Lipid profile and socioeconomic status in healthy middle aged women in Sweden.

STUDY OBJECTIVE: To examine the relationship between socioeconomic status (SES) and full lipid profile in middle aged healthy women. PARTICIPANTS: These comprised 300 healthy Swedish women between 30 and 65 years who constitute the control group of the Stockholm female coronary risk study, a population based, case-control study of women with coronary heart disease (CHD). The age matched control group, drawn from the census register of greater Stockholm, was representative of healthy Swedish women aged 30-65 years. Five measures of SES were used; educational level, occupation, decision latitude at work, annual income, and size of house or apartment. MAIN RESULTS: Swedish women with low decision latitude at work, low income, low educational level, blue collar jobs, and who were living in small houses or apartments had an unhealthy lipid profile, suggesting an increased risk of CHD. Part of this social gradient in lipids was explained by an unhealthy lifestyle, but the lipid gradients associated with decision latitude at work and annual income were independent of these factors. Decision latitude, educational level, and annual income had the strongest associations with lipid profile. These associations were independent of age, menopausal status, smoking, sedentary lifestyle, alcohol consumption, obesity, excess abdominal fat, and unhealthy dietary habits. Of the lipid variables, low high density lipoprotein cholesterol (HDL) levels were most consistently associated with low SES. CONCLUSIONS: Decision latitude at work was the strongest SES predictor of HDL levels in healthy middle aged Swedish women, after simultaneous adjustment for other SES measures, age, and all lifestyle factors in the multivariable regression model.     

Coronary heart disease: prevalence and dietary sugars in Scotland.

STUDY OBJECTIVE--The aim was to investigate the effects of dietary intakes of different types of sugars (extrinsic, intrinsic, and lactose) and the dietary fat to sugar ratio on prevalent coronary heart disease (CHD). DESIGN--This was a baseline cross sectional survey of CHD risk factors. SETTING--Twenty two Scottish health districts were surveyed between 1984 and 1986. PARTICIPANTS--A total of 10,359 men and women aged 40-59 years were screened as part of the Scottish Heart Health Study, and a further 1267 men and women aged 25-39 and 60-64 years were screened as part of the Scottish MONICA (monitoring trends and determinants in cardiovascular disease) Study. The response rates were 74% and 64% respectively. METHODS--Subjects completed a questionnaire which included sociodemographic, health, and food frequency information. Medical history, response to the Rose chest pain questionnaire, and results of a 12 lead ECG recording were used to categorize subjects into CHD diagnosed, previously CHD undiagnosed, or no CHD groups. The chi 2 statistic was used to determine whether the CHD groups differed in their sugar consumption, and multiple logistic regression analysis, with adjustment for other potential coronary risk factors, was used to calculate odds ratios for prevalent CHD by intake fifths of dietary sugars. MAIN RESULTS--Men, but not women, differed in their sugar consumption by CHD group. The odds ratios showed a tendency for a U shaped relationship for extrinsic sugar intake with CHD prevalence, but no significant effect of the fat to sugar ratio (possible marker of obesity) on CHD was seen. CONCLUSIONS--The results suggest that neither extrinsic sugar, intrinsic sugar, nor the fat to sugar ratio are significant independent predictors of prevalent CHD in the Scottish population, when the other major risk factors such as cigarette smoking, blood cholesterol concentration, and antioxidant vitamins intake are accounted for. These new data for different sugar types agree with the consensus view that total sugar intake is not a major marker of coronary heart disease.     

Waist-to-hip ratio and dietary factors in adults

OBJECTIVES: To assess the association between diet factors and abdominal fat accumulation. METHODS: A household survey carried out in the city of Rio de Janeiro during 1995-1996. The usual diet of a sample of 2,441 individuals (42.8% men and 57.2% women), aged 20 to 60 years, was investigated using a food frequency questionnaire and data about height, weight, waist and hip perimeter was collected. The cut-off points for inadequate waist-to-hip ratio (WHR) for men and women were 0.95 and 0.80, respectively. RESULTS: Inadequate WHR was positively associated with age, cigarette smoking, body mass index, and inversely associated with education level, income and leisure physical activity in both men and women (p<0.05). Inadequate WHR was not associated with lipids, carbohydrates and total fiber intake. Positive association was found with inadequate WHR and spirits consumption among menopause women (p<0.001), and the consumption of four or more glasses of beer per day in men (p<0.001). CONCLUSION: In agreement with other studies, alcohol intake was associated with abdominal fat accumulation.     

