Smoking, physical activity, and active life expectancy

Critical Illness, Major Surgery, and Other Hospitalizations and Active and Disabled Life Expectancy

Importance

Estimates of active and disabled life expectancy, defined as the projected number of remaining years without and with disability in essential activities of daily living, are commonly used by policymakers to forecast the functional well-being of older persons.

Objective

To determine how estimates of active and disabled life expectancy differ based on exposure to intervening illnesses and injuries (or events).

Design, Setting, and Participants

This prospective cohort study was conducted in south-central Connecticut from March 1998 to December 2021 among 754 community-living persons aged 70 years or older who were not disabled. Data were analyzed from January 25 to September 18, 2024.

Exposures

Exposure to intervening events, which included critical illness, major elective and nonelective surgical procedures, and hospitalization for other reasons, was assessed each month.

Main Outcomes and Measures

Disability in 4 essential activities of daily living (bathing, dressing, walking, and transferring) was ascertained each month. Active and disabled life expectancy were estimated using multistate life tables under a discrete-time Markov process assumption.

Results

The study included 754 community-living older persons who were not disabled (mean [SD] age, 78.4 [5.3] years; 487 female [64.6%]; 67 Black [8.9%], 4 Hispanic [0.5%], 682 non-Hispanic White [90.5%], and 1 other race [0.1%]). Within 5-year age increments from 70 to 90 years, active life expectancy decreased monotonically as the number of admissions for critical illness and other hospitalization increased. For example, at age 70 years, sex-adjusted active life expectancy decreased from 14.6 years (95% CI, 13.9-15.2 years) in the absence of a critical illness admission to 11.3 years (95% CI, 10.3-12.2 years), 8.1 years (95% CI, 6.3-9.9 years), and 4.0 years (95% CI, 2.6-5.7 years) in the setting of 1, 2, or 3 or more critical illness admissions, respectively. Corresponding values for other hospitalization were 19.4 years (95% CI, 18.0-20.8 years), 13.5 years (95% CI, 12.2-14.7 years), 10.0 years (95% CI, 8.9-11.2 years), and 7.0 years (95% CI, 6.1-7.9 years), respectively. Consistent monotonic reductions were observed for sex-adjusted estimates in active life expectancy for nonelective but not elective surgical procedures as the number of admissions increased; for example, at age 70 years, estimates of active life expectancy were 13.9 years (95% CI, 13.3-14.5 years), 11.7 years (95% CI, 10.5-12.8 years), and 9.2 years (95% CI, 7.4-11.0 years) for 0, 1, and 2 or more nonelective surgical admissions, respectively; corresponding values were 13.4 years (95% CI, 12.8-3-14.1 years), 14.6 years (95% CI, 13.5-15.5 years), and 12.6 years (95% CI, 11.5-13.8 years) for elective surgical admissions. Sex-adjusted disabled life expectancy decreased as the number of admissions increased for critical illness and other hospitalization but not for nonelective or elective surgical procedures; for example, at age 70 years, disabled life expectancy decreased from 4.4 years (95% CI, 3.5-5.8 years) in the absence of other hospitalization to 3.4 years (95% CI, 2.8-4.1 years), 3.4 years (95% CI, 2.7-4.2 years), and 2.3 years (95% CI, 1.9-2.8 years) in the setting of 1, 2, or 3 or more other hospitalizations, respectively.

Conclusions and Relevance

This study found that active life expectancy among community-living older persons who were not disabled was considerably diminished in the setting of serious intervening illnesses and injuries. These findings suggest that prevention and more aggressive management of these events, together with restorative interventions, may be associated with improved functional well-being among older persons.

Health benefits of leisure-time physical activity by socioeconomic status, lifestyle risk, and mental health: a multicohort study

BACKGROUND

Regular physical activity is recommended for all aged 5 years and older, but the health benefits gained might differ across population subgroups. The aim of this study was to examine these benefits in terms of years lived free from major non-communicable diseases in subgroups with varying levels of risk factors.

METHODS

Our analysis was based on a multicohort study of initially healthy European adults from the IPD-Work Consortium and initially healthy participants from the UK Biobank study. Self-reported leisure-time physical activity levels at baseline (1986-2010) were categorised as low (no or very little), intermediate (between low and recommended levels), and WHO-recommended (≥2·5 h of moderate or ≥1·25 h of vigorous physical activity per week). We divided the study population into 36 overlapping subgroups based on socioeconomic factors, lifestyle, and mental health at baseline, and assessed disease-free years between ages 40 years and 75 years for both the overall population and subgroups, accounting for coronary heart disease, stroke, type 2 diabetes, cancer, asthma, and chronic obstructive pulmonary disease.

FINDINGS

14 IPD-Work studies were assessed and six studies were excluded due to missing outcome data and unavailable data for pooling, resulting in the inclusion of eight studies with 124 909 participants. After the exclusion of 7685 participants due to prevalent diseases and 9265 due to missing data, the sample consisted of 107 959 initially healthy European adults (63 567 [58·9%] females and 44 392 [41·1%] males) from the IPD-Work consortium. For the UK Biobank sample, 9 238 453 million individuals were invited, 8 736 094 (94·6%) were non-respondents, and 502 359 participated in the baseline examination. After the exclusion of 73 460 participants, 428 899 participants had data on at least one measure of physical activity. 236 258 (55·1%) were female and 192 641 (44·9%) were male. During 1·6 million person-years at risk, 21 231 IPD-Work participants developed a non-communicable disease, while 101 319 UK Biobank participants developed a non-communicable disease over 4·8 million person-years at risk. Compared with individuals with low physical activity, those meeting the recommended physical activity levels during leisure-time gained an additional 1·1 (95% CI 1·0-1·2) to 2·0 (1·7-2·3) disease-free years, depending on sex and study. In males from the IPD-Work and UK Biobank cohorts, greater gains in disease-free years were observed in current smokers (2·4 [95% CI 2·1-2·8]) versus never smokers (0·7 [0·5-0·9]); those with low education (1·4 [1·1-1·7]) versus high education (0·8 [0·7-1·0]); low socioeconomic status (1·7 [1·5-2·0]) versus high socioeconomic status (0·9 [0·7-1·1]); and those with (1·6 [1·3-1·9]) versus without depressive symptoms (1·0 [0·9-1·1]; p value range <0·0001-0·0008). Similar differences were seen in women for smoking (2·3 [95% CI 1·9-2·7] vs 0·9 [0·7-1·1]), socioeconomic status (1·7 [1·4-2·0] vs 0·8 [0·5-1·0]), depressive symptoms (1·4 [1·1-1·7] vs 1·0 [0·9-1·1]), and for heavy drinkers compared with moderate drinkers (1·4 [1·1-1·6] vs 0·9 [0·7-1·1]; p value range <0·0001-0·010). No differences in physical activity-related health gains were observed between risk groups and non-risk groups by BMI, history of depression, and, in men, alcohol use (p value range 0·11-0·86).

INTERPRETATION

In addition to confirming the association between leisure-time physical activity and increased disease-free years across population subgroups, our findings show that these health benefits are often more pronounced among individuals with pre-existing health risks or disadvantaged backgrounds than in those with more favourable risk factor profiles. This suggests that enhancing population-wide physical activity initiatives could help reduce health disparities, while incorporating physical activity into targeted strategies addressing social disadvantage, unhealthy lifestyles, and depression might enhance their effectiveness.

FUNDING

Wellcome Trust, UK Medical Research Council, US National Institute on Aging, and Research Council of Finland.

Japan's intensive health guidance program has limited effects on cardiovascular risk factors: a regression discontinuity analysis

OBJECTIVES

It is uncertain whether the effects of health counselling programs differ depending on their intensity. This study compared the effectiveness of intensive health guidance (IHG) and less intensive motivation-enhancing guidance (MEG) on cardiovascular risk factors.

STUDY DESIGN

A regression discontinuity design (RDD) was applied.

