaviors.

Moderate Alcohol Intake in Non-Alcoholic Fatty Liver Disease: To Drink or Not to Drink?

Nonalcoholic fatty liver disease (NAFLD) is defined by hepatic steatosis in the presence of alcohol intake within safe limits, defined by guidelines of scientific associations (usually 20 g or 2 units/day in women, 30 g or 3 units in men). The diagnosis is usually followed by medical counseling of total abstinence, in order to prevent disease progression. This policy has been challenged by epidemiological studies, suggesting that the risk of liver disease and disease progression is lower in modest drinkers than in total abstainers. We revised the literature on the effects of modest alcohol intake on disease burden. Epidemiological data may suffer from several potential biases (recall bias for retrospective analyses, difficulties in the calculation of g/day), limiting their validity. Prospective data suggest that NAFLD patients with regular alcohol intake, although within the safe thresholds, are at higher risk of liver disease progression, including hepatocellular carcinoma; a detrimental effect of modest alcohol drinking is similarly observed in liver disease of viral etiology. Alcohol intake is also a risk factor for extrahepatic cancers, particularly breast, oral, and pharyngeal cancers, with gender difference and no floor effect, which outweigh the possible beneficial effects on cardiovascular system, also derived from retrospective studies. Finally, the negative effects of the calorie content of alcohol on dietary restriction and weight loss, the pivotal intervention to reduce NAFLD burden, should be considered. In summary, the policy of counseling NAFLD patients for alcohol abstinence should be maintained.

Long-term risk of stroke and its predictors in transient ischaemic attack patients in Germany

BACKGROUND AND PURPOSE

Little is known about the long-term association between transient ischaemic attack (TIA) and stroke. Therefore, the goal of this study was to analyze the long-term risk of stroke and associated predictors in a large cohort of TIA patients followed in general practices in Germany.

METHODS

This study included patients with an initial TIA diagnosis and subsequently followed up in one of 1262 general practices in Germany between January 2007 and December 2016 (N = 19 824 patients). The primary outcome of the study was the risk of ischaemic stroke within 10 years of the initial diagnosis of TIA. The secondary outcome was the identification of demographic, clinical and pharmaceutical variables significantly associated with stroke in TIA patients.

RESULTS

Within 10 years of the initial TIA diagnosis, 18.3% of individuals were diagnosed with stroke. Age was positively associated with stroke, with hazard ratios ranging from 1.88 in patients aged 51-60 years to 4.00 in those aged >80 years (reference group: patients aged ≤50 years). Furthermore, male sex, hypertension, diabetes mellitus, atrial fibrillation and ischaemic heart diseases had an additional impact on the risk of stroke. Finally, new oral anticoagulants, heparins, diuretics, angiotensin II receptor blockers and platelet aggregation inhibitors were identified as protective factors.

CONCLUSIONS

In a cohort of almost 20 000 TIA patients, 18.3% were diagnosed with stroke within 10 years after the TIA index event. Several demographic, clinical and pharmaceutical variables significantly predicted the long-term risk of stroke in TIA patients.

Plasma vitamin C concentrations and risk of incident respiratory diseases and mortality in the European Prospective Investigation into Cancer-Norfolk population-based cohort study

BACKGROUND/OBJECTIVES

Cancerous and non-cancerous respiratory diseases are common and contribute significantly to global disease burden. We aim to quantify the association between plasma vitamin C concentrations as an indicator of high fruit and vegetable consumption and the risk of incident respiratory diseases and associated mortality in a general population.

SUBJECTS/METHODS

Nineteen thousand three hundred and fifty-seven men and women aged 40-79 years without prevalent respiratory diseases at the baseline (1993-1997) and participating in the European Prospective Investigation into Cancer (EPIC)-Norfolk study in the United Kingdom were followed through March 2015 for both incidence and mortality from respiratory diseases.

RESULTS

There were a total of 3914 incident events and 407 deaths due to any respiratory diseases (excluding lung cancers), 367 incident lung cancers and 280 lung cancer deaths during the follow-up (total person-years >300,000 years). Cox's proportional hazards models showed that persons in the top quartiles of baseline plasma vitamin C concentrations had a 43% lower risk of lung cancer (hazard ratio (HR) 0.57; 95% confidence interval (CI): 0.41-0.81) than did those in the bottom quartile, independently of potential confounders. The results are similar for any non-cancerous respiratory diseases (HR 0.85; 0.77-0.95), including chronic respiratory diseases (HR 0.81; 0.69-0.96) and pneumonia (HR 0.70; 0.59-0.83). The corresponding values for mortality were 0.54 (0.35-0.81), 0.81 (0.59-1.12), 0.85 (0.44-1.66) and 0.61 (0.37-1.01), respectively. Confining analyses to non-smokers showed 42% and 53% risk reduction of non-smoking-related lung cancer incidence and death.