Fat intake is more strongly associated with lifestyle factors than with socio-economic characteristics, regardless of energy adjustment approach.

OBJECTIVE: To compare how three different energy adjustment approaches influence the ranking of individuals on fat intake, and to examine the relation between fat intake and socio-economic, demographic and lifestyle characteristics for each energy adjustment approach. DESIGN: A cross-sectional analysis project, using a sub-sample (7055 women and 3240 men) from the Malm? Diet and Cancer Study. Dietary habits were assessed with an interview based diet history method. Fat intake was, depending on energy-adjustment method, defined as absolute intake (FATg), percentage energy from fat (FAT%), and residuals from total fat regressed on total energy (FATres). Cross-classification compared categorisation into fat intake quintiles. Logistic regression estimated, separately for each of the three approaches, the associations between high fat intake and socio-economic, demographic and lifestyle characteristics. RESULTS: Agreement in individuals' ranking was high between FAT% and FATres, but FATg differed substantially from the others. Current smoking, low level of leisure time physical activity and low alcohol intakes were, in multivariate analysis, consistently associated with risk of high fat consumption regardless of energy adjustment method. However, the associations with socio-economic characteristics varied with energy adjustment method and gender groups. CONCLUSIONS: The similarities between FAT% and FATres, in the ranking of individuals and in the association with lifestyle factors and socio-economic characteristics implies that it is possible to translate results obtained with FATres to recommendations using FAT%. The consistent lifestyle pattern across fat intake definitions (in energy adjusted models) may indicate that fat consumption is more strongly related to lifestyle factors than to socio-economic characteristics.     

Association between lifestyle and white blood cell count: a study of Japanese male office workers

METHODS: We assessed the association of lifestyle factors with white blood cell (WBC) count in 3681 Japanese male office workers aged 35-59 years. RESULTS: The WBC count differed significantly across lifestyle factors (overall obesity, alcohol consumption, cigarette smoking, eating breakfast, nutritional balance, physical exercise and hours of work). From multiple linear regression analyses, overall obesity, alcohol intake, cigarette smoking, nutritional balance and hours of work remained as statistically significant factors associated with WBC count. The WBC count increment showed a positive dose-response relationship with poor lifestyle factors regarding overall obesity, cigarette smoking and nutritional balance. On the other hand, the WBC count increment showed a negative dose-response relationship with alcohol intake and hours of work. CONCLUSION: These data indicate that lifestyle factors may exert an important effect on WBC count.     

Associations between plasma lipid concentrations and dietary, lifestyle and physical factors in the Oxford Vegetarian Study

Blood lipids data were available for 3773 subjects from a cohort study of 11 000 individuals, 6000 of whom do not eat meat. The effects of dietary, lifestyle and physical factors on concentrations of total and HDL cholesterol were investigated. Meat, cheese and dietary fibre, with smoking habit and height were found to be significantly related to total cholesterol in men. For women, meat, cheese, dietary fibre and tomatoes, and type of spreading fat were all significantly related to total cholesterol. Current alcohol consumption and body mass index were significantly related to HDL cholesterol concentration for men. The same factors, plus type of spreading fat, were related to HDL cholesterol levels in women. The findings provide further evidence of the hypolipidaemic effect of vegetarian or near vegetarian diets with a high fibre content and limited use of meat and cheese. The exclusion of meat from the diet might result in a 15–25% reduction in CHD risk.     

Intake of fish and long-chain n-3 fatty acids and the risk of coronary heart mortality in men and women

This prospective study investigated the relationship between the consumption of fish and intake of long-chain n-3 fatty acids and the risk of coronary heart mortality in 2775 men and 2445 women aged from 30 to 79 years who were free of CHD and had participated in a health examination survey from 1967 to 1972. In total, 335 men and 163 women died of CHD during a follow-up until the end of 1992. A dietary history interview method provided data on habitual consumption of fish and other foods over the preceding year at baseline. The intakes of long-chain n-3 fatty acids were calculated on the basis of food composition values of Finnish foods. Higher consumption of fish was associated with a decreased risk of CHD among women, whereas no significant association was seen among men. The relative risk between the highest and the lowest quintile for fish consumption was 1.00 (95 % CI 0.70, 1.43; P for trend 0.83) for men and 0.59 (95 % CI 0.36, 0.99; P for trend 0.02) for women in analysis adjusting for age, energy intake, geographical area, BMI, serum cholesterol, blood pressure, smoking, occupation and diabetes; however, after adjustment for dietary confounders this association was no longer significant. The intake of n-3 fatty acids was not significantly associated with the risk of CHD in either men or women. In conclusion, our results for women are in line with the suggested protective effect of fish consumption against CHD but a similar association was not, however, found in men.     