METHODS

In Japan's specific health checkup (SHC) and guidance program, those with a high risk of metabolic syndrome are assigned to IHG or MEG. An RDD was applied using an SHC results database. Four groups were created in which IHG or MEG assignment was solely determined by single cut-off values of the running variables of triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), or haemoglobin A1c (HbA1c) measured during SHC. Outcomes were one year's changes in body mass index (BMI), waist circumference (WCF), systolic and diastolic blood pressure, HDL-C, low-density lipoprotein cholesterol, FBG, and HbA1c.

RESULTS

A total of 541,809 observations among 225,115 people from 2008 to 2017 were analysed. Men assigned to IHG had a significantly but slightly lower BMI and WCF than those assigned to MEG the next year, only when TG or FBG was a running variable. There were no significant differences between IHG and MEG for women's BMI and WCF and other cardiovascular risk factors for both sexes.

CONCLUSION

Since IHG has limited additional effects on cardiovascular risk factors compared with MEG, abolishing IHG may have little negative impact on the general public's health.

Urban-rural differences in the association between occupational physical activity and mortality in Chinese working population: evidence from a nationwide cohort study

Background

Despite emerging studies suggesting that occupational physical activity (OPA) might be harmful to health, the available evidence is not definitive. Most of these research studies were conducted in high-income Western countries or in urbanized setting. In China, where over one-third of the population resides in rural area, the impact of OPA on health is not well understood. The goal of this study is to investigate how the association between OPA and mortality vary by urban-rural settings.

Methods

Baseline data on OPA was gathered using the Global Physical Activity Questionnaire from 30,650 urban and 49,674 rural working adults as part of the 2013-2014 China Chronic Disease and Risk Factor Surveillance. Participants were followed for a median of 6.2 years, and death records were retrieved from the National Mortality Surveillance System until December 31, 2019. The multivariable Cox proportional hazard model was used to examine urban-rural differences in the association between OPA and all-cause and cardiovascular disease (CVD) mortality. Subgroup analyses were performed by sex, socioeconomic status, leisure time, transportation, and non-occupational physical activity.

Findings

During the study period, 1342 deaths were recorded, of which 426 were caused by CVD. In rural area, working adults engaging in occupational moderate-to-vigorous physical activity (MVPA) for ≥40 h per week, compared to those without any, had an adjusted hazard ratio of 0.60 (95% CI: 0.49-0.73) for all-cause mortality and 0.55 (95% CI: 0.37-0.83) for CVD mortality. However, no significant association was found in urban area (0.84 [0.61-1.15] for all-cause mortality, Pinteraction = 0.036; and 0.94 [0.53-1.66] for CVD mortality, Pinteraction = 0.098). The negative associations of occupational MVPA with mortality were more pronounced in women, non-smokers, and those with less non-occupational physical activities. Hypertension, heart rate, and diabetes were important contributors to the relationship between occupational MVPA and mortality.

Interpretation

The findings from the current study did not support the notion that high levels of OPA would induce harm. On the contrary, in rural setting, higher levels of OPA were associated with lower mortality risks. Furthermore, the observed urban-rural differences in the association between OPA and mortality underscored the need for context-specific public health guidelines on physical activities.

Funding

R&D Program of Beijing Municipal Education Commission (KM202210025026),National Key Research and Development Program of China (2021YFC2500201), and Young Elite Scientist Sponsorship Program by BAST (BYESS2023385).

Correlates of life course physical activity in participants of the Baltimore longitudinal study of aging

Physical activity is consistently associated with better health and longer life spans. However, the extent to which length and intensity of exercise across the life course impact health outcomes relative to current activity is undefined. Participants of the Baltimore Longitudinal Study of Aging were asked to categorize their level of physical activity in each decade of life from adolescence to the current decade. In linear mixed effects models, self-reported past levels of physical activity were significantly associated with activity assessed at study visits in the corresponding decade of life either by questionnaire or accelerometry. A pattern of life course physical activity (LCPA) derived by ranking participants on reported activity intensity across multiple decades was consistent with the trajectories of activity estimated from standard physical activity questionnaires assessed at prior study visits. In multivariable linear regression models LCPA was associated with clinical characteristics, measures of body composition and indicators of physical performance independent of current physical activity. After adjustment for minutes of high intensity exercise, LCPA remained significantly associated with peak VO2, fasting glucose, thigh muscle area and density, abdominal subcutaneous fat, usual gait speed, lower extremity performance, and multimorbidity (all p < 0.01) at the index visit. The observed associations suggest that an estimate of physical activity across decades provides complementary information to information on current activity and reemphasizes the importance of consistently engaging in physical activity over the life course.

Objectively measured the impact of ambient air pollution on physical activity for older adults

BACKGROUND

Air pollution poses a significant health risk to the human population, especially for vulnerable groups such as the elderly, potentially discouraging their engagement in physical activity. However, there is a lack of sufficient objective and longitudinal data in current research on how air pollution affects physical activity among older adults. With these gaps, we aimed to explore the relationship between air pollution and objective measurement-based physical activity among older adults by engaging in a longitudinal study design.

METHODS

A total of 184 older adults were recruited from three cities with varying levels of air quality. Mean daily minutes of physical activity were measured with 7 consecutive days of accelerometer monitoring (ActiGraph GT3X-BT). Corresponding air pollution data including daily PM2.5 (µg/m3), PM10 (µg/m3) and air quality index (AQI) were sourced from the China National Environmental Monitoring Centre at monitor locations close to older adults' addresses. Associations between air quality and physical activity were estimated using a fixed effect model, adjusting for average daytime temperature, rain, age and weight.

RESULTS

AQI and PM2.5 were observed to exhibit significant, inverse, and linear associations with mean daily walk steps, minutes of light physical activity (LPA), moderate physical activity (MPA) and moderate-to-vigorous physical activity (MVPA) in the single variable models. A one-level increase in AQI corresponded to a decline in 550.04 steps (95% [CI] = -858.97, -241.10; p < 0.001), 10.43 min (95% [CI] = -17.07, -3.79; p < 0.001), 4.03 min (95% [CI] = -7.48, -0.59; p < 0.001) and 4.16 min (95% [CI] = -7.77, -0.56; p < 0.001) in daily walking steps, LPA, MPA, and MVPA, respectively. A one-level increase in PM2.5 correlated with a decline in daily walk steps, LPA, MPA and MVPA by 361.85 steps (95% [CI] = -516.53, -207.16; p < 0.001), 8.97 min (95% [CI] = -12.28, -5.66; p < 0.001), 3.73 min (95% [CI] = -5.46, -2.01; p < 0.001,) and 3.79 min (95% [CI] = -5.59, -1.98; p < 0.001), respectively. However, PM10 displayed a significant negative association exclusively with LPA, with one-level increase in PM10 resulting in a 3.7-minute reduction in LPA (95% [CI] = -6.81, -0.59, p < 0.05).

CONCLUSION

Air pollution demonstrates an inverse association with physical activity levels among older adults, potentially discouraging their engagement in physical activity. Different air quality indicators may exert varying impacts on physical activity. Future studies are warranted to enhance policy interventions aimed at reducing air pollution and promoting physical activity.

Exercise and Smoking Cessation

Smoking is a public health crisis, leading to a multitude of health complications. Exercise is associated with numerous health benefits and is accepted by health professionals and smokers as a potentially effective smoking cessation aid. This chapter discusses the extant literature on the relation between exercise and smoking, including cross-sectional studies, experiments, and randomized clinical trials. There is robust evidence for exercise's efficacy in reducing cigarette craving, tobacco withdrawal symptoms, and negative affect. Further, exercise-based interventions appear to boost short-term abstinence yet may fall short of facilitating long-term abstinence. Methodological limitations of extant work are reviewed. We conclude with a discussion of the next steps in this line of work to fine-tune exercise interventions and their application for smoking cessation.