CONCLUSIONS

Higher levels of vitamin C concentrations as a marker of high fruit and vegetable consumption reduces the risk of cancerous and non-cancerous respiratory illnesses including non-smoking-related cancer incidence and deaths.

Weight Loss After Stroke Through an Intensive Lifestyle Intervention (Group Lifestyle Balance-Cerebrovascular Accident): Protocol for a Randomized Controlled Trial

BACKGROUND

Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), because of impaired mobility, behavioral and emotional disorders, and sensory losses. Weight gain increases the patient's risk of recurrent stroke and chronic diseases, such as diabetes, metabolic syndrome, and pulmonary and heart disease. Approaches to weight loss in this population are lacking, although necessary because of the unique physiological and cognitive needs of persons after a stroke. Evidence shows that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight loss. The Group Lifestyle Balance (GLB) intervention is a 12-month, evidence-based weight loss program that has been used extensively with the general population; this program was modified to meet the needs of people who have had a stroke (GLB-CVA).

OBJECTIVE

This randomized controlled trial (RCT) aims to examine the efficacy of the GLB-CVA on weight and secondary outcomes, compared with that of a waitlist control group.

METHODS

This RCT will enroll and randomize 64 patients over an 18-month period.

RESULTS

Currently, 51 people are waitlisted, with 23 out of 51 screened and 16 out of 23 eligible.

CONCLUSIONS

It is anticipated that the findings from this RCT will contribute to the evidence base regarding weight loss strategies for people living with stroke.

CLINICAL TRIAL

ClinicalTrials.gov NCT03873467; https://clinicaltrials.gov/ct2/show/NCT03873467.

Time trends in healthy lifestyle among adults in Germany: Results from three national health interview and examination surveys between 1990 and 2011

BACKGROUND

The combined impact of multiple healthy behaviors on health exceeds that of single behaviors. This study aimed to estimate trends in the prevalence of a healthy lifestyle among adults in Germany.

METHODS

A data set of 18,058 adults aged 25-69 years from three population-based national health examination surveys 1990-92, 1997-99 and 2008-11 with complete information for five healthy behavior factors was used. A 'daily intake of both fruits and vegetables, 'sufficient physical exercise', 'no current smoking' and 'no current risk drinking' were assessed with self-reports and 'normal body weight' was calculated based on measured body weight and height. A dichotomous 'healthy lifestyle' indicator was defined as meeting at least four out of five healthy behaviors. Age-standardized prevalence was calculated stratified by sex, age groups (25-34, 35-44, 45-54 and 55-69 years) and education level (low, medium and high). Trends were expressed in relative change (RC) between 1990-92 and 2008-11.

RESULTS

In Germany, the overall prevalence of healthy lifestyle increased from 9.3% in 1990-92 to 13.5% in 1997-99 and to 14.7% in 2008-11 (RC: +58.1%). The prevalence increased among men and women and in all age groups, with the exception of men aged 45-54 years. The RC of increasing healthy lifestyle prevalence between 1990-92 and 2008-11 was stronger albeit on a higher level among women compared to men. Therefore, the gender difference in healthy lifestyle has increased, but age-related differences have overall decreased in this period. Among high educated men the prevalence of a healthy lifestyle increased between 1990-92 and 2008-11 from 10.6% to 16.3% (p = 0.01) and among high educated women from 16.4% to 30.3% and also among medium educated women (10.9 to 16.6, p<0.01), but no significant increase in healthy lifestyle prevalence was observed among men with low and medium education and among women with low education level.

CONCLUSIONS

The prevalence of a lifestyle with at least four out of five healthy behaviors markedly increased from 1990-92 to 2008-11. Nevertheless, additional health promotion interventions are needed to improve the number of combined healthy behavior factors and the awareness in the population that each additional healthy behavior factor leads to a further improvement in health, especially in men in the age-range 45 to 54 years, and among persons with low education level.

Impact of combined healthy lifestyle factors on survival in an adult general population and in high-risk groups: prospective results from the Moli-sani Study

BACKGROUND

There is poor knowledge on the association between combined lifestyles with mortality risk among individuals at high risk, and little is known on the biological mechanisms that could be on the pathway.

