The contribution of diet and lifestyle to socioeconomic inequalities in cardiovascular morbidity and mortality

Background

The role of differences in diet on the relationship between socioeconomic factors and cardiovascular diseases remains unclear. We studied the contribution of diet and other lifestyle factors to the explanation of socioeconomic inequalities in cardiovascular diseases.

Methods

We prospectively examined the incidence of coronary heart disease (CHD) and stroke events amongst 33,106 adults of the EPIC-NL cohort. Education and employment status indicated socioeconomic status. We used Cox proportional models to estimate hazard ratios ((HR (95% confidence intervals)) for the association of socioeconomic factors with CHD and stroke and the contribution of diet and lifestyle.

Results

During 12 years of follow-up, 1617 cases of CHD and 531 cases of stroke occurred. The risks of CHD and stroke were higher in lowest (HR = 1.98 (1.67;2.35); HR = 1.55 (1.15;2.10)) and lower (HR = 1.50 (1.29;1.75); HR = 1.42 (1.08;1.86)) educated groups than in the highest. Unemployed and retired subjects more often suffered from CHD (HR = 1.37 (1.19;1.58); HR = 1.20 (1.05;1.37), respectively), but not from stroke, than the employed. Diet and lifestyle, mainly smoking and alcohol, explained more than 70% of the educational differences in CHD and stroke and 65% of employment status variation in CHD. Diet explained more than other lifestyle factors of educational and employment status differences in CHD and stroke (36% to 67% vs. 9% to 27%).

Conclusion

The socioeconomic distribution of diet, smoking and alcohol consumption largely explained the inequalities in CHD and stroke in the Netherlands. These findings need to be considered when developing policies to reduce socioeconomic inequalities in cardiovascular diseases.     

A pilot comprehensive lifestyle intervention program (CLIP) - Comparison with qualitative lifestyle advice and simvastatin on cardiovascular risk factors in overweight hypercholesterolaemic individuals

Background and Aims

Escalating costs of pharmaceuticals for cardiovascular management highlight the need to develop effective lifestyle intervention programs to reduce reliance on these agents. The aim of this pilot study was to evaluate the efficacy of a Comprehensive Lifestyle Intervention Program (CLIP) compared with qualitative lifestyle advice (L) and Simvastatin plus qualitative lifestyle (S + L) on cardiovascular risk factors.

Methods and Results

Sixty-five overweight adults with hypercholesterolemia were randomised to either L (qualitative advice on diet, exercise), S + L (20 mg/day Simvastatin plus L) or CLIP (6500 kJ structured menu plan: conventional and functional foods contributing <10% energy from saturated fat, ≥3 g soluble fibre, 2.4 g plant sterols, oily fish ≥2 times/week at lunch and dinner, plus exercise advice and self monitoring) for 6 weeks. LDL-cholesterol was lowered in CLIP (−0.57 ± 0.67 mmol/L, 15%) and S + L (−1.43 ± 0.59 mmol/L, 37%), but did not change significantly in L (−0.17 ± 0.59, 4%) (P < 0.001 time-by-treatment interaction). Weight and waist circumference were significantly lowered by CLIP (−4.2 ± 2.2 kg; −5.1 ± 2.3 cm) compared to L (−1.0 ± 1.6 kg; −2.7 ± 3.3 cm) and L + S (−0.7 ± 1.4 kg; −2.4 ± 2.3 cm), (P ≤ 0.003 time-by-treatment interactions). B-carotene levels within treatment groups did not change over time and were not lowered by the CLIP diet compared to L (P > 0.05, all). Blood pressure changes were not different between groups.

Conclusions

The structured CLIP program was more effective than qualitative lifestyle advice in improving weight, waist circumference and LDL-cholesterol without adverse effects on plasma carotenoids over a 6 week period. This program may therefore assist in comprehensive risk factor management, although the sustainability of these benefits needs confirmation.     

Diet,lifestyle and cognitive function in old Chinese adults

BackgroundThe relationship between diet, lifestyle and cognition of old adults has been indicated in several population-based studies. However, the conclusions derived from these studies are inconsistent.MethodsA cross-sectional study was carried out in 894 old Chinese adults aged 50 and above. Cognitive function of the participants was measured by using Montreal Cognitive Assessment (MoCA) test. Demographic characteristics and lifestyle was collected with a questionnaire. A semi-quantified FFQ method was used for dietary intake survey.ResultsComparing with normal subjects, mild cognition impairment (MCI) patients were characterized as old age and lower education (P < 0.01). The nuts and cooking oil intake of MCI patients was less than the normal subjects (P < 0.05). Fruit and vegetable intake will benefit orientation, name and attention ability in the elderly (P < 0.05). Fruit and vegetable juice drinking will benefit abstraction ability (P < 0.01).Subjects with regular reading and housekeeping habit had better cognition (P < 0.01).ConclusionsNuts, vegetables and fruit-rich diet might decrease the risk of cognition impairment. Reading and housekeeping help to maintain healthy cognition in the elderly.     