Healthy Lifestyle Is Associated with Reduced Mortality in Patients with Non-Alcoholic Fatty Liver Disease

Background and Aims: It is unclear whether a healthy lifestyle impacts mortality in the presence of non-alcoholic fatty liver disease (NAFLD). The present study aimed to examine the joint association of several modifiable lifestyle factors with mortality risk for NAFLD patients. Methods: We collected lifestyle behavior data form the National Health and Nutrition Examination Survey (NHANES) III from 1988 to 1994 and follow-up data form NHANES III-linked mortality data through 2015. We estimated joint association between four healthy lifestyle factors (non-smoking, non-drinking, regular physical activity, a healthy diet) after NAFLD diagnosis and mortality using Cox proportional hazards regression models. Results: During a median of 22.83 years of follow-up, 2932 deaths occurred. The risk of all-cause mortality decreased significantly with the healthy lifestyle scores increasing (p < 0.001). NAFLD patients with a favorable lifestyle (3 or 4 healthy lifestyle factors) reduced 36% of all-cause mortality and 43% of cardiovascular disease (CVD) mortality compared with those with an unfavorable lifestyle (0 or 1 healthy lifestyle factor) (HR, 0.64 [95% CI, 0.50−0.81], 0.57 [95% CI, 0.37−0.88]). Compared with the non-NAFLD group, the number of NAFLD patients required to adhere to a favorable lifestyle to prevent one cardiovascular disease death in 20 years was fewer (77 vs. 125). Conclusions: For the NAFLD patients, adopting a healthy lifestyle could significantly reduce their risk of death.

Association of Physical Activity with Anthropometrics Variables and Health-Related Risks in Healthy Male Smokers

Anthropometric variables (AV) are shown to be essential in assessing health status and to serve as markers for evaluating health-related risks in different populations. Studying the impact of physical activity (PA) on AV and its relationship with smoking is a non-trivial task from a public health perspective. In this study, a total of 107 healthy male smokers (37 ± 9.42 years) were recruited from different states in Malaysia. Standard procedures of measurement of several anthropometric indexes were carried out, and the International Physical Activity Questionnaire (IPPQ) was used to ascertain the PA levels of the participants. A principal component analysis was employed to examine the AV associated with physical activity, k-means clustering was used to group the participants with respect to the PA levels, and discriminant analysis models were utilized to determine the differential variables between the groups. A logistic regression (LR) model was further employed to ascertain the efficacy of the discriminant models in classifying the two smoking groups. Six AV out of twelve were associated with smoking behaviour. Two groups were obtained from the k-means analysis, based on the IPPQ and termed partially physically active smokers (PPAS) or physically nonactive smokers (PNAS). The PNAS were found to be at high risk of contracting cardiovascular problems, as compared with the PPAS. The PPAS cluster was characterized by a desirable AV, as well as a lower level of nicotine compared with the PNAS cluster. The LR model revealed that certain AV are vital for maintaining good health, and a partially active lifestyle could be effective in mitigating the effect of tobacco on health in healthy male smokers.

Virtual Reality Technology Use in Cigarette Craving and Smoking Interventions (I "Virtually" Quit): Systematic Review

BACKGROUND

Over the last 2 decades, virtual reality technologies (VRTs) have been proposed as a way to enhance and improve smoking cessation therapy.

OBJECTIVE

This systematic review aims to evaluate and summarize the current knowledge on the application of VRT in various smoking cessation therapies, as well as to explore potential directions for future research and intervention development.

METHODS

A literature review of smoking interventions using VRT was conducted.

RESULTS

Not all intervention studies included an alternative therapy or a placebo condition against which the effectiveness of the intervention could be benchmarked, or a follow-up measure to ensure that the effects were lasting. Virtual reality (VR) cue exposure therapy was the most extensively studied intervention, but its effect on long-term smoking behavior was inconsistent. Behavioral therapies such as a VR approach-avoidance task or gamified interventions were less common but reported positive results. Notably, only 1 study combined Electronic Nicotine Delivery Devices with VRT.

CONCLUSIONS

The inclusion of a behavioral component, as is done in the VR approach-avoidance task and gamified interventions, may be an interesting avenue for future research on smoking interventions. As Electronic Nicotine Delivery Devices are still the subject of much controversy, their potential to support smoking cessation remains unclear. For future research, behavioral or multicomponent interventions are promising avenues of exploration. Future studies should improve their validity by comparing their intervention group with at least 1 alternative or placebo control group, as well as incorporating follow-up measures.

Optimal design of sin taxes in the presence of nontaxable sin goods

Sin good consumption entails health damage, which is in general not fully perceived by individuals, what results in its overconsumption. One way to tackle this problem is to tax these unhealthy goods. However, not all the individual choices that affect health status can be easily observed and effectively taxed by the government. This paper considers a setting where individuals can consume two types of sin goods that differ in their observability (taxability) by the government. As a benchmark, the first-best taxes for the observable and non-observable sin good are derived, considering homogeneous individuals. In the second-best setting, where observability on sin good consumption is limited, the rule for the taxable sin good is shown to depend on the degree of complementarity or substitutability with the unobservable sin good. Finally, redistributional considerations are incorporated by extending the analysis to a setting where individuals differ in their wealth and in their degree of misperception of the health damage caused by sin good consumption. Policy implications are illustrated considering physical inactivity and illicit drugs as examples of non-taxable sin goods, while alcohol, tobacco, fat and sugar account for the taxable sin goods.

Healthy Aging Within an Image: Using Muscle Radiodensitometry and Lifestyle Factors to Predict Diabetes and Hypertension

The strong age dependency of many deleterious health outcomes likely reflects the cumulative effects from a variety of risk and protective factors that occur over one's life course. This notion has become increasingly explored in the etiology of chronic disease and associated comorbidities in aging. Our recent work has shown the robust classification of individuals at risk for cardiovascular pathophysiology using CT-based soft tissue radiodensity parameters obtained from nonlinear trimodal regression analysis (NTRA). Past and present lifestyle influences the incidence of comorbidities like hypertension (HTN), diabetes (DM) and cardiac diseases. 2,943 elderly subjects from the AGES-Reykjavik study were sorted into a three-level binary-tree structure defined by: 1) lifestyle factors (smoking and self-reported physical activity level), 2) comorbid HTN or DM, and 3) cardiac pathophysiology. NTRA parameters were extracted from mid-thigh CT cross-sections to quantify radiodensitometric changes in three tissue types: lean muscle, fat, and loose-connective tissue. Between-group differences were assessed at each binary-tree level, which were then used in tree-based machine learning (ML) models to classify subjects with DM or HTN. Classification scores for detecting HTN or DM based on lifestyle factors were excellent (AUCROC: 0.978 and 0.990, respectively). Finally, tissue importance analysis underlined the comparatively-high significance of connective tissue parameters in ML classification, while predictive models of DM onset from five-year longitudinal data gave a classification accuracy of 94.9%. Altogether, this work serves as an important milestone toward the construction of predictive tools for assessing the impact of lifestyle factors and healthy aging based on a single image.

Mixed evidence for the compression of morbidity hypothesis for smoking elimination-a systematic literature review

BACKGROUND

There is debate around the composition of life years gained from smoking elimination. The aim of this study was to conduct a systematic review of the literature to synthesize existing evidence on the effect of smoking status on health expectancy and to examine whether smoking elimination leads to compression of morbidity.

METHODS

Five databases were systematically searched for peer-reviewed articles. Studies that presented quantitative estimates of health expectancy for smokers and non-/never-smokers were eligible for inclusion. Studies were searched, selected and reviewed by two reviewers who extracted the relevant data and assessed the risk of bias of the included articles independently.

RESULTS

The search identified 2491 unique records, whereof 20 articles were eligible for inclusion (including 26 cohorts). The indicators used to measure health included disability/activity limitations (n=9), health-related quality of life (EQ-5D) (n=2), weighted disabilities (n=1), self-rated health (n=9), chronic diseases (n=6), cardiovascular diseases (n=4) and cognitive impairment (n=1). Available evidence showed consistently that non-/never-smokers experience more healthy life years throughout their lives than smokers. Findings were inconsistent on the effect of smoking on the absolute number of unhealthy life years. Findings concerning the time proportionally spent unhealthy were less heterogeneous: nearly all included articles reported that non-/never-smokers experience relatively less unhealthy life years (e.g. relative compression of morbidity).