The contribution of lifestyle factors to socioeconomic differences in obesity in men and women--a population-based study in Sweden

BACKGROUND: The objective was to investigate whether and to what extent the association between socioeconomic status and obesity can be explained by lifestyle factors. METHODS: The relationship between socioeconomic status (SES) and obesity, and the role of lifestyle factors such as smoking, physical activity, heavy alcohol use, avoidance of dietary fat and propensity to eat fiber-rich food, was studied in a cross-sectional population-based study consisting of 6394 men and women aged 25-74 years in V?rmland County in Sweden. Educational level was used for measuring SES. The contribution of the measured lifestyle factors was assessed using logistic regression models. RESULTs: 12% of men and 14% of women were obese. Subjects with high education were leaner than subjects with low education, except among elderly women (65-74 years). Although many lifestyle factors were related to obesity and SES in this study, only a part (18-29%) of the association between educational level and obesity could be explained by the measured lifestyle factors. Physical inactivity and heavy alcohol use were the main factors contributing to this association, whereas smoking and the measured dietary attitudes towards fat and fiber had little additional effect. CONCLUSIONS: The findings of this study are consistent with the view that socioeconomic differences in obesity and its consequences can only partly be reduced by changes in lifestyle. Longitudinal studies, a more detailed investigation of the role of dietary factors and more studies including elderly subjects are, however, recommended to further elucidate the association between SES and obesity.     

Clustering of risk behaviors with cigarette consumption: A population-based survey

OBJECTIVE: This study assessed clustering of multiple risk behaviors (i.e., low leisure-time physical activity, low fruits/vegetables intake, and high alcohol consumption) with level of cigarette consumption. METHODS: Data from the 2002 Swiss Health Survey, a population-based cross-sectional telephone survey assessing health and self-reported risk behaviors, were used. 18,005 subjects (8052 men and 9953 women) aged 25 years old or more participated. RESULTS: Smokers more frequently had low leisure time physical activity, low fruits/vegetables intake, and high alcohol consumption than non- and ex-smokers. Frequency of each risk behavior increased steadily with cigarette consumption. Clustering of risk behaviors increased with cigarette consumption in both men and women. For men, the odds ratios of multiple (> or =2) risk behaviors other than smoking, adjusted for age, nationality, and educational level, were 1.14 (95% confidence interval: 0.97, 1.33) for ex-smokers, 1.24 (0.93, 1.64) for light smokers (1-9 cigarettes/day), 1.72 (1.36, 2.17) for moderate smokers (10-19 cigarettes/day), and 3.07 (2.59, 3.64) for heavy smokers (> or =20 cigarettes/day) versus non-smokers. Similar odds ratios were found for women for corresponding groups, i.e., 1.01 (0.86, 1.19), 1.26 (1.00, 1.58), 1.62 (1.33, 1.98), and 2.75 (2.30, 3.29). CONCLUSIONS: Counseling and intervention with smokers should take into account the strong clustering of risk behaviors with level of cigarette consumption.     

A longitudinal analysis of the impact of dietary intake and physical activity on weight change in adults.

The current investigation is a longitudinal analysis of the relationship between dietary intake, physical activity, and body weight change in adult men (n = 142) and women (n = 152). Measures of dietary intake, physical activity, and cigarette and alcohol consumption were obtained for 3 y. Results indicated a different pattern of predictors of weight change for men vs women. For women a high dietary energy and fat intake as well as increases in total energy intake were related to higher weight gain and increases in work activity levels were related to decreased weight gain. For men weight gain was predicted by increases in dietary fat intake. Sex differences are discussed as a possible moderator variable in the energy balance equation.     

