Health for life

Study shows clear benefits of a healthy diet, exercise, maintaining normal weight and not smoking

A large, multi-center study led by Johns Hopkins researchers has found a significant link between lifestyle factors and heart health, adding even more evidence in support of regular exercise, eating a Mediterranean-style diet, keeping a normal weight and, most importantly, not smoking.

The researchers found that adopting those four lifestyle behaviors protected against coronary heart disease as well as the early buildup of calcium deposits in heart arteries, and reduced the chance of death from all causes by 80 percent over an eight-year period. Results of the study, "Low-Risk Lifestyle, Coronary Calcium, Cardiovascular Events, and Mortality: Results from the Multi-Ethnic Study of Atherosclerosis," are described in an online article posted June 3, 2013 by the American Journal of Epidemiology.

"To our knowledge, this is the first study to find a protective association between low-risk lifestyle factors and early signs of vascular disease, coronary heart disease and death, in a single longitudinal evaluation," says Haitham Ahmed, M.D., M.P.H., the lead author who is an internal medicine resident with the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins.

"We evaluated data on more than 6,200 men and women, age 44-84, from white, African-American, Hispanic and Chinese backgrounds. All were followed for an average of 7.6 years. Those who adopted all four healthy behaviors had an 80 percent lower death rate over that time period compared to participants with none of the healthy behaviors," says Ahmed.

Study participants all took part in the ongoing Multi-Ethnic Study of Atherosclerosis (MESA), a prospective examination of the risk factors, prevalence and prevention of cardiovascular disease. MESA participants were recruited from six academic medical centers and did not have a diagnosis of cardiovascular disease when they were enrolled.

All participants had coronary calcium screening using computed tomography (a CT scan) when they were first enrolled in the study to see if there were early signs of calcium deposits in their heart arteries that are known to contribute to heart attack risk. As the study progressed, the researchers also assessed whether the participants had a heart attack, sudden cardiac arrest, chest pain, angioplasty or died due to coronary heart disease or other causes.

The researchers developed a lifestyle score for each of the participants, ranging from 0 (least healthy) to 4 (healthiest), based on their diet, body mass index (BMI), amount of regular moderate-intensity physical activity and smoking status. Only 2 percent, or 129 participants, satisfied all four healthy lifestyle criteria.

"Of all the lifestyle factors, we found that smoking avoidance played the largest role in reducing the risk of coronary heart disease and mortality," says Roger Blumenthal, M.D., a cardiologist and professor of medicine at the Johns Hopkins University School of Medicine, director of the Ciccarone Center and senior author of the study. "In fact, smokers who adopted two or more of the healthy behaviors still had lower survival rates after 7.6 years than did nonsmokers who were sedentary and obese."

Blumenthal, who is also the president of the American Heart Associations Maryland affiliate, says the findings "bolster recent recommendations by the American Heart Association, which call for maintaining a diet rich in vegetables, fruits, nuts, whole grains and fish, keeping a BMI of less than 25, being physically active and not smoking."

The researchers emphasize that their study shows the importance of healthy lifestyle habits not just for reducing the risk of heart disease, but also for preventing mortality from all causes.

"While there are risk factors that people cant control, such as their family history and age," says Ahmed, "these lifestyle measures are things that people can change and consequently make a big difference in their health. Thats why we think this is so important."

Stroke is a debilitating and often deadly condition that strikes more than 800,000 people each year and ranks as the third leading cause of death. A stroke is caused by a blockage of blood flow to the brain from either a clot or blood vessel constriction.

Research has shown that healthy behaviors are associated with a lower risk of Alzheimers disease and dementia, but less is known about the potential link between positive lifestyle choices and milder memory complaints, especially those that occur earlier in life and could be the first indicators of later problems.

To examine the impact of these lifestyle choices on memory throughout adult life, UCLA researchers and the Gallup organization collaborated on a nationwide poll of more than 18,500 individuals between the ages of 18 and 99. Respondents were surveyed about both their memory and their health behaviors, including whether they smoked, how much they exercised and how healthy their diet was.

As the researchers expected, healthy eating, not smoking and exercising regularly were related to better self-perceived memory abilities for most adult groups. Reports of memory problems also increased with age. However, there were a few surprises.

Older adults (age 60–99) were more likely to report engaging in healthy behaviors than middle-aged (40–59) and younger adults (18–39), a finding that runs counter to the stereotype that aging is a time of dependence and decline. In addition, a higher-than-expected percentage of younger adults complained about their memory.

"These findings reinforce the importance of educating young and middle-aged individuals to take greater responsibility for their health — including memory — by practicing positive lifestyle behaviors earlier in life," said the studys first author, Dr. Gary Small, director of the UCLA Longevity Center and a professor of psychiatry and biobehavioral sciences at the Semel Institute for Neuroscience and Human Behavior at UCLA who holds the Parlow–Solomon Chair on Aging.

Published in the June issue of International Psychogeriatrics, the study may also provide a baseline for the future study of memory complaints in a wide range of adult age groups.

For the survey, Gallup pollsters conducted land-line and cell phone interviews with 18,552 adults in the U.S. The inclusion of cell phone–only households and Spanish-language interviews helped capture a representative 90 percent of the U.S. population, the researchers said.