CONCLUSIONS

Support for the relative compression of morbidity due to smoking elimination was evident. Further research is needed into the absolute compression of morbidity hypothesis since current evidence is mixed, and methodology of studies needs to be harmonized.

The Significant Association between Health Examination Results and Population Health: A Cross-Sectional Ecological Study Using a Nation-Wide Health Checkup Database in Japan

In Japan, population health with life expectancy (LE) and healthy life expectancy (HALE) as indicators varies across the 47 prefectures (administrative regions). This study investigates how health examination results, including attitude toward improving life habits, are associated with population health. The association between health checkup variables and summary population health outcomes (i.e., life expectancy and healthy life expectancy) was investigated using a cross-sectional ecological design with prefectures as the unit of analysis. The medical records, aggregated by prefecture, gender, and age in the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan, were used as health checkup variables. Body weight, blood pressure, liver enzymes, drinking habits, smoking habits, diabetes, serum lipids, and answers to questions regarding attitude toward improving health habits were significantly correlated to population health outcomes. Multiple regression analysis also revealed significant influence of these variables on population health. This study highlights that health examination results, including attitude toward improving health habits, are positively associated with population health. Consequently, implementing measures to improve health habits in response to the examination results could help the population maintain a healthy life.

Identification of determinants of healthy ageing in Italy: results from the national survey IDAGIT

Healthy ageing is a public health problem globally. In Europe, the dependency ratio of the elderly is expected to increase by 21.6 per cent to 51.2 per cent in 2070. The World Health Organization (WHO) study on healthy ageing started in 2002 as a concept whereby all people of all ages should be able to live in a healthy, safe and socially inclusive way. The aim of this study is to present preliminary results of the project Identification of Determinants of Healthy Ageing in Italy (IDAGIT) that aimed to collect data on the active and healthy ageing of the Italian population aged over 18 using the conceptual framework of the WHO's ageing model. To link the determinants of the IDAGIT studies to those of the WHO model, we performed a confirmatory factor analysis which reported these variables as significant (in order of factor loading): smoking, cognition score, comorbidity, outdoor built environment, participation, working expertise and income. Considering comorbidity, 83.8 per cent of the sample declared not having any chronic diseases or to have only one, and regarding neurological diseases, only nine people had received a diagnosis of stroke. Regarding gender, the personal determinants and physical and social environments did not result in statistically significant differences, whereas we found statistical differences between the aged groups in all variables analysed. These results provide a first bio-psycho-social perspective on ageing in the Italian population.

Impairment Mechanisms and Intervention Approaches for Aged Human Neuromuscular Junctions

The neuromuscular junction (NMJ) is a chemical synapse formed between a presynaptic motor neuron and a postsynaptic muscle cell. NMJs in most vertebrate species share many essential features; however, some differences distinguish human NMJs from others. This review will describe the pre- and postsynaptic structures of human NMJs and compare them to NMJs of laboratory animals. We will focus on age-dependent declines in function and changes in the structure of human NMJs. Furthermore, we will describe insights into the aging process revealed from mouse models of accelerated aging. In addition, we will compare aging phenotypes to other human pathologies that cause impairments of pre- and postsynaptic structures at NMJs. Finally, we will discuss potential intervention approaches for attenuating age-related NMJ dysfunction and sarcopenia in humans.

Estimating the number and length of episodes in disability using a Markov chain approach

Background

Markov models are a key tool for calculating expected time spent in a state, such as active life expectancy and disabled life expectancy. In reality, individuals often enter and exit states recurrently, but standard analytical approaches are not able to describe this dynamic. We develop an analytical matrix approach to calculating the expected number and length of episodes spent in a state.

Methods

The approach we propose is based on Markov chains with rewards. It allows us to identify the number of entries into a state and to calculate the average length of episodes as total time in a state divided by the number of entries. For sampling variance estimation, we employ the block bootstrap. Two case studies that are based on published literature illustrate how our methods can provide new insights into disability dynamics.

Results

The first application uses a classic textbook example on prednisone treatment and liver functioning among liver cirrhosis patients. We replicate well-known results of no association between treatment and survival or recovery. Our analysis of the episodes of normal liver functioning delivers the new insight that the treatment reduced the likelihood of relapse and extended episodes of normal liver functioning. The second application assesses frailty and disability among elderly people. We replicate the prior finding that frail individuals have longer life expectancy in disability. As a novel finding, we document that frail individuals experience three times as many episodes of disability that were on average twice as long as the episodes of nonfrail individuals.

Conclusions

We provide a simple analytical approach for calculating the number and length of episodes in Markov chain models. The results allow a description of the transition dynamics that goes beyond the results that can be obtained using standard tools for Markov chains. Empirical applications using published data illustrate how the new method is helpful in unraveling the dynamics of the modeled process.

Germline mutation rates in young adults predict longevity and reproductive lifespan

Ageing may be due to mutation accumulation across the lifespan, leading to tissue dysfunction, disease, and death. We tested whether germline autosomal mutation rates in young adults predict their remaining survival, and, for women, their reproductive lifespans. Age-adjusted mutation rates (AAMRs) in 61 women and 61 men from the Utah CEPH (Centre d’Etude du Polymorphisme Humain) families were determined. Age at death, cause of death, all-site cancer incidence, and reproductive histories were provided by the Utah Population Database, Utah Cancer Registry, and Utah Genetic Reference Project. Higher AAMRs were significantly associated with higher all-cause mortality in both sexes combined. Subjects in the top quartile of AAMRs experienced more than twice the mortality of bottom quartile subjects (hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.21–3.56; p = 0.008; median survival difference = 4.7 years). Fertility analyses were restricted to women whose age at last birth (ALB) was ≥ 30 years, the age when fertility begins to decline. Women with higher AAMRs had significantly fewer live births and a younger ALB. Adult germline mutation accumulation rates are established in adolescence, and later menarche in women is associated with delayed mutation accumulation. We conclude that germline mutation rates in healthy young adults may provide a measure of both reproductive and systemic ageing. Puberty may induce the establishment of adult mutation accumulation rates, just when DNA repair systems begin their lifelong decline.

Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study

OBJECTIVE

To examine how a healthy lifestyle is related to life expectancy that is free from major chronic diseases.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

The Nurses' Health Study (1980-2014; n=73 196) and the Health Professionals Follow-Up Study (1986-2014; n=38 366).

MAIN EXPOSURES

Five low risk lifestyle factors: never smoking, body mass index 18.5-24.9, moderate to vigorous physical activity (≥30 minutes/day), moderate alcohol intake (women: 5-15 g/day; men 5-30 g/day), and a higher diet quality score (upper 40%).

MAIN OUTCOME

Life expectancy free of diabetes, cardiovascular diseases, and cancer.

RESULTS

The life expectancy free of diabetes, cardiovascular diseases, and cancer at age 50 was 23.7 years (95% confidence interval 22.6 to 24.7) for women who adopted no low risk lifestyle factors, in contrast to 34.4 years (33.1 to 35.5) for women who adopted four or five low risk factors. At age 50, the life expectancy free of any of these chronic diseases was 23.5 (22.3 to 24.7) years among men who adopted no low risk lifestyle factors and 31.1 (29.5 to 32.5) years in men who adopted four or five low risk lifestyle factors. For current male smokers who smoked heavily (≥15 cigarettes/day) or obese men and women (body mass index ≥30), their disease-free life expectancies accounted for the lowest proportion (≤75%) of total life expectancy at age 50.

CONCLUSION

Adherence to a healthy lifestyle at mid-life is associated with a longer life expectancy free of major chronic diseases.