METHODS

Longitudinal analysis on 22 839 individuals from the Moli-sani Study (Italy, 2005-2010). Among them, we identified 5200 elderly individuals (≥65 year), 2127 subjects with diabetes and 1180 with cardiovascular disease (CVD) at baseline. A healthy lifestyle score (HLS) was calculated, allocating 1 point for each of the following: abstention from smoking; adherence to Mediterranean diet; physical activity; absence of abdominal obesity. Hazard ratios (HR) with 95% confidence intervals (95%CI) were calculated by multivariable Cox regression and competing risk models.

RESULTS

During 8.2 years of follow-up, 1237 deaths occurred. In the general population, adherence to all four healthy lifestyles, compared with none or 1, was associated with lower risk of all-cause (HR = 0.53; 95%CI:0.39-0.72), CVD (HR = 0.54; 0.32-0.91), cancer (HR = 0.62; 0.39-1.00) and mortality from other causes (HR = 0.39; 0.19-0.81). A 1-point increase in HLS was associated with 20%, 22% and 24% lower risk of total mortality among the elderly, in subjects with diabetes or CVD, respectively. Traditional (e.g. blood lipids), inflammatory (e.g. C-reactive protein) and novel biomarkers (e.g. markers of cardiac damage) accounted for up to 24% of the association of HLS with all-cause mortality risk in the general population.

CONCLUSIONS

The impact of combined four healthy lifestyles on survival was considerable, both in the general population and among high-risk subgroups. Inflammatory and novel biomarkers of CVD risk explained a substantial proportion of this association.

Association between lifestyle risk factors and incident hypertension among middle-aged and older Australians

This study aimed to examine the association between individual and combined lifestyle risk factors and the incidence of hypertension 1) in middle-aged and older Australians, and 2) to compare findings in men and women. A sample of 32,393 adults aged ≥45 years from New South Wales completed baseline (2006-2008) and follow-up (2010) questionnaires. Self-reported incident hypertension was defined as not having physician-diagnosed hypertension nor taking antihypertensive medications at baseline and reporting a diagnosis/treatment of hypertension at follow-up. High-risk categories for six lifestyle risk factors were defined as: a BMI ≥ 25 kg/m², physical activity levels <150 min/week, consuming ≥14 alcohol drinks/week, being a current smoker, consuming <2 fruit and/or <3 vegetable serves/day, and being at high risk of psychological distress (Kessler-10 score ≥ 22). The association between baseline risk factors and incident hypertension was examined using logistic regression models, adjusted for socio-demographic, medical and lifestyle risk factors. After 2.7 (SD: 0.9) years of follow-up, 17.1% developed hypertension. Compared to low-risk categories, high BMI (AOR [95% CI]: 1.99 [1.85, 2.13]), high alcohol intake (1.58 [1.44, 1.73]), low physical activity levels (1.17 [1.07, 1.27]) and being a current smoker (1.15 [1.0, 1.31]) were associated with a higher incidence of hypertension in the overall sample, with similar associations in men and women. The number of high-risk lifestyle factors was positively associated with higher odds of developing hypertension in the overall sample, men and women; with a stronger association in middle-aged men. Adopting a low-risk lifestyle may prevent hypertension among middle-aged and older adults.

Genetic risk, incident stroke, and the benefits of adhering to a healthy lifestyle: cohort study of 306 473 UK Biobank participants

OBJECTIVE

To evaluate the associations of a polygenic risk score and healthy lifestyle with incident stroke.

DESIGN

Prospective population based cohort study.

SETTING

UK Biobank Study, UK.

PARTICIPANTS

306 473 men and women, aged 40-73 years, recruited between 2006 and 2010.

MAIN OUTCOME MEASURE

Hazard ratios for a first stroke, estimated using Cox regression. A polygenic risk score of 90 single nucleotide polymorphisms previously associated with stroke was constructed at P<1×10^-5 to test for an association with incident stroke. Adherence to a healthy lifestyle was determined on the basis of four factors: non-smoker, healthy diet, body mass index <30 kg/m², and regular physical exercise.

RESULTS

During a median follow-up of 7.1 years (2 138 443 person years), 2077 incident strokes (1541 ischaemic stroke, 287 intracerebral haemorrhage, and 249 subarachnoid haemorrhage) were ascertained. The risk of incident stroke was 35% higher among those at high genetic risk (top third of polygenic score) compared with those at low genetic risk (bottom third): hazard ratio 1.35 (95% confidence interval 1.21 to 1.50), P=3.9×10^-8. Unfavourable lifestyle (0 or 1 healthy lifestyle factors) was associated with a 66% increased risk of stroke compared with a favourable lifestyle (3 or 4 healthy lifestyle factors): 1.66 (1.45 to 1.89), P=1.19×10^-13. The association with lifestyle was independent of genetic risk stratums.