Clustering of lifestyle risk factors in a general adult population

BACKGROUND: The objective of the study was to evaluate the degree of clustering of common lifestyle risk factors in a general adult population and to define subgroups with elevated clustering. METHODS: Data on lifestyle risk factors (smoking, low vegetable and fruit consumption, excessive alcohol intake, and low physical activity), sociodemographics, and health perception were collected by questionnaire from 16,789 men and women aged 20 to 59. RESULTS: About 20% of the subjects had at least three lifestyle risk factors. Prevalence of risk factors was higher among unemployed, low-educated subjects and those who had experienced health deterioration. All lifestyle risk factors showed significant clustering, except for low physical activity and excessive alcohol consumption. The strongest association was observed for alcohol and smoking (prevalence odds ratio (POR): 2.38; 95% confidence interval: 2.18-2.61). Clustering of smoking and alcohol consumption was strongest among the young subjects (POR: 3.78) and, although moderately, clustering of lifestyle risk factors was elevated in subjects who had experienced a deterioration in health. CONCLUSIONS: These findings suggest that common lifestyle risk factors cluster among adult subjects. The tendency for risk factors to aggregate has important implications for health promotion. Information on high-risk groups will help in planning future preventive strategies.     

Gender, alcohol consumption, and renal cell carcinoma

The nature of the association between alcohol consumption and renal cell carcinoma (RCC) is not well understood, but there are indications of effect modification by gender. The authors report data from a population-based case-control study conducted in Iowa from 1986 to 1989. RCC cases (261 men and 145 women) were identified through the Iowa Cancer Registry, while controls (1,598 men and 831 women) were randomly selected from the general population, frequency matched on age and gender. Subjects provided detailed information on a mailed questionnaire regarding demographic, anthropometric, lifestyle, dietary, and medical history risk factors. In age-adjusted analysis, there was a decrease in risk for women who reported consuming more than three servings (median among drinkers) of alcohol per week (odds ratio = 0.5, 95% confidence interval: 0.2, 0.9) compared with never drinkers. No evidence of an association among men was noted (odds ratio = 1.1, 95% confidence interval: 0.8, 1.5). Multivariate adjustment for anthropometric, lifestyle, smoking, and dietary factors did not alter the findings. Analysis by type of alcohol suggested that the inverse association was strongest for beer consumption, but estimates were imprecise. These findings suggest an inverse association of alcohol consumption and RCC development among women but not among men.     

Cigarette smoking and fat distribution in 21,828 British men and women: a population-based study

OBJECTIVE: To examine the relationship between cigarette smoking habits and fat distribution in a population-based cohort of men and women. RESEARCH METHODS AND PROCEDURES: We analyzed cross-sectional data from 21,828 men and women who were 45 to 79 years of age, residents in Norfolk, United Kingdom, and were recruited between 1993 and 1997. Cigarette smoking habits and other lifestyle factors were assessed using self-reported questionnaires. Anthropometric measures were obtained during a health examination. RESULTS: Waist-hip ratio was highest among current smokers and least among never smokers after adjusting for age, BMI, alcohol intake, total energy intake, physical activity, and education. Higher waist-hip ratio was directly associated with higher smoking pack-years in current and former smokers and inversely with duration since quitting smoking in former smokers. Adjusting for age, BMI, and other covariates, current smokers had higher waist circumference but lower hip circumference compared with former or never smokers. DISCUSSION: Cigarette smoking habits seem to influence fat distribution patterns. Although smokers have lower mean BMI compared with nonsmokers, they have a more metabolically adverse fat distribution profile, with higher central adiposity. The explanation for this association may help elucidate the mechanisms underlying the adverse health consequences of cigarette smoking and abdominal obesity.     

The contribution of lifestyle factors to socioeconomic differences in obesity in men and women – a population-based study in Sweden