A Short-Duration Combined Exercise and Education Program to Improve Physical Function and Social Engagement in Community-Dwelling Elderly Adults

Exercise is a key intervention for improving older adults' physical function and life expectancy. Here, we investigated a short-term intervention program designed to improve the physical functioning of elderly adults in a community-dwelling setting. We examined the effect of a 5-week combined exercise and education program on the physical function, social engagement, mobility performance, and fear of falling in 42 subjects older than 65 years. Eleven subjects dropped out. There was significant improvement in the 30-second chair stand test (p < .001) and timed up-and-go test (p < .001) between the baseline and the last session. At the end of the intervention, the subjects' social engagement was significantly higher than at baseline (p = .022), but this improvement was not maintained in the follow-up assessment. These results suggest that a combined exercise and education program can improve the physical function and social engagement of elderly individuals living in a community dwelling.

Potential impact of reduced tobacco use on life and health expectancies in Belgium

OBJECTIVES

We investigated the potential impact of reduced tobacco use scenarios on total life expectancy and health expectancies, i.e., healthy life years and unhealthy life years.

METHODS

Data from the Belgian Health Interview Survey 2013 were used to estimate smoking and disability prevalence. Disability was based on the Global Activity Limitation Indicator. We used DYNAMO-HIA to quantify the impacts of risk factor changes and to compare the "business-as-usual" with alternative scenarios.

RESULTS

The "business-as-usual" scenario estimated that in 2028 the 15-year-old men/women would live additional 50/52 years without disability and 14/17 years with disability. The "smoking-free population" scenario added 3.4/2.8 healthy life years and reduced unhealthy life years by 0.79/1.9. Scenarios combining the prevention of smoking initiation with smoking cessation programs are the most effective, yielding the largest increase in healthy life years (1.9/1.7) and the largest decrease in unhealthy life years (- 0.80/- 1.47).

CONCLUSIONS

Health impact assessment tools provide different scenarios for evidence-informed public health actions. New anti-smoking strategies or stricter enforcement of existing policies potentially gain more healthy life years and reduce unhealthy life years in Belgium.

Contribution of chronic conditions to smoking differences in life expectancy with and without disability in Belgium

Background

Smoking is the leading cause of premature mortality and morbidity. This study aimed at assessing the impact of smoking on life expectancy (LE) and LE with (LED) and without disability (DFLE). We further estimated the contribution of disability and mortality and their causes to differences in LED and DFLE by smoking.

Methods

Data on disability, chronic conditions, and smoking from 17 148 participants of the 1997, 2001, 2004 Belgian Health Interview Surveys were used to estimate causes of disability using the attribution method. A 10-year mortality follow-up of survey participants was used. The Sullivan method was applied to estimate LED and DFLE. The contribution of disability and mortality and of causes of disability and death to smoking differences in LED and DFLE was assessed using decomposition methods.

Results

Never smokers live longer than daily smokers. DFLE advantage at age 15 of +8.5/+4.3 years (y) in men/women never compared with daily smokers was the result of lower mortality (+6.2y/+3y) and lower disability (2.3y/1.3y). The extra 0.3y/1.6y LED in never smokers was due to lower mortality (+2.6y/+2.9y) and lower disability (-2.3y/-1.3y). Lower mortality from lung/larynx/trachea cancer, chronic respiratory, and ischaemic heart diseases was the main contributor to higher LED and DFLE in never smokers. Lower disability from musculoskeletal conditions in men and chronic respiratory diseases in women increased LED and DFLE in never smokers.

Conclusions

Mortality and disability advantage among never smokers contributed to longer DFLE, while mortality advantage contributed to their longer LED.

Impact of tobacco use on health and work productivity in Malaysia

Background

The loss of productivity arising from tobacco use in low/middle-income countries has not been well described. We sought to examine the impact of cigarette smoking on population health and work productivity in Malaysia using a recently published measure, the productivity-adjusted life year (PALY).

Methods

A life table model was constructed using published Malaysian demographic and mortality data. Our analysis was limited to male smokers due to the low smoking prevalence in females (1.1%). Male smokers aged 15–64 years were followed up until 65 years or until death. The population attributable risk, health-related quality of life decrements and relative reduction in productivity due to smoking were sourced from published data. The analysis was repeated assuming the cohorts were never smokers, and the differences in outcomes represented the health and productivity burden conferred by smoking. The cost of productivity loss was estimated based on the gross domestic product per equivalent full-time worker in Malaysia.

Results

Tobacco use is highly prevalent among working-age males in Malaysia, with 4.2 million (37.5%) daily smokers among men aged between 15 and 64 years. Overall, our model estimated that smoking resulted in the loss of over 2.1 million life years (2.9%), 5.5 million (8.2%) quality-adjusted life years (QALYs) and 3.0 million (4.8%) PALYs. Smoking was estimated to incur RM275.3 billion (US$69.4 billion) in loss of productivity.

Conclusion

Tobacco use imposes a significant public health and economic burden among working-age males in Malaysia. This study highlights the need of effective public health interventions to reduce tobacco use.

Smoking Predicting Physical Activity in an Aging America

OBJECTIVES

Tobacco smoking and physical inactivity are among leading behavioral risk factors for ill health in older adults. This study considers how smoking is associated with physical activity.

DESIGN

Using a Life-Course model, data are analyzed regarding this relationship, controlling for, and interacted with, life-course and other factors. Daily smokers and sometimes smokers were hypothesized to engage in less leisure-time physical activity than those who never smoked, while those who stopped smoking were expected to do more than never smokers. Analyses were performed using SAS-Callable SUDAAN.

SETTING AND PARTICIPANTS

Secondary data from ten years of a national sample of adults aged 18 and over of the National Health Interview Survey, 2001-2010, are used (N = 264,945, missing data excluded, of 282,313 total cases).

MEASUREMENTS

Daily smokers, occasional smokers, and smoking quitters are compared to never smokers with regard to requisite physical activity (150 minutes per week of moderate, 100 of vigorous, and/or 50 of strengthening activity). Life-course measures include birth cohorts, age, and year of survey, as well as gender, race/ethnicity, and education.

RESULTS

Overall, hypotheses are supported regarding daily smokers and quitters; but the hypothesis is strongly rejected among sometimes smokers, who are much more likely to do requisite physical activity. Findings differ by age, sometimes smokers age 65 and over being less likely to do physical activity. Findings among all men are similar to the overall findings, while those among all women are similar to those for older respondents. Associations of smoking status with physical activity vary greatly by race/ethnicity.

CONCLUSIONS

Daily smokers may be most in need of both smoking cessation and leisure-time physical activity interventions. Smoking-cessation efforts may pay greater physical activity benefits among women and the aged, while smoking-reduction efforts may provide better outcomes among men. Smoking reduction efforts may pay more exercise benefits among African-Americans and Hispanics.

Recreational Activity and Facial Trauma Among Older Adults

Importance

As the US population ages, public health agencies have released guidelines encouraging aerobic activity and muscle-strengthening exercises among older individuals. Facial trauma from such activities among elderly individuals has long been underappreciated.

Objectives

To evaluate the incidence of recreational activity-associated facial fractures among older adults and to further delineate injury characteristics including demographics, fracture location, and specific activities.

Design, Setting, and Participants

The National Electronic Injury Surveillance System was used to collect data on emergency department visits from January 1, 2011, to December 31, 2015, for individuals 55 years of age or older who sustained facial fractures from recreational activities. Individual entries were evaluated for activity code, fracture site, and demographics. Weighting data were used to extrapolate national incidence.

Main Outcomes and Measures

Incidence and location of facial fractures and associated recreational activity.

Results

During the study period, there were 20 519 emergency department visits for recreational activity-associated facial fractures among adults 55 years of age or older (8107 women and 12 412 men; mean [SD] age, 66.5 [9.1] years). The annual incidence of facial fractures increased by 45.3% from 2011 (n = 3174) through 2015 (n = 4612). Bicycling (26.6%), team sports (15.4%), outdoor activities (10.1%), and gardening (9.5%) were the most common causes of facial fractures. Walking and jogging caused 5.5% of fractures. In cases specifying site of fracture, nasal (65.4%) and orbital (14.1%) fractures were the most common. A greater proportion of men than women sustained bicycle-associated fractures (35.7% vs 14.9%; P = 3.1056 × 10-170), while more women than men sustained fractures associated with gardening (15.5% vs 6.1%; P = 2.1029 × 10-97), outdoor activities (14.6% vs 7.7%; P = 4.3156 × 10-50), and gym exercise (7.7% vs 1.3%; P = 3.0281 × 10-114). Men harbored a greater likelihood than women of orbital (14.9% vs 12.8%; P = 6.1468 × 10-5) and mandible fractures (9.3% vs 2.0%; P = 9.3760 × 10-64). Walking and jogging and gardening comprised a greater proportion of injuries in older cohorts.