Alcohol Availability and the Formal Power and Resources of State Alcohol Beverage Control Agencies

The formal powers and resources of state alcohol beverage control agencies place them in a position to regulate access to alcoholic beverages through restrictions on retail distribution and sales. For example, monopoly states restrict access to spirits, and sometimes wine, by allowing retail sales only through state stores. On the other hand, license and monopoly states share in restricting sales through the use of price posting and fixing provisions. The degree to which these powers are realized in restrictions on alcohol outlets (e.g., licenses) and subsequent alcohol consumption (e.g., sales) was investigated in the current study. In a cross-sectional analysis of data available from 44 alcohol beverage control (ABC) jurisdictions in the United States, it was shown that states with greater restrictions on retail sales had greater resources for the conduct of ABC activities and lower densities of spirit outlets. These states, however, had greater densities of wine and beer outlets. States with greater marketplace restrictions had more resources for ABC enforcement activities and lower outlet densities across all beverage types. Further, supporting the suggestion that availability and demand may be simultaneously related, greater outlet densities were related to greater alcohol consumption (for beer) and greater levels of consumption were related to greater outlet densities (for wine).     

Alcohol and Self-Rated Health in a Mediterranean Country: The Role of Average Volume, Drinking Pattern, and Alcohol Dependence

Background: The association between average alcohol consumption and self‐rated ill‐health is “J‐shaped” in Scandinavian and Anglo‐Saxon countries, but it has shown an inverse linear relationship in the few studies conducted in Mediterranean countries, based on average volume solely. Objective: To examine the relationship between alcohol and self‐rated health in the general population of a Mediterranean country, by simultaneously taking into account average volume, drinking pattern, and alcohol abuse. Methods: From 2000 to 2005, we conducted telephone interviews on 12,037 persons, representative of the population aged 18 to 64 years in Madrid, Spain. The drinking pattern encompassed binge drinking, beverage preference, and drinking at mealtimes. Alcohol abuse was estimated by the CAGE test. The association between each alcohol‐related variable and self‐rated suboptimal (fair, poor, or very poor) health was estimated from logistic regression, with adjustment for the remaining alcohol‐related variables and other potential confounders. Results: In comparison with never‐drinkers, suboptimal health was less frequent among occasional drinkers [odds ratio (OR) 0.72; 95% confidence interval (CI): 0.61 to 0.86], average moderate drinkers (OR 0.57; 95% CI: 0.48 to 0.69), and excessive drinkers (OR 0.51; 95% CI: 0.36 to 0.72), but more frequent among former drinkers with ≥1 year of abstinence (OR 1.30; 95% CI: 1.03 to 1.64). Frequency of suboptimal health was likewise higher in subjects with ≥3 episodes of binge drinking (OR 1.55; 95% CI: 1.12 to 2.14) or alcohol abuse (OR 1.47; 95% CI: 1.22 to 1.76). No differences were observed in suboptimal health according to beverage preference or drinking at mealtimes. Results in each gender were similar to those for total study participants. Conclusions: Occasional, moderate, and excessive consumption of alcohol are associated with better self‐rated health, even after adjustment for drinking pattern and alcohol abuse. In contrast, former‐drinking, frequent binge drinking, and alcohol abuse are all associated with suboptimal self‐rated health.     

The results of Look AHEAD do not row against the implementation of lifestyle changes in patients with type 2 diabetes

The Look AHEAD trial, evaluating the effects of weight loss on cardiovascular (CV) morbidity and mortality in overweight/obese people with type 2 diabetes (T2D), was interrupted after a median 9.5-year follow-up because the incidence of CV events was not different between the Intensive Lifestyle Intervention (ILI) and the control groups, and unlikely to statistically change thereafter. This made health providers and patients wondering about clinical value of diet and physical exercise in diabetic patients. Many factors may have made difficult to ascertain benefits of lifestyle intervention, besides the lower than predicted CV event rates. Among others, LDL-cholesterol was lowered more, with a higher use of statins, in the control group. Anyhow, ILI significantly improved numerous health conditions, including quality of life, CV risk factors and blood glucose control, with more diabetes remissions and less use of insulin.The intervention aimed at weight loss by reducing fat calories, and using meal replacements and, eventually, orlistat, likely underemphasizing dietary composition. There is suggestive evidence, in fact, that qualitative changes in dietary composition aiming at higher consumption of foods rich in fiber and with a high vegetable/animal fat ratio favorably influence CV risk in T2D patients.In conclusion, the Look AHEAD showed substantial health benefits of lifestyle modifications. Prevention of CV events may need higher attention to dietary composition, contributing to stricter control of CV risk factors. As a better health-related quality of life in people with diabetes is an important driver of our clinical decisions, efforts on early implementation of behavioral changes through a multifactorial approach are strongly justified.     