Background: The objective was to investigate whether and to what extent the association between socioeconomic status and obesity can be explained by lifestyle factors. Methods: The relationship between socioeconomic status (SES) and obesity, and the role of lifestyle factors such as smoking, physical activity, heavy alcohol use, avoidance of dietary fat and propensity to eat fiber-rich food, was studied in a cross-sectional population-based study consisting of 6394 men and women aged 25–74 years in Värmland County in Sweden. Educational level was used for measuring SES. The contribution of the measured lifestyle factors was assessed using logistic regression models. Results: 12% of men and 14% of women were obese. Subjects with high education were leaner than subjects with low education, except among elderly women (65–74 years). Although many lifestyle factors were related to obesity and SES in this study, only a part (18–29%) of the association between educational level and obesity could be explained by the measured lifestyle factors. Physical inactivity and heavy alcohol use were the main factors contributing to this association, whereas smoking and the measured dietary attitudes towards fat and fiber had little additional effect. Conclusions: The findings of this study are consistent with the view that socioeconomic differences in obesity and its consequences can only partly be reduced by changes in lifestyle. Longitudinal studies, a more detailed investigation of the role of dietary factors and more studies including elderly subjects are, however, recommended to further elucidate the association between SES and obesity.     

Dietary fats and 16-year coronary heart disease mortality in a cohort of men and women in Great Britain

OBJECTIVE: The paper aims to investigate the relationships of dietary fats to subsequent coronary heart disease (CHD) mortality in men and women while taking account of other CHD-related behaviours. DESIGN: A cohort of randomly selected men and women were interviewed in 1984-85 and monitored subsequently for 16 y for deaths. The interview covered health, health-related behaviours, physical measurements, socio-demographic details and a dietary questionnaire. Appropriate exclusions left 1225 men and 1451 women aged 40-75 with 98 and 57 CHD deaths, respectively. Saturated, polyunsaturated and total fat intakes were estimated. SETTING: The sample was randomly selected from households in Great Britain. The interviews took place in participants' own homes. RESULTS: Not consuming alcohol, smoking, not exercising and being socially disadvantaged were related to high saturated fat intake and CHD death. Cox survival analyses adjusting for these factors found that a level of saturated fat 100 g per week higher corresponded to a relative risk for CHD death for men of 1.00 (0.86-1.18) and 1.40 (1.09-1.79) for women. This difference between the effects of saturated fat in men and women was statistically significant (P=0.019). Results are also reported for total fat and the relative effects of polyunsaturated and saturated fats. CONCLUSIONS: Strong evidence was found for the within cohort relationship of dietary fat and CHD death in women while no evidence was found for a relationship in men. Possible explanations for this are discussed.     

Behavior change at the worksite: does social support make a difference?

PURPOSE: This study examines whether social support for behavior change at work is associated with changes in employee heart disease risk factors. DESIGN: A prospective correlational design was used with data sets collected 12 months apart. SETTING: Twenty-five small to medium worksites in Oregon. SUBJECTS. Participants were 689 men and 421 women volunteers who participated in two health assessments at the worksite on company time. MEASURES: Demographic characteristics, gender, social support, smoking behavior, dietary fat intake, and total blood cholesterol. RESULTS: Employees reporting strong social support at work for not smoking and for limiting dietary fat were less likely to smoke (r = -.11, odds ratio [OR] = .86) and to consume fat in their diets (r = -.10) at baseline. Employees who reported the most change in social support over a 12-month period were most likely to have stopped smoking (r = .15, OR = 1.31). Social support at baseline, however, was unrelated to change in smoking, dietary fat, or total blood cholesterol in a prospective design. Although women reported more social support at work than did men, no differential gender effects of social support were reported on heart disease risk status or change in risk status. CONCLUSION: Baseline social support at work did not predict future behavior change. The observed association between social support and lifestyle may be better explained as cognitive rationalization than by the impact of social support on behavior.     

Relationship of socioeconomic status with cardiovascular risk factors and lifestyle in a Mediterranean population

BACKGROUND: Socioeconomic status greatly affects cardiovascular risk factors and lifestyle. Aim of the study To analyse the relationship between socioeconomic status and both cardiovascular risk factors and behavioural variables. AIM OF THE STUDY: To analyse the relationship between socioeconomic status and both cardiovascular risk factors and behavioural variables. METHODS: The present random sample of 838 men and 910 women of the 25 to 74 year old general population of Gerona according to the 1991 census, included cardiovascular risk factor measurements (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, glycaemia, systolic blood pressure, diastolic blood pressure, body mass index, waist to hip ratio, and waist circumferences) and evaluation of dietary habits, alcohol consumption, smoking, and leisure-time physical activity with corresponding questionnaires. RESULTS: In this study, we used lifestyle factors (leisure-time physical activity, tobacco consumption, and alcohol drinking habits) in addition to dietary habits to determine whether changes in these factors correlate with the socioeconomic status, classified as degree of educational level, in a representative Spanish Mediterranean population. Multiple linear regression analysis adjusted for several confounders revealed a direct association of LDL-cholesterol (p = 0.03) and body mass index (p = 0.02) with low levels of educational status in men and women, respectively. A higher educational status was directly (p = 0.04) related to the smoking status in women. The two composite dietary scores, indicating overall dietary quality and cardiovascular protecting properties, were not associated with low socioeconomic status in our population. CONCLUSION: Dietary habits, alcohol drinking, and leisure-time physical activity seems not to be affected by educational status in either gender. This finding might partially explain the relationship between cardiovascular risk factors and socioeconomic status in our population. The importance of cultural values in the rural area of the Spanish province seems to be the stronger factor compared with education.     