Conclusions and Relevance

Facial fractures sustained from recreational activity increased by 45.3% during a 5-year period among older adults. Although bicycling was the most common activity facilitating these injuries, many other pursuits represent areas of concern. Nasal fractures predominated, although orbital fractures increased with age. These findings offer areas for targeted prevention and provide valuable information for patient counseling. Furthermore, initiatives encouraging greater activity among this population may need to be accompanied by guidelines for injury prevention.

Level of Evidence

NA.

Sports engagement and age at first myocardial infarction in men under 55 years of age

Objective

Low levels of physical activity in childhood are associated with clustering of cardiovascular risk factors (CVRF) as predisposition for atherosclerosis. We assessed the association between sports engagement and age at first myocardial infarction (MI) in a cohort of men under 55 years of age.

Methods

The Bern percutaneous coronary intervention Registry (NCT 02241291) was analyzed from March 2009 until January 2012. Male patients with first MI, age 18 to 54 years and body mass index ≤25kg/m² were included. Patients were stratified into two groups based on their starting age with organized sports ≥1 h/week outside school (EARLY: <18, CONTROL: ≥18 years or never). We assessed age at time of first MI, CVRF, and volume of sports training.

Results

Of 4,394 consecutive patients, 123 fulfilled the inclusion criteria (EARLY n = 81, CONTROL n = 42). Age at the time of first MI was 3 years younger in the EARLY compared to the CONTROL group (46.8±6.0 vs. 49.8±4.6 years, p = 0.006). Total lifetime training hours, and average yearly training hours, both, before and after age 18, were significantly greater in the EARLY group. Years of training <18 years were weakly inversely correlated with age at first MI (r² = 0.075, p = 0.002). The proportion of sports-related MI was not different between EARLY and CONTROL (13.6% vs. 11.9%). Patients in the EARLY group had fewer CVRF (2 vs. 3; p = 0.001). Prevalence of smoking was equally high in both groups (63.0% and 64.3%).

Conclusions

In our patients aged 54 and younger, the first MI occurred 3 years earlier in those who started regular sports activity before age 18, despite a more active lifestyle and favorable CVRF profile.

Are Optimism and Cynical Hostility Associated with Smoking Cessation in Older Women?

BACKGROUND

Optimism and cynical hostility independently predict morbidity and mortality in Women's Health Initiative (WHI) participants and are associated with current smoking. However, their association with smoking cessation in older women is unknown.

PURPOSE

The purpose of this study is to test whether optimism (positive future expectations) or cynical hostility (mistrust of others) predicts smoking cessation in older women.

METHODS

Self-reported smoking status was assessed at years 1, 3, and 6 after study entry for WHI baseline smokers who were not missing optimism or cynical hostility scores (n = 10,242). Questionnaires at study entry assessed optimism (Life Orientation Test-Revised) and cynical hostility (Cook-Medley, cynical hostility subscale). Generalized linear mixed models adjusted for sociodemographics, lifestyle factors, and medical and psychosocial characteristics including depressive symptoms.

RESULTS

After full covariate adjustment, optimism was not related to smoking cessation. Each 1-point increase in baseline cynical hostility score was associated with 5% lower odds of cessation over 6 years (OR = 0.95, CI = 0.92-0.98, p = 0.0017).

CONCLUSIONS

In aging postmenopausal women, greater cynical hostility predicts lower smoking cessation over time. Future studies should examine whether individuals with this trait may benefit from more intensive cessation resources or whether attempting to mitigate cynical hostility itself may aid smoking cessation.

Physical activity, body functions and disability among middle-aged and older Spanish adults

BACKGROUND

Physical activity (PA) is a health determinant among middle-aged and older adults. In contrast, poor health is expected to have a negative impact on PA. This study sought to assess to what extent specific International Classification of Functioning, Disability and Health (ICF) health components were associated with PA among older adults.

METHODS

We used a sample of 864 persons aged ≥50 years, positively screened for disability or cognition in a cross-sectional community survey in Spain. Weekly energy expenditure during PA was measured with the Yale Physical Activity Survey (YPAS) scale. The associations between body function impairment, health conditions or World Health Organization Disability Assessment Schedule (WHODAS 2.0) disability scores and energy expenditure were quantified using negative-binomial regression, and expressed in terms of adjusted mean ratios (aMRs).

RESULTS

Mean energy expenditure was 4542 Kcal/week. A lower weekly energy expenditure was associated with: severe/extreme impairment of mental functions, aMR 0.38, 95% confidence interval, CI (0.21-0.68), and neuromusculoskeletal and movement functions, aMR 0.50 (0.35-0.72); WHODAS 2.0 disability, aMR 0.55 (0.34-0.91); dementia, aMR 0.45 (0.31-0.66); and heart failure, aMR 0.54 (0.34-0.87). In contrast, people with arthritis/osteoarthritis had a higher energy expenditure, aMR 1.27 (1.07-1.51).

CONCLUSION

Our results suggest that there is a strong relationship between selected body function impairments, mainly mental, and PA. Although more research is needed to fully understand causal relationships, strategies to improve PA among the elderly may require targeting mental, neuromusculoskeletal and movement functions, disability determinants (including barriers), and specific approaches for persons with dementia or heart failure.

The life-course impact of smoking on hypertension, myocardial infarction and respiratory diseases

The objective of this study was to examine the impact of smoking on respiratory diseases, hypertension and myocardial infarction, with a particular focus from a life-course perspective. In this study, 28,577 males from a Chinese longitudinal survey were analysed. The effects of smoking on the risk of respiratory diseases, hypertension and myocardial infarction were assessed from a life-course perspective and a current view separately. No significant associations were found between smoking and the risk of incident respiratory diseases, hypertension and myocardial infarction in the group younger than 35. Among study participants aged between 36–55 and 56–80, smoking was positively associated with the risk of incident respiratory diseases, hypertension and myocardial infarction from the life-course perspective, and the risk increased with age. In contrast, the results from a current view showed inverse associations between smoking and the risk of the diseases mentioned above. Our findings highlight that it is essential to quantify the effects of smoking from a life-course perspective in future research and to suggest that smokers quit smoking as soon as possible, regardless of the temporary side effects of quitting.

Factors Associated with Physical Inactivity among Adult Urban Population of Puducherry, India: A Population Based Cross-sectional Study

INTRODUCTION

Physical inactivity is the fourth leading cause of death worldwide. Increase in physical activity decreases the incidence of cardiovascular diseases, Type 2 diabetes, stroke, and improves psychological wellbeing.

AIM

To study the level of physical inactivity among the adult population in an urban area of Puducherry in India and its associated risk factors.

MATERIALS AND METHODS

This cross-sectional study was conducted among 569 adult participants from an urban area of Pondicherry. The level of physical inactivity was measured by using WHO standard Global Physical Activity Questionnaire (GPAQ).

RESULTS

Overall prevalence of physical inactivity in our study was 49.7% (CI: 45.6-53.8). Among the physically active people, contribution of physical activity by work was 77.4%, leisure time activities were 11.6% and transport time was 11%. Both men and women were equally inactive {Physically inactive among women was 50% (CI:44.1-55.9)} and {Physically inactive among men was 49.5% (CI:43.8-55.2)}. Prevalence of physical inactivity was increasing with increasing age. Non tobacco users were two times more active than tobacco users {Adjusted Odds Ratio: 2.183 (1.175- 4.057)}. Employed were more active as compared to retired {Adjusted Odds Ratio: 0.412 (0.171-0.991)}, students {Adjusted Odds Ratio: 0.456 (0.196-1.060)}, house wives {Adjusted Odds Ratio: 0.757 (0.509-1.127)} and unemployed {Adjusted Odds Ratio: 0.538 (0.271-1.068)}. Non alcoholics were only 0.34 times as active as alcoholics.