Impact of hepatitis C virus infection on lifestyle

AIM: To evaluate the impact of the diagnosis of hepatitis C infection on lifestyle habits such as smoking, drinking, sports activity and diet.METHODS: A self-administered, anonymous question-naire was offered to out-patients with HCV infection consecutively attending three clinical centres in Italy.RESULTS: Of the 275 respondents, 62.2% (171) were male. Mean age was 51 (range 20-80) years. Overall, after the diagnosis of hepatitis C, 74.5% of drinkers had modified (giving up or reducing) alcohol consumption, 21.3% of smokers had modifi ed their habits and 32.3% of subjects who reported sports activity had either stopped or reduced frequency of activity or chose a less fatiguing sport. Sixty-four percent of the respondents reported having modified their diet, most of them on physician's advice. CONCLUSION: After the diagnosis of hepatitis C many patients correctly modif ied their alcohol consumption and a minority their smoking habits. The reason for reported changes in diet and physical activity needs further investigations.     

Role of diet and lifestyle changes in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) has become one of the most common causes of liver disease worldwide and has been recognized as a major health burden. The prevalence of NAFLD has grown proportionally with the rise in obesity, sedentary lifestyle, unhealthy dietary pattern, and metabolic syndrome. Currently, there is no drug therapy that can be formulated for treating NAFLD. A combination of dietary modifications and increased physical activity remains the mainstay of NAFLD management. It is hard to maintain this mode of management; however, it seems to have significant long-term benefits. Furthermore, NAFLD patients, whether obese or not, should be educated that a healthy diet and physical activity have benefits beyond weight reduction. Further large controlled randomized trials are needed in order to identify the best dietary regimen and physical activity in the management of NAFLD patients. This review highlights the role of diet and lifestyle modifications in the management of NAFLD, and focuses on human studies regarding dietary modifications and physical activity.     

量化运动及饮食对代谢综合征干预疗效观察

目的观察生活方式对代谢综合征（MS）发病率的影响,探讨量化运动及饮食干预对代谢综合征的疗效。方法以2008年1月至2009年12月进入深圳市慢性病防治中心健康体检的人群作为观察对象,选取有效观察对象256例,根据生活方式、工作劳动强度、身体活动问卷调查将观察对象分成积极运动生活方式组及静坐生活方式组,分析不同运动、生活方式对MS患病率的影响。选取新发现MS患者58例,随机分为运动饮食干预组（A组）29例,采取运动、饮食干预联合基础药物治疗;基础药物干预组（B组）29例,仅采取基础药物治疗。两组病例分别于干预前、干预后3个月和6个月检测体重指数、血压、血糖、血脂,观察两组干预疗效。结果积极运动生活方式组MS发病率为12．3％,明显低于静坐生活方式组的31．0％。量化饮食运动干预组患者体重指数下降明显,其3个月、6个月MS控制达标率分别为86．2％和93．1％,明显高于基础药物干预组的69．0％和82．8％（P〈0．05）。结论积极运动是MS的保护因素。多食少动的生活方式是MS发生的不良因素,加强健康教育,改变不健康生活方式,可有效预防MS的发生。运动饮食干预治疗能有效改善胰岛素敏感性,增强MS疗效。     

Reducing metabolic syndrome through a community-based lifestyle intervention in African American women