CONCLUSION

In this cohort study, genetic and lifestyle factors were independently associated with incident stroke. These results emphasise the benefit of entire populations adhering to a healthy lifestyle, independent of genetic risk.

Lifestyle Indices and Cardiovascular Disease Risk: A Meta-analysis

CONTEXT

Several studies investigated lifestyle indices to account for interrelations between lifestyle behaviors and cardiovascular disease risk. So far, no systematic review has been conducted. Thus, the aim is to summarize the evidence of associations between lifestyle indices and cardiovascular disease risk in observational prospective studies.

EVIDENCE ACQUISITION

A systematic literature search was conducted in two databases in February 2018. Multivariable-adjusted risk estimates were combined using random effects models comparing the highest with the lowest healthy lifestyle score. Additionally, meta-analyses for cardiovascular disease types, such as stroke and heart failure, were conducted. Heterogeneity was assessed using I² index.

EVIDENCE SYNTHESIS

The search identified 27 studies, of which 22 were included in the meta-analyses. Most lifestyle indices included physical activity, smoking, diet, alcohol consumption, and body weight. A healthy lifestyle was associated with a reduced risk of 66% for cardiovascular disease (95% CI=0.28, 0.41, I²=79.1%), 60% for stroke, and 69% for heart failure. A dose-response effect for adherence to an increasing number of healthy behaviors and cardiovascular disease risk was observed. Statistical heterogeneity was found, suggesting that the definition of the lifestyle indices and components varied substantially between the studies.

CONCLUSIONS

Adherence to several healthy lifestyle behaviors simultaneously was associated with a 66% reduced cardiovascular disease risk compared with adopting none or only one behavior. Despite heterogeneity of indices, consistent inverse associations across studies underscore the relevance of adopting healthy behaviors at all. More research on other lifestyle behaviors, such as sleep duration or sedentary behavior in combination, is warranted.

Number of Risky Lifestyle Behaviors and Breast Cancer Risk

Background

Lifestyle factors are associated with overall breast cancer risk, but less is known about their associations, alone or jointly, with risk of specific breast cancer subtypes.

Methods

We conducted a case-control subjects study nested within a cohort of women who participated in the Norwegian Breast Cancer Screening Program during 2006-2014 to examine associations between risky lifestyle factors and breast cancer risk. In all, 4402 breast cancer cases subjects with information on risk factors and hormone receptor status were identified. Conditional logistic regression was used to estimate odds ratios (ORs), with 95% confidence intervals (CIs), in relation to five risky lifestyle factors: body mass index (BMI) of 25 kg/m² or greater, three or more glasses of alcoholic beverages per week, ever smoking, fewer than four hours of physical activity per week, and ever use of menopausal hormone therapy. Analyses were adjusted for education, age at menarche, number of pregnancies, and menopausal status. All statistical tests were two-sided.

Results

Compared with women with no risky lifestyle behaviors, those with five had 85% (OR = 1.85, 95% CI = 1.42 to 2.42, P _trend < .0001) increased risk of breast cancer overall. This association was limited to luminal A-like (OR = 2.20, 95% CI = 1.55 to 3.12, P _trend < .0001) and luminal B-like human epidermal growth factor receptor 2 (HER2)-positive (OR = 1.66, 95% CI = 0.61 to 4.54, P _trend < .004) subtypes. Number of risky lifestyle factors was not associated with increased risk of luminal B-like HER2-negative, HER2-positive, or triple-negative subtypes (P _trend > .18 for all).

Conclusions

Number of risky lifestyle factors was positively associated with increased risk for luminal A-like and luminal B-like HER2-positive breast cancer.

Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial

BACKGROUND

Prevalent co-occurring poor diet and physical inactivity convey chronic disease risk to the population. Large magnitude behavior change can improve behaviors to recommended levels, but multiple behavior change interventions produce small, poorly maintained effects.

OBJECTIVE

The Make Better Choices 2 trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity.