CONCLUSION

Level of physical activity was found to be insufficient among adult urban population of Puducherry. Working adult population found to be active, that too due to their work pattern. There is a need to promote leisure time and travelling time physical activity.

Health-related behaviour in relation to transition into age retirement: An observational study based on HUNT3

Objectives

In western countries, more years are being spent in age retirement. The transition phase into age retirement may be important for physical and mental health in the years following retirement. The aim of the present study was to investigate whether age retirement is associated with changes in the level of physical activity, smoking habits and alcohol habits.

Design

Using data on self-reported health-related behaviour from a population-based study (The Nord-Trøndelag Health Study (HUNT3)) linked to registry data on age retirement, participants who retired within two years prior to and two years after participating in the Nord-Trøndelag Health Study (N = 2,197) were compared.

Participants

A total of 2,197 participants were included.

Setting

Population-based study in Norway.

Main outcome measures

Registry data on age retirement.

Results

No systematic differences in alcohol consumption, smoking or physical activity over the strata defined by time before or after age retirement were identified.

Conclusion

The current and previous findings do not suggest that transition into age retirement changes health-related behaviours. However, there is probably merit in investigating complicating factors related to the retirement process, such as degree of voluntariness, as these factors may influence the impact of age retirement on health behaviours.

Characteristics of physical activity in patients with critical limb ischemia

[Purpose] The purpose of this study was to evaluate the amount of physical activity of the patients with critical limb ischemia consecutively in order to clarify the characteristics of physical activity of critical limb ischemia. [Subjects and Methods] Twelve patients who were eligible for the 2 months of consecutive evaluation of the amount of physical activity were enrolled in the study (men: 11; woman: 1; mean age: 64.4 [range: 44-80]). A pedometer with an accelerometer was used for the measurement of the number of steps walked as an index of the amount of physical activity. Participants were asked to lead a regular life and no instruction was given as to the number of steps. [Results] The average number of daily steps walked was 2,323 steps (range: 404-6,505). There was no clear tendency in the number of amputation site-specific steps walked. There was also no correlation between the number of steps walked and age as well as the maximum strength of the knee-extension muscle, skin perfusion pressure of the sole and the dorsum, and QOL scores. [Conclusion] The number of steps walked of the patients with critical limb ischemia was remarkably low and no significant association with health-related QOL.

Can a Healthy Lifestyle Compress the Disabled Period in Older Adults?

OBJECTIVES

To determine whether lifestyle factors, measured late in life, could compress the disabled period toward the end of life.

DESIGN

Community-based cohort study of older adults followed from 1989 to 2015.

SETTING

Four U.S. communities.

PARTICIPANTS

Community-living men and women aged 65 and older (N = 5,248, mean age 72.7 ± 5.5, 57% female, 15.2% minority) who were not wheelchair dependent and were able to give informed consent at baseline.

MEASUREMENTS

Multiple lifestyle factors, including smoking, alcohol consumption, physical activity, diet, body mass index (BMI), social networks, and social support, were measured at baseline. Activities of daily living (ADLs) were assessed at baseline and throughout follow-up. Years of life (YoL) was defined as years until death. Years of able life (YAL) was defined as years without any ADL difficulty. YAL/YoL%, the proportion of life lived able, was used to indicate the relative compression or expansion of the disabled period.

RESULTS

The average duration of disabled years was 4.5 (out of 15.4 mean YoL) for women and 2.9 (out of 12.4 mean YoL) for men. In a multivariable model, obesity was associated with 7.3 percentage points (95% confidence interval (CI) = 5.4-9.2) lower YAL/YoL% than normal weight. Scores in the lowest quintile of the Alternate Healthy Eating Index were associated with a 3.7% (95% CI = 1.6-5.9) lower YAL/YoL% than scores in the highest quintile. Every 25 blocks walked in a week was associated with 0.5 percentage points (95% CI = 0.3-0.8) higher YAL/YoL%.

CONCLUSION

The effects of healthy lifestyle factors on the proportion of future life lived free of disability indicate that the disabled period can be compressed, given the right combination of these factors.

All-cause mortality risk as a function of sedentary behavior, moderate-to-vigorous physical activity and cardiorespiratory fitness

OBJECTIVE

Emerging work demonstrates individual associations of sedentary behavior, moderate-to-vigorous physical activity (MVPA) and cardiorespiratory fitness (CRF) on mortality risk. Limited research has evaluated all three of these parameters in a model when considering mortality risk, and their potential additive association on mortality risk has not been fully evaluated, which was the purpose of this study.

METHODS

Data from the 2003-2006 National Health and Nutrition Examination Survey were used (N = 2,295 adults 20-85 yrs), with follow-up through 2011. Sedentary behavior and MVPA were objectively assessed (accelerometry) with cardiorespiratory estimated from a prediction equation taking into consideration participant demographic, anthropometric and behavioral characteristics. Using the median values, a PACS (Physical Activity Cardiorespiratory Sedentary) score was created that ranged from 0-3, indicating the number of these three positive characteristics.

RESULTS

Those with below median sedentary behavior did not have a reduced all-cause mortality risk (HR = 0.59; 95% CI: 0.34-1.04; P = 0.07), but those with above median MVPA (HR = 0.35; 95% CI: 0.15-0.82; P = 0.02) and above median CRF did (HR = 0.20; 95% CI: 0.09-0.43; P < 0.001). Compared to those with a PACS score of 0, those with a PACS score of 1, 2, and 3, respectively, had a 67% (HR = 0.33; 95% CI: 0.17-0.63, P = 0.002), 82% (HR = 0.12; 95% CI: 0.05-0.30; P < 0.001) and 96% (HR = 0.04; 95% CI: 0.02-0.11; P < 0.001) reduced risk of all-cause mortality.

CONCLUSION

Cardiorespiratory fitness and MVPA, but not sedentary behavior, were independently associated with reduced mortality risk. Adults with all three characteristics (below median sedentary and above median MVPA and CRF), however, had the lowest mortality risk.

Prevalence of University Students' Sufficient Physical Activity: A Systematic Review

This study reviewed and analyzed the prevalence of university students' participation in physical activity at the level necessary to acquire health benefits. 19 primary studies (published 1985–2001) representing a total of 35,747 students (20,179 women and 15,568 men) from a total of 27 countries (Australia, Canada, China, Germany, Nigeria, United States, and 21 European countries) are described and the amount of activity identified within each study is analyzed in accordance with the American College of Sports Medicine (ACSM) guidelines for physical activity. With respect to these guidelines, more than one-half of university students in the United States and Canada are not active enough to gain health benefits. Internationally, the same is true, although Australian students appear to have the highest level of sufficient activity (at 60%). Women, and especially African-American women, are among the least active students, and students living off-campus are more active than those on-campus. Insufficient activity is a serious health concern among university students. Appropriate interventions and tools to measure ACSM-recommended physical activity are needed.

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.

Future healthy life expectancy among older adults in the US: a forecast based on cohort smoking and obesity history

BACKGROUND

In the past three decades, the elderly population in the United States experienced increase in life expectancy (LE) and disability-free life expectancy (LE(ND)), but decrease in life expectancy with disability (LE(D)). Smoking and obesity are two major risk factors that had negative impacts on these trends. While smoking prevalence continues to decline in recent decades, obesity prevalence has been growing and is currently at a high level. This study aims to forecast the healthy life expectancy for older adults aged 55 to 85 in the US from 2011 to 2040, in relation to their smoking and obesity history.

METHODS

First, population-level mortality data from the Human Mortality Database (HMD) and individual-level disability data from the US National Health Interview Survey (NHIS) were used to estimate the transition rates between different health states from 1982 to 2010, using a multi-state life table (MSLT) model. Second, the estimated transition rates were fitted and projected up to 2040, using a modified Lee-Carter model that incorporates cohort smoking and obesity history from NHIS.