Background and aimsMetabolic syndrome (MetS) increases the risk of cardiovascular disease and type 2 diabetes. Despite a higher prevalence of MetS in African American (AA) women, little is known about the effectiveness of lifestyle interventions in improving metabolic markers in this high-risk group. This study investigated the effectiveness of a community-based lifestyle intervention delivered by lay health coaches in reducing MetS among AA women.Methods and resultsA cluster-randomized diabetes prevention program (DPP) was implemented in 11 churches utilizing a community-based participatory research (CBPR) approach to develop and deliver the interventions. A total of 221 adults, AA women who were overweight or obese, and did not have diabetes were included in this study. The prevalence of MetS was 42.08% before receiving the DPP intervention and 31.22% after the intervention that represented a 10.86% absolute reduction and a 25.81% relative reduction from baseline. The adjusted odds ratio (OR) of being free from MetS at post-intervention in contrast to baseline was 2.14 (p = 0.02). Factors that increased the odds of being free from MetS were younger age, reduction in intake of total calories, total fat, saturated and trans-fat, and dietary sodium.ConclusionA faith adapted lifestyle intervention held in church settings and delivered by minimally trained lay health coaches reduced the prevalence of MetS in AA women who were overweight or obese. Findings from this study can be used to translate evidence into public health programs at the community level for the prevention of type 2 diabetes and cardiovascular disease.Clinical trial registration numberNCT 04082702 (www.clinicaltrials.gov).     

Alcohol and the heart

Alcohol consumption and disease or mortality display a J-shaped curve, with moderate amounts of alcohol being more protective than abstention, binge drinking, or heavy drinking. Red wine appears to be particularly protective for cardiovascular disease and associated conditions such as type 2 diabetes. There are, however, controversies concerning the effect of red wine on hypertension, in which there may be significant gender and ethnic differences. Overall, it seems that both ethanol and the polyphenols in red wine may contribute to the protective effect.     

The dietary and lifestyle indices of insulin resistance are associated with increased risk of cardiovascular diseases: A prospective study among an Iranian adult population

Background and aimsPrevious studies have introduced insulin resistance (IR) as a major risk factor for poor cardiovascular diseases (CVDs) outcomes. Diet, body weight, and physical activity are three key pillars of lifestyle that can significantly impact the IR status. We aimed to assess the possible link between the empirical dietary index for IR (EDIR) and the empirical lifestyle index for IR (ELIR) with the risk of chronic heart disease (CHD) and CVDs.Methods and resultsThis study was conducted on 4980 participants aged ≥30 years (follow-up rate: 99.85%). Dietary intake data was collected using a validated food frequency questionnaire. Cox proportional hazard regression was used to estimate the hazard ratio and 95% confidence intervals (HRs and 95% CIs) of CVDs and CHD across tertiles of EDIR and ELIR scores. In the final model, after adjusting for all potential confounding variables, participants in the highest tertile of EDIR had a higher risk of CVD (HR:1.36, 95%CI:1.03–1.80, P-trend = 0.016) and CHD (HR:1.36, 95% CI:1.01–1.83, P-trend = 0.023) compared to the lowest tertile. Also, participants with a higher score of ELIR had a higher risk of CVD (HR: 1.64, 95%CI:1.24–2.16, P-trend=<0.001) and CHD (HR: 1.72, 95%CI:1.28–2.32, P-trend=<0.001).ConclusionA greater adherence to the lifestyle and diet with a higher EDIR and ELIR may be associated with an increased risk of CVD and CHD outcomes in the adult population.     

Alcohol prices, beverage quality, and the demand for alcohol: quality substitutions and price elasticities

BACKGROUND: Although the published literature on alcohol beverage taxes, prices, sales, and related problems treats alcoholic beverages as a simple good, alcohol is a complex good composed of different beverage types (i.e., beer, wine, and spirits) and quality brands (e.g., high-, medium-, and low-quality beers). As a complex good, consumers may make substitutions between purchases of different beverage types and brands in response to price increases. For this reason, the availability of a broad range of beverage prices provides opportunities for consumers to mitigate the effects of average price increases through quality substitutions; a change in beverage choice in response to price increases to maintain consumption. METHODS: Using Swedish price and sales data provided by Systembolaget for the years 1984 through 1994, this study assessed the relationships between alcohol beverage prices, beverage quality, and alcohol sales. The study examined price effects on alcohol consumption using seemingly unrelated regression equations to model the impacts of price increases within 9 empirically defined quality classes across beverage types. The models enabled statistical assessments of both own-price and cross-price effects between types and classes. RESULTS: The results of these analyses showed that consumers respond to price increases by altering their total consumption and by varying their brand choices. Significant reductions in sales were observed in response to price increases, but these effects were mitigated by significant substitutions between quality classes. CONCLUSIONS: The findings suggest that the net impacts of purposeful price policy to reduce consumption will depend on how such policies affect the range of prices across beverage brands.     

Diet,Alcohol and Hypertension

Obesity, diet and alcohol consumption constitute major environmental determinations of blood pressure elevation. The long term setting of blood pressure in response to these factors will be determined by genetic susceptibility, and interactions with effects of physical fitness and smoking. Dietary changes which independently influence both atherosclerosis and hypertension are likely to be of greatest value in helping to control morbidity and mortality from hypertensive cardiovascular disease.