METHODS

Between 2012 and 2014, the 9-month randomized controlled trial enrolled 212 Chicago area adults with low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity (MVPA) and high sedentary leisure screen time. Participants were recruited by advertisements to an open-access website, screened, and randomly assigned to either of two active interventions targeting MVPA simultaneously with, or sequentially after other diet and activity targets (N=84 per intervention) or a stress and sleep contact control intervention (N=44). They used a smartphone app and accelerometer to track targeted behaviors and received personalized remote coaching from trained paraprofessionals. Perfect behavioral adherence was rewarded with an incentive of US $5 per week for 12 weeks. Diet and activity behaviors were measured at baseline, 3, 6, and 9 months; primary outcome was 9-month diet and activity composite improvement.

RESULTS

Both simultaneous and sequential interventions produced large, sustained improvements exceeding control (P<.001), and brought all diet and activity behaviors to guideline levels. At 9 months, the interventions increased fruits and vegetables by 6.5 servings per day (95% CI 6.1-6.8), increased MVPA by 24.7 minutes per day (95% CI 20.0-29.5), decreased sedentary leisure by 170.5 minutes per day (95% CI -183.5 to -157.5), and decreased saturated fat intake by 3.6% (95% CI -4.1 to -3.1). Retention through 9-month follow-up was 82.1%. Self-monitoring decreased from 96.3% of days at baseline to 72.3% at 3 months, 63.5% at 6 months, and 54.6% at 9 months (P<.001). Neither attrition nor decline in self-monitoring differed across intervention groups.

CONCLUSIONS

Multicomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to reduce chronic disease risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01249989; https://clinicaltrials.gov/ct2/show/NCT01249989 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01249989).

The Role of Motivation to Reduce Obesity among Elderly People: Response to Priming Temptation in Obese Individuals

The risk of obesity-related disorders is increased among the elderly, so changing eating habits can be an important element of prevention. The main aim of this article is to consider whether looking at pictures that present either fattening food or healthy food may motivate elderly people to change their nutrition habits. Might priming different kinds of food influence the attractiveness of the food for people in late adulthood undergoing obesity therapy? Based on priming theories, we analysed the effects of the conscious processing of stimuli associated with dietary habits in individuals aged with BMI ≥ 30 kg/m². Our experiments confirmed the influence of a higher-priority goal of "slimming" on the perception and internalization of nutrition-related stimuli. In response to such stimuli, individuals who are actively involved in weight reduction and health-oriented programs use strategies for resisting temptation and to effectively "slim". We present our findings in the context of their theoretical background and practical application.

[Healthy behavior patterns and levels of schooling in Brazil: time trend from 2008 to 2013]

This study analyzed data from the telephone-based Surveillance System of Risk and Protective Factors for Chronic Non-Communicable Diseases (VIGITEL) to assess the prevalence of clusters of healthy behavior patterns (non-smoker, non-alcohol-drinker, regular leisure-time physical activity and recommended consumption of fruit and vegetables) and the temporal trend between 2008 and 2013. Additionally, we evaluated whether the association between level of schooling and clustering of three or more healthy behavior patterns decreased in this same period. Prevalence ratios were obtained using Poisson regression. We found that between 2008 and 2013, the clustering prevalence of three or more healthy behavior patterns increased from 20% to 25% in men, and from 26% to 32% in women, suggesting an increase in the prevalence of healthy behavior patterns in Brazil. This increase was found at all levels of schooling. However, the association between levels of schooling and the prevalence of clustering of three or more healthy behavior patterns remained constant during the period. Thus, the results suggest that educational disparities in clustering of three or more healthy behavior patterns did not change over time, despite the social improvements observed in the country in recent years.

Combined impact of healthy lifestyle factors on lifespan: two prospective cohorts

BACKGROUND

The impact of multiple healthy lifestyle factors on survival time is unclear.

OBJECTIVE

The aim of this study was to examine differences in survival time associated with a healthy lifestyle versus a less healthy lifestyle.

METHODS

This study consisted of 33 454 men (Cohort of Swedish Men) and 30 639 women (Swedish Mammography Cohort) aged 45-83 years and free of cancer and cardiovascular disease at baseline. The healthy lifestyle factors included the following: (i) nonsmoking; (ii) physical activity at least 150 min per week; (iii) alcohol consumption of 0-14 drinks per week; (iv) and healthy diet defined as a modified Dietary Approaches to Stop Hypertension Diet score above the median. Cox proportional hazards regression models and Laplace regression were used to estimate, respectively, hazard ratios of all-cause mortality and differences in survival time.