Dietary fat and body fat: a multivariate study of 205 adult females.

This study examined the association between diet composition, particularly dietary fat intake, and body-fat percentage in 205 adult females. Subjects completed a written questionnaire regarding lifestyle factors, such as exercise participation and smoking, demographic data, and the diet section of the National Cancer Institute's Health Habits and History Questionnaire by Block. Skinfold-thickness measures were used to ascertain the body-fat percentage of each subject. Results showed that intake of dietary fat was related significantly with adiposity, without (F = 13.65, R2 = 0.063, P = 0.0003) and with (F = 8.74, R2 = 0.033, P = 0.0035) control for multiple potential confounding factors: age, total energy intake, total exercise time per week, years of regular physical activity, consumption of other macronutrients, and smoking. Unlike dietary fat intake, protein consumption and carbohydrate intake were not significant individual predictors of body-fat percentage when the potential confounding variables were controlled. The findings suggest that dietary fat intake may play a role in obesity beyond dietary energy content.     

Moderate dietary fat consumption as a risk factor for ischemic heart disease in a population with a low fat intake: a case-control study in Korean men

BACKGROUND: Dietary fat intake is associated with the incidence of ischemic heart disease (IHD) in Western countries. In populations in which both the average dietary fat consumption and the incidence of IHD are lower than in Western countries, the association of dietary fat intake with IHD incidence remains unknown. OBJECTIVE: We conducted a case-control study to examine the association of dietary fat with IHD incidence in Korean men. DESIGN: The case group consisted of 108 patients with electrocardiogram-confirmed myocardial infarction or angiographically confirmed (> or =50% stenosis) IHD who were admitted to a university teaching hospital in Seoul, Republic of Korea. The controls were 142 age-matched patients admitted to the departments of ophthalmology and orthopedic surgery at the same hospital. Dietary fat intake was assessed by a nutritionist using a semiquantitative food-frequency questionnaire. Body mass index (BMI), cigarette use, alcohol intake, exercise, and history of disease were determined during an interview and examination. RESULTS: In a univariate analysis, the mean percentages of energy from total fat, saturated fatty acids, and monounsaturated fatty acids were significantly higher in the cases than in the controls. BMI, smoking, and a history of hypertension were associated with the occurrence of IHD. In multiple logistic analyses, total fat intake was a significant risk factor (odds ratio: 1.08 for 1% of energy intake; 95% CI: 1.02, 1.14) after adjustment for BMI and smoking. CONCLUSION: In a population with a relatively low fat intake (19% of energy intake), a moderate increase in total fat intake may be a risk factor for IHD.     

Smoking associated with other behavioral risk factors for chronic non-communicable diseases

The study interviewed 1,410 adults by telephone. Respondents comprised a random sample and represented the population over 18 years of age living in households with landline telephone services. Smoking prevalence was 21.8%, higher in males (25%) and in the 18-29 year bracket. Smoking and sedentary lifestyle occurred together in 13.9% of males and 14.2% of females; smoking and low fruit consumption in 12.9% of males and 12.3% of females; and smoking and low vegetable consumption in 5.8% of males and 5.1% of females. An association between smoking and excessive alcohol intake was only observed in males (3.5%). As observed for smoking alone, the simultaneous occurrence of smoking and other behavioral risk factors for CNCD was inversely associated with schooling. Evidence of clustering between smoking and sedentary lifestyle, smoking and excessive alcohol intake, and smoking and improper diet thus calls for interventions focused on prevention and the concomitant reduction of major behavioral risk factors.