Recommendations should focus on diets low in total and saturated fat intake and high in fruit and vegetables, containing potassium and fibre, coupled with weight control, alcohol moderation to less than two drinks per day in drinkers and regular physical exercise. Sodium restriction will help lower blood pressure in older hypertensives in particular. The role of dietary calcium or fish oils in blood pressure regulation is still uncertain.

Dietary and related recommendations on smoking and exercise should be ‘first line’ treatment in mild hypertensives, and complimentary to therapy in all patients requiring drugs.     

Protective role of the Mediterranean diet on several cardiovascular risk factors: Evidence from Sicily,southern Italy

Background and aimsEpidemiological studies conducted in European countries demonstrated that the adoption of a Mediterranean diet protect against clustered risk factors but those evaluating such benefits specifically in southern Italy are scarce. Thus, the aim of this study was to assess the association between the adherence to the Mediterranean diet and cardiovascular risk factors obesity, diabetes, and hypertension.Methods and resultsA cross-sectional population-based survey including 3090 subjects was conducted in Sicily, southern Italy. Food intake was evaluated through a validated food frequency questionnaire and adherence to the dietary pattern was assessed using the MedDietScore. Linear and logistic regression models were performed to estimate odds ratios (ORs) and respective confidence intervals (CIs). After adjusting for confounding factors such as age and gender, participants in the highest tertile of the MedDietScore were less likely to be obese (OR 0.35, 95% CI: 0.24–0.51), hypertensive (OR 0.73, 95% CI: 0.55–0.97), and diabetic (OR 0.43, 95% CI: 0.24–0.77). Linear inverse relation between the MedDietScore and BMI (r² = 0.34, P < 0.001), waist circumference (r² = 0.17, P < 0.001), and waist-to-hip ratio (r² = 0.06, P < 0.001) was found.ConclusionDespite the prevalence rates of nutrition-related diseases are high in Sicily, greater adherence to the Mediterranean dietary pattern is still associated with a better health status.     

Dynamics of cardiovascular and all-cause mortality in Western and Eastern Europe between 1970 and 2000

Aims Important changes in cardiovascular and all-cause mortalityrates are occurring in Western and Eastern Europe, each withtheir own dynamics. Differences in trends will be analysed andpossible causes are discussed. Methods and results Mortality data for cardiovascular and all-causemortality rates from different countries were obtained fromWHO and were analysed for the period 1970–2000. The annualchanges in cause-specific mortality rates were calculated usinglinear and polynomial regression models. Mortality rates declinedalmost linearly for ischaemic heart disease, stroke, and totalcardiovascular diseases between 1970 and 2000 in Western Europe.In both men and women, the decline for these diseases variedbetween 50 and 65% or 2%/year in this period. In contrast, inEastern Europe cardiovascular mortality rates reached a maximumin the period 1990–94, followed by a decline of 3%/yearin Poland, 2%/year in Hungary, and 5%/year in the Baltic states.The changes in cardiovascular mortality rates were reflectedin all-cause mortality rates in both Western and Eastern Europe. Conclusion Over the past 30 years, mortality rates in cardiovasculardiseases increased or decreased very rapidly. The causes arecomplex but changes in diet appear to play a major role. Themore recent declines in Western Europe also reflect improvementsin modern cardiovascular treatment.     

强化生活方式干预对2型糖尿病疗效观察

目的 探讨在药物治疗的基础上强化饮食、运动干预对2型糖尿病患者疗效的影响.方法 选择无运动禁忌证的2型糖尿病患者65例,随机分为生活方式干预组（32例）和普通治疗组（33例）,检测患者空腹血糖（FPG）、胆固醇（TC）、甘油三酯（TG）、低密度脂蛋白胆固醇（LDL-c）、高密度脂蛋白胆固醇（HDL-c）、体重指数（BMI）、糖化血红蛋白（HbA1c）及血压等指标,前后自身对照及组间对照评价其治疗效果.结果 （1）与单纯药物治疗组比较,生活方式干预组患者的体重、BMI、舒张压、FPG、HbA1c控制明显优于普通治疗组（P＜0.05）.（2）经过干预治疗后,2型糖尿病患者的体重、BMI、血压、FPG、HbA1c极显著下降（P＜0.01）.结论 严格的饮食控制,适量的运动干预能更有效地控制糖尿病患者血糖、HbA1c、血压和体重等危险因素.