RESULTS

During follow-up from 1998 through 2014, 8630 deaths amongst men and 6730 deaths amongst women were ascertained through linkage to the Swedish Cause of Death Register. Each of the four healthy lifestyle factors was inversely associated with all-cause mortality and increased survival time. Compared with individuals with no or one healthy lifestyle factor, the multivariable hazard ratios of all-cause mortality for individuals with all four health behaviours were 0.47 (95% 95% confidence interval [CI]: 0.44-0.51) in men and 0.39 (95% CI: 0.35-0.44) in women. This corresponded to a difference in survival time of 4.1 (95% CI: 3.6-4.6) years in men and 4.9 (95% CI: 4.3-5.6) years in women.

CONCLUSION

Adopting healthy lifestyle behaviours may markedly increase lifespan.

Dietary intake of antioxidant vitamins and risk of stroke: the Japan Public Health Center-based Prospective Study

BACKGROUND/OBJECTIVES

Epidemiologic evidence on the relationship between antioxidant vitamin intake and stroke is limited. We aimed to investigate the association between dietary intake of antioxidant vitamins and the incidence of total stroke and ischemic stroke.

SUBJECTS/METHODS

The subjects were 82 044 Japanese men and women aged 45-74 years under the Japan Public Health Center-based Prospective Cohort Study. Between 1995 and 1997, dietary assessment was done using a food frequency questionnaire. During 983 857 person-years of follow-up until the end of 2009 we documented 3541 incident total strokes and 2138 ischemic strokes.

RESULTS

Dietary intakes of α-carotene, β-carotene, α-tocopherol and vitamin C were not inversely associated with the incidence of total stroke and ischemic stroke adjustment for cardiovascular risk factors and selected lifestyle variables. When stratified by current smoking status, the inverse association between dietary vitamin C intake and incidence of total stroke observed among non-smokers but not smokers, with respective multivariable hazard ratios for the highest versus lowest quintiles of vitamin C of 0.81 (95% confidence interval (CI), 0.68-0.96; P-trend=0.03) among non-smokers; and 1.03 (0.84-1.25; P-trend=0.55) among smokers. As for ischemic stroke, the corresponding multivariable hazard ratios were 0.76 (0.60-0.96; P-trend=0.02) among non-smokers; and 1.00 (0.78-1.28; P-trend=0.61) among smokers.

CONCLUSIONS

Dietary vitamin C intake was inversely associated with the incidence of total stroke and ischemic stroke among non-smokers.

Multiple Risk Behavior Interventions: Meta-analyses of RCTs

CONTEXT

Multiple risk behaviors are common and associated with developing chronic conditions such as heart disease, cancer, or Type 2 diabetes. A systematic review, meta-analysis, and meta-regression of the effectiveness of multiple risk behavior interventions was conducted.

EVIDENCE ACQUISITION

Six electronic databases including MEDLINE, EMBASE, and PsycINFO were searched to August 2016. RCTs of non-pharmacologic interventions in general adult populations were selected. Studies targeting specific at-risk groups (such as people screened for cardiovascular risk factors or obesity) were excluded. Studies were screened independently. Study characteristics and outcomes were extracted and risk of bias assessed by one researcher and checked by another. The Behaviour Change Wheel and Oxford Implementation Index were used to code intervention content and context.

EVIDENCE SYNTHESIS

Random-effects meta-analyses were conducted. Sixty-nine trials involving 73,873 individuals were included. Interventions mainly comprised education and skills training and were associated with modest improvements in most risk behaviors: increased fruit and vegetable intake (0.31 portions, 95% CI=0.17, 0.45) and physical activity (standardized mean difference, 0.25; 95% CI=0.13, 0.38), and reduced fat intake (standardized mean difference, -0.24; 95% CI=-0.36, -0.12). Although reductions in smoking were found (OR=0.78, 95% CI=0.68, 0.90), they appeared to be negatively associated with improvement in other behaviors (such as diet and physical activity). Preliminary evidence suggests that sequentially changing smoking alongside other risk behaviors was more effective than simultaneous change. But most studies assessed simultaneous rather than sequential change in risk behaviors; therefore, comparisons are sparse. Follow-up period and intervention characteristics impacted effectiveness for some outcomes.

CONCLUSIONS

Interventions comprising education (e.g., providing information about behaviors associated with health risks) and skills training (e.g., teaching skills that equip participants to engage in less risky behavior) and targeting multiple risk behaviors concurrently are associated with small changes in diet and physical activity. Although on average smoking was reduced, it appeared changes in smoking were negatively associated with changes in other behaviors, suggesting it may not be optimal to target smoking simultaneously with other risk behaviors.