"We found that the more healthy lifestyle behaviors were practiced, the less likely one was to complain about memory issues," said senior author Fernando Torres-Gil, a professor at UCLAs Luskin School of Public Affairs and associate director of the UCLA Longevity Center.

In particular, the study found that respondents across all age groups who engaged in just one healthy behavior were 21 percent less likely to report memory problems than those who didnt engage in any healthy behaviors. Those with two positive behaviors were 45 percent less likely to report problems, those with three were 75 percent less likely, and those with more than three were 111 percent less likely.

Interestingly, the poll found that healthy behaviors were more common among older adults than the other two age groups. Seventy percent of older adults engaged in at least one healthy behavior, compared with 61 percent of middle-aged individuals and 58 percent of younger respondents.

In addition, only 12 percent of older adults smoked, compared with 25 percent of young adults and 24 percent of middle-aged adults, and a higher percentage of older adults reported eating healthy the day before being interviewed (80 percent) and eating five or more daily servings of fruits and vegetables during the previous week (64 percent).

According to the researchers, older adults may participate in more healthy behaviors because they feel the consequences of unhealthy living and take the advice of their doctors to adopt healthier lifestyles. Or there simply could be fewer older adults with bad habits, since they may not live as long.

While 26 percent of older adults and 22 percent of middle-aged respondents reported memory issues, it was surprising to find that 14 percent of the younger group complained about their memory too, the researchers said.

"Memory issues were to be expected in the middle-aged and older groups, but not in younger people," Small said. "A better understanding and recognition of mild memory symptoms earlier in life may have the potential to help all ages."

Small said that, generally, memory issues in younger people may be different from those that plague older generations. Stress may play more of a role. He also noted that the ubiquity of technology — including the Internet, texting and wireless devices that can result in constant multi-tasking, especially with younger people — may impact attention span, making it harder to focus and remember.

Small noted that further study and polling may help tease out such memory-complaint differences. Either way, he said, the survey reinforces the importance, for all ages, of adopting a healthy lifestyle to help limit and forestall age-related cognitive decline and neurodegeneration.

The Gallup poll used in the study took place between December 2011 and January 2012 and was part of the Gallup–Healthways Well-Being Index, which includes health- and lifestyle-related polling questions. The five questions asked were: (1) Do you smoke? (2) Did you eat healthy all day yesterday? (3) In the last seven days, on how many days did you have five or more servings of vegetables and fruits? (4) In the last seven days, on how many days did you exercise for 30 minutes or more? (5) Do you have any problems with your memory?

People with job stress and an unhealthy lifestyle are at higher risk of coronary artery disease than people who have job stress but lead healthy lifestyles, found a study published in CMAJ (Canadian Medical Association Journal).

To determine whether a healthy lifestyle can help reduce the effects of job stress on coronary artery disease, researchers looked at 7 cohort studies from a large European initiative that included 102 128 people who were disease-free during the 15-year study period (1985-2000). Participants, ranging in age from 17-70 (mean 44.3) years were from the United Kingdom, France, Belgium, Sweden and Finland. More than half (52%) were women.

Of the total participants, 15 986 (16%) reported job stress, which was determined from specific job-related questions in the studies. The investigators defined three lifestyle categories based on smoking, alcohol consumption, physical activity/inactivity and obesity (body mass index). A "healthy lifestyle" had no lifestyle risk factors, "moderately unhealthy lifestyle" had one risk factor and "unhealthy lifestyle" included 2-4 lifestyle risk factors.

A total of 1086 participants had incident events of coronary artery disease events during the follow-up period. The 10-year incidence of coronary artery disease was 18.4 per 1000 people for people with job strain and 14.7 for those without job strain. People with an unhealthy lifestyle had a significantly higher 10-year incidence rate (30.6 per 1000) compared to those with a healthy lifestyle (12.0 per 1000). The incidence rate was 31.2 per 1000 for participants with job strain and an unhealthy lifestyle but only 14.7 for those with job strain and a healthy lifestyle.

"The risk of coronary artery disease was highest among participants who reported job strain and an unhealthy lifestyle; those with job strain and a healthy lifestyle had about half the rate of this disease," writes Dr. Mika Kivimäki, Department of Epidemiology and Public Health, University College London (UCL), London, United Kingdom. "These observational data suggest that a healthy lifestyle could substantially reduce the risk of coronary artery disease risk among people with job strain."

Evidence from randomized controlled trials has shown that lifestyle changes such as weight loss and stopping smoking can reduce the risk of disease.

"In addition to stress counselling, clinicians might consider paying closer attention to lifestyle risk factors in patients who report job strain," the authors conclude.

Achieving and maintaining a healthy body weight, staying physically active and maintaining a healthy diet improved survival after cancer diagnosis in an elderly female cancer survivor population, according to data presented at the 11th Annual AACR International Conference on Frontiers in Cancer Prevention Research, held here Oct. 16-19, 2012.

Researchers examined cancer survivors adherence to the 2007 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) guidelines for body weight, physical activity and diet.