Psychosocial determinants of clustering health-compromising behaviors among Saudi male adolescents

BACKGROUND AND OBJECTIVES

To assess whether the clustering of six specific health-compromising behaviors, namely, low fruit consumption, high sweet consumption, infrequent tooth brushing, physical inactivity, fighting and smoking, varied by different psychosocial determinants such as life satisfaction, peer relationships, self-confidence, and future orientation among male adolescents in Saudi Arabia.

PATIENTS AND METHODS

A representative stratified cluster random sample of 1335 Saudi Arabian male adolescents living in the city of Riyadh answered a questionnaire on health-related behaviors. Poisson regression models were constructed separately for younger (13-14-years-old) and older (17-19-years-old) adolescents to assess variations between explanatory psychosocial variables and the clustering of six health-compromising behaviors, adjusting for father's education.

RESULTS

Older adolescents who perceived high levels of life satisfaction had a lower rate of clustering of multiple health-compromising behaviors compared to those reporting lower levels (RR: 1.22; 95%CI: 1.09-1.37), and the respective difference between those with high and those with middle levels of satisfaction was marginally non-significant (RR: 1.08; 95%CI: 0.98-1.19). Younger adolescents who reported that they felt "less than always" self-confident were more likely to have high clustering of health compromising behaviors compared to those who were always confident (RR: 1.08; 95%CI: 1.01-1.21). The clustering of multiple health-compromising behaviors was marginally associated with the frequency of evening meetings among older adolescents (RR: 1.03; 95%CI: 1.01-1.04 for each extra meeting), while the respective association among younger adolescents was marginally non-significant (RR: 1.02; 95%CI: 0.99-1.05). The association between clustering of health-compromising behaviors and future orientation was non-significant among both younger and older adolescents.

CONCLUSIONS

Clustering of health-compromising behaviors was found to be associated with perceived life satisfaction and peer relationships among older male Saudi adolescents and with self-confidence among younger male Saudi adolescents in Riyadh.

Epidemiological aspects of heart diseases

Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide. Coronary heart disease (CHD) is the main cause of mortality in heart patients following stroke, rheumatic heart disease and myocardial infarctions. Approximately 80% of individuals succumb to CVDs, due to poor living conditions in low and middle income families and malnutrition. Infectious diseases, human immunodeficiency, tuberculosis, malaria, high blood pressure or hypertension, obesity and overweight, and nutritional disorders including smoking, excessive alcohol consumption, high salt and sugar intake, as well as other factors are responsible for CVDs and CHDs in young as well as elderly individuals. The focus of the present review are recent epidemiological aspects of CVD and CHD as well as the usefulness of a Mediterranean diet for heart patients and the prevention of heart diseases.

Fatigue is associated with excess mortality in the general population: results from the EPIC-Norfolk study

BACKGROUND

Significant fatigue is a frequent reason for seeking medical advice in the general population. Patients, however, commonly feel their complaint is ignored. This situation may be because clinicians perceive fatigue to be benign, unrelated to traditional biomedical outcomes such as premature mortality. The present study aimed to investigate whether an association between significant fatigue and mortality actually exists, and, if so, to identify potential mechanisms of this association.

METHODS

A population-based cohort of 18,101 men and women aged 40-79 years who completed a measure of fatigue (Short Form 36 vitality domain, SF36-VT) in addition to providing information on possible confounding factors (age, sex, body mass index, marital status, smoking, education level, alcohol consumption, social class, depression, bodily pain, diabetes, use of β blockers, physical activity and diet) and mechanisms (haemoglobin, C-reactive protein and thyroid function) were followed up prospectively for up to 20 years. Mortality from all causes, cancer and cardiovascular disease was ascertained using death certification linkage with the UK Office of National Statistics.

RESULTS

During 300,322 person years of follow-up (mean 16.6 years), 4397 deaths occurred. After adjusting for confounders, the hazard ratio (HR) for all-cause mortality was 1.40 (95 % confidence interval [CI] 1.25-1.56) for those reporting the highest fatigue (bottom SF36-VT quartile) compared with those reporting the lowest fatigue (top SF36-VT quartile). This significant association was specifically observed for those deaths related to cardiovascular disease (HR 1.45, 95 % CI 1.18-1.78) but not cancer (HR 1.09, 95 % CI 0.90-1.32). Of the considered mechanisms, thyroid function was most notable for attenuating this association. The risk of all-cause mortality, however, remained significant even after considering all putative confounders and mechanisms (HR 1.26, 95 % CI 1.10-1.45).

CONCLUSIONS

High levels of fatigue are associated with excess mortality in the general population. This commonly dismissed symptom demands greater evaluation and should not automatically be considered benign.

Smoking, physical inactivity and obesity as predictors of healthy and disease-free life expectancy between ages 50 and 75: a multicohort study

Background: Smoking, physical inactivity and obesity are modifiable risk factors for morbidity and mortality. The aim of this study was to examine the extent to which the co-occurrence of these behaviour-related risk factors predict healthy life expectancy and chronic disease-free life expectancy in four European cohort studies.

Methods: Data were drawn from repeated waves of four cohort studies in England, Finland, France and Sweden. Smoking status, physical inactivity and obesity (body mass index ≥30 kg/m²) were examined separately and in combination. Health expectancy was estimated by using two health indicators: suboptimal self-rated health and having a chronic disease (cardiovascular disease, cancer, respiratory disease and diabetes). Multistate life table models were used to estimate sex-specific healthy life expectancy and chronic disease-free life expectancy from ages 50 to 75 years.

Results: Compared with men and women with at least two behaviour-related risk factors, those with no behaviour-related risk factors could expect to live on average8 years longer in good health and 6 years longer free of chronic diseases between ages 50 and 75. Having any single risk factor was also associated with reduction in healthy years. No consistent differences between cohorts were observed.

Conclusions: Data from four European countries show that persons with individual and co-occurring behaviour-related risk factors have shorter healthy life expectancy and shorter chronic disease-free life expectancy. Population level reductions in smoking, physical inactivity and obesity could increase life-years lived in good health.

Risk factors of transient ischemic attack: An overview

Transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused due to loss of blood flow to the brain or spinal cord without acute infarction. Depending on the area of the brain involved, symptoms of TIA vary widely from patient to patient. Since the blockage period in TIA is very short-lived, there is no permanent damage. Risk factors for TIA include family history of stroke or TIA, age above 55 years or older, higher risk of TIA in males than females, high blood pressure, diabetes mellitus, and tobacco smoking. Genetics, race, and imbalance in lipid profile are other risk factors of TIA. TIA is usually diagnosed after taking a thorough history and a physical examination. Several radiological tests such as computed tomography and magnetic resonance imaging are useful in the evaluation of patients who have had a TIA. Ultrasound of the neck and an echocardiogram of the heart are other tests useful in the diagnosis and evaluation of the attack. The treatment following acute recovery from a TIA depends on the underlying cause. Patients who have more than 70% stenosis of the carotid artery, removal of atherosclerotic plaque is usually done by carotid endarterectomy surgery. One-third of the people with TIA can later have recurrent TIAs and one-third can have a stroke because of permanent nerve cell loss. Having a TIA is a risk factor for eventually having a stroke. Educating the patients and inculcating lifestyle modifications in them are initial steps to minimize the prevalence of transient ischemic attack.

Longitudinal patterns and predictors of multiple health risk behaviors among adolescents: The TRAILS study

BACKGROUND

Most studies on multiple health risk behaviors among adolescents have cross-sectionally studied a limited number of health behaviors or determinants.

PURPOSE

To examine the prevalence, longitudinal patterns and predictors of individual and multiple health risk behaviors among adolescents.

METHODS

Eight health risk behaviors (no regular consumption of fruit, vegetables or breakfast, overweight or obesity, physical inactivity, smoking, alcohol use and cannabis use) were assessed in a prospective population study (second and third wave). Participants were assessed in three waves between ages 10 and 17 (2001-2008; n=2230). Multiple linear regression was used to assess the influence of gender, self-control, parental health risk behaviors, parental monitoring and socioeconomic factors on the number of health risk behaviors adjusted for preceding multiple health risk behaviors (analysis: 2013-2014).

RESULTS

Rates of >5 health risk behaviors were high: 3.6% at age 13.5 and 10.2% at age 16. Smoking at age 13.5 was frequently associated with health risk behaviors at age 16. No regular consumption of fruit, vegetables and breakfast, overweight or obesity, physical inactivity and smoking predicted the co-occurrence of health risk behaviors at follow-up. Significant predictors of the development of multiple health risk behaviors were adolescents' levels of self-control, socioeconomic status and maternal smoking.

CONCLUSIONS

Multiple health risk behaviors are common among adolescents. Individual and social factors predict changes in multiple health risk behaviors, showing that prevention targeting multiple risk behaviors is needed. Special attention should be paid to adolescents with low self-control and families with low socioeconomic status or a mother who smokes.