"Elderly female cancer survivors who achieve and maintain an ideal body weight, stay physically active and eat a healthy diet have an almost 40 percent lower risk for death compared with women who do not follow these recommendations," said Maki Inoue-Choi, Ph.D., R.D., research associate in the Division of Epidemiology and Community Health in the School of Public Health at the University of Minnesota.

Study participants included 2,080 women from the Iowa Womens Health Study who had a confirmed cancer diagnosis between 1986 and 2002 and who completed a follow-up questionnaire in 2004. Women provided information on body weight, physical activity level, dietary intake and other demographic and lifestyle factors.

Through annual linkage with the State of Health Registry of Iowa and the National Death Index, researchers identified 495 deaths from 2004 to 2009, including 197 from cancer and 153 from cardiovascular disease. Researchers adjusted for age, number of comorbid conditions, general health, smoking, type and stage of cancer, current cancer treatment and subsequent cancer diagnosis. They found all-cause mortality was 37 percent lower for women with the highest (6 to 8) versus the lowest (0 to 4) adherence scores.

Reaching the WCRF/AICR physical activity recommendation was also associated with lower risk for death from any cause, from cardiovascular disease or from cancer after the researchers adjusted for dietary and body weight recommendation adherence scores and other covariates.

However, reaching the dietary recommendations was not associated with mortality following adjustment for body weight and physical activity recommendation adherence scores.

A recent study in the Archives of Internal Medicine investigated the effect of combined lifestyle factors on the development of type 2 diabetes in older adults.¹

Researchers analyzed data from participants of the Cardiovascular Health Study:

• 4883 men and women 65 years or older
  
• Followed for a 10-year period (1989-1998)

Five lifestyle factors were studied:

• Physical activity level.
  
• Dietary score. A low-risk score lected:
  • Higher fiber intake
    
  • Higher polyunsaturated-to-saturated fat ratio
    
  • Lower trans-fat intake
    
  • Lower glycemic index
• Smoking. Never smoked or former smoker greater than 20 years lected low-risk.
  
• Alcohol use. Light or moderate intake lected low-risk.
  
• Body fat. Low-risk lected:
  • BMI less than 25 (Calculate your BMI here.)
    
  • Waist circumference 88 cm or less for women (34.6 in), 92 cm for men (36.2 in)

The study found:

"The rate of incident diabetes was 35% lower for each 1 additional lifestyle factor in the low-risk group.

Participants whose physical activity level and dietary, smoking, and alcohol habits were all in the low-risk group had an 82% lower incidence of diabetes.

When absence of adiposity (either body mass index < 25 or waist circumference ≤ 88/92 cm for women/men) was added to the other 4 low-risk lifestyle factors, incidence of diabetes was 89% lower.

Overall, 9 of 10 new cases of diabetes appeared to be attributable to these 5 lifestyle factors."

The authors concluded:

"Even later in life, combined lifestyle factors are associated with a markedly lower incidence of new-onset diabetes mellitus."

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¹ Lifestyle Risk Factors And New-Onset Diabetes Mellitus In Older Adults, Archives of Internal Medicine, April 27, 2009

Youve been told by your doctor that your blood sugars are high, not high enough to be diagnosed with diabetes but theyre going in that direction.

What should be your primary course of action? Lifestyle changes or drugs?

The conclusion from what HeartWire called "a lively debate" at this months annual meeting of the European Association for the Study of Diabetes is ... lifestyle changes. ¹

Defense for lifestyle changes:

• Drugs may have no proven benefits as preventative medications.
  
• Drugs can have undesirable side-effects.
  
• Lifestyle changes, even if stopped, have long-lasting effects.
  
• Lifestyle changes are more cost-effective.
  
• Lifestyle changes get at the root of type 2 diabetes. ("Not only are they effective at reducing diabetes risk, but they also have "halo effects," including anthropometric, physiological, metabolic, psychological, behavioral, and quality-of-life benefits," claimed Dr. Nick Wareham.)
  
• Drugs may discourage people from making lifestyle changes.

Defense for early drug intervention:

• Effective lifestyle changes are difficult to enact and challenging to upkeep. ("Environmental, cultural, economic, and sociopolitical forces work against lifestyle changes in developed countries," claimed Dr. Paul Zimmet.)
  
• Lifestyle changes alone may not be effective for high-risk individuals.
  
• There is a lack of evidence from long-term studies on the benefits of specific lifestyle interventions.

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¹ Lifestyle, Not Drugs, For Preventing Type 2 Diabetes: "Gladiatorial" Debate Concludes, HeartWire, September 11, 2008

Diabetes is the seventh leading cause of death in the US as new cases continue to be diagnosed at a rate of 4000 per day. This sobering statistic places millions of people at greatly increased risk of coronary heart disease, stroke, sudden death from a heart attack and contributes to the obesity epidemic.

Would you be willing to make six simple lifestyle changes if you knew you could lower your risk of developing Alzheimer`s disease by 50%? Researchers publishing the result of a study in the journal Lancet Neurology found that the exploding incidence of this horrific form of dementia is due in large part to lifestyle changes involving diet, physical activity and education.