RESULTS

Mortality and morbidity for both sexes will continue to decline in the next decades. Relative to 2010, men are expected to have 3.2 years gain in LE(ND) and 0.8 years loss in LE(D). For women, there will be 1.8 years gain in LE(ND) and 0.8 years loss in LE(D). By 2040, men and women are expected to spend respectively 80 % and 75 % of their remaining life expectancy between 55 and 85 disability-free.

CONCLUSIONS

Smoking and obesity have independent negative impacts on both the survival and disability of the US older population in the coming decades, and are responsible for the present and future gender disparity in mortality and morbidity. Overall, the US older population is expected to enjoy sustained health improvements and compression of disability, largely due to decline in smoking.

Physical activity levels in Bangladeshi adults: results from STEPS survey 2010

Objectives

Physical inactivity is an established risk factor for non-communicable diseases (NCD) and identified as the major public health concern worldwide. However, nationally representative and internationally comparable data on physical activity (PA) are lacking in Bangladesh. The objective of this paper was to determine nationally representative prevalence of PA levels among Bangladeshi adults.

Study design

Cross-sectional survey.

Methods

Data, on PA for this paper, were analysed from the NCD risk factors survey 2010 in Bangladesh. A standardized approach known as STEPS (STEPSwise approach to Surveillance for NCD risk factors) was followed for this survey. A total of 9275 adults (aged ≥ 25 years) were interviewed. Data on PA were processed and analysed according to Global Physical Activity Questionnaire (GPAQ) version 2 analysis framework.

Results

Of total 9275 respondents 4312 were men and 4963 women with a mean age of 42.4 (±13.5) years. Median MET-minutes of total PA in a typical week was double in rural areas (3360) than urban (1680) areas. The overall country wide prevalence of low PA was 34.5% (95% confidence interval, 33.5–35.5), urban 37.7% (36.3–39.1) and rural 31.6% (30.3–32.9). Women in general were more inactive (women, 53.6% [52.2–55.0], men 15.4% [14.9–17.1]). The main contributions to total PA were from work (urban 47.0%, rural 61.0%), and active commuting (38.0%, 30.0%) domains. Leisure-time PA represented only a small proportion (15.0%, 9.0%).

Conclusions

Insufficient physical activity is highly prevalent among the Bangladeshi adult population. Promoting overall PA at leisure-time and commuting considering country context can be feasible options with special attention to the women.

The period prevalence of risk behavior co-occurrence among Canadians

INTRODUCTION

While the benefits of complying with health recommendations is well documented, a considerable proportion of Canadians engage in multiple modifiable risk behaviors. The purpose of this multi-wave longitudinal study was to identify the individual period prevalence and co-occurrence of multiple modifiable risk behaviors, particularly excessive alcohol consumption, physical inactivity, and tobacco use, within a nationally representative sample of Canadians.

METHODS

Secondary data analysis was conducted on the first seven cycles of the National Population Health Survey. This longitudinal sample included 15,167 Canadians aged 12years of age or older. Gender-specific criteria were employed to define excessive alcohol consumption. Individuals expending <3.0kcal/kg/day during their leisure-time and smoking cigarettes (daily or occasionally) met the criteria for physical inactivity and tobacco use, respectively.

RESULTS

The period prevalence of the Canadian general population that participated in multiple risk behaviors was 21.5% in cycle 7. The most common pairwise combination of co-occurring risk behaviors was physical inactivity and smoking. The proportion of Canadians reporting the co-occurrence of all three risk behaviors in cycle 7 was 2.6%.

CONCLUSIONS

Understanding patterns of modifiable risk behaviors is an initial step in developing and implementing public health interventions. The co-occurrence of these three risk behaviors is a viable concern for one in five Canadians. For these individuals, the likelihood of encountering premature morbidity and mortality is escalated. As the majority of Canadians reported being physically inactive, allocating limited resources towards enhancing leisure-time physical activity levels could have significant population-level implications for improving the health of Canadians.

Physical activity in older age: perspectives for healthy ageing and frailty

Regular physical activity helps to improve physical and mental functions as well as reverse some effects of chronic disease to keep older people mobile and independent. Despite the highly publicised benefits of physical activity, the overwhelming majority of older people in the United Kingdom do not meet the minimum physical activity levels needed to maintain health. The sedentary lifestyles that predominate in older age results in premature onset of ill health, disease and frailty. Local authorities have a responsibility to promote physical activity amongst older people, but knowing how to stimulate regular activity at the population-level is challenging. The physiological rationale for physical activity, risks of adverse events, societal and psychological factors are discussed with a view to inform public health initiatives for the relatively healthy older person as well as those with physical frailty. The evidence shows that regular physical activity is safe for healthy and for frail older people and the risks of developing major cardiovascular and metabolic diseases, obesity, falls, cognitive impairments, osteoporosis and muscular weakness are decreased by regularly completing activities ranging from low intensity walking through to more vigorous sports and resistance exercises. Yet, participation in physical activities remains low amongst older adults, particularly those living in less affluent areas. Older people may be encouraged to increase their activities if influenced by clinicians, family or friends, keeping costs low and enjoyment high, facilitating group-based activities and raising self-efficacy for exercise.

Impact of Cognitive Frailty on Daily Activities in Older Persons

OBJECTIVES

To identify the relationships between physical and/or cognitive frailty and instrumental activities of daily living (IADL) functioning in community living older persons.

DESIGN

Cross sectional observation study.

SETTING

Data extracted from the 2011-2013 of the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes (NCGG-SGS) database.

PARTICIPANTS

A total of 8,864 older adults aged ≥ 65 years who were enrolled in the NCGG-SGS.

MEASUREMENTS

We characterized physical frailty as limitations in three or more of the following five domains: slow walking speed, muscle weakness, exhaustion, low activity and weight loss. To screen for cognitive impairment, we used the National Center for Geriatrics and Gerontology-Functional Assessment Tool (NCGG-FAT) which included tests of word list memory, attention and executive function (tablet version of the Trail Making Test, part A and B), and processing speed (tablet version of the Digit Symbol Substitution Test). Two or more cognitive impairments indicated by an age-adjusted score of at least 1.5 standard deviations below the reference threshold was characterized as cognitive impairment. Each participant reported on their IADL status (use of public transportation, shopping, management of finances, and housekeeping) and several potential confounders such as demographic characteristics.

RESULTS

The overall prevalence of physical frailty, cognitive impairment, and cognitive frailty, i.e. co-occurrence of frailty and cognitive impairment, was 7.2%, 5.2%, and 1.2%, respectively. We found significant relationships between IADL limitations and physical frailty (Odds Ratio (OR) 1.24, 95% confidence interval (95% CI) 1.01 to 1.52), cognitive impairment (OR 1.71, 95% CI 1.39 to 2.11), and cognitive frailty (OR 2.63, 95% CI 1.74 to 3.97).

CONCLUSION

Using the NCGG-SGS frailty criteria, we found more participants with physical frailty than with cognitive frailty. The individuals with cognitive frailty had the highest risks of IADL limitations. Future investigation is necessary to determine whether this population is at increased risk for incidence of disability or mortality.

Predictors of 49-month mortality in Chinese nonagenarians and centenarians in PLAD study

OBJECTIVE

To examine whether a set of well-known predictors of mortality in younger elderly also maintain their importance in Chinese oldest old group.

DESIGN

A cross-sectional study of 1401 inhabitants aged 90 and older were conducted in the area of Dujiangyan, China. 825 subjects participated and were followed up for vital status after 49 months. Professional interviewers collected baseline data concerning socio-demographic characteristics, lifestyle habits, physical factors and geriatric assessment. Bivariate analysis was conducted between survivors and deceased. Cox regression models were used to evaluate predictors of mortality.

RESULTS

Four hundred and thirty-six (52.8%) of 825 participants eligible for the analysis died during the 49 months of follow-up period. Older age, comorbidity, lower MMSE score, lower ADL and IADL scores increased the risk of mortality in the study group. Multivariate analyses showed older age (HR = 1.03, 95% CI 1.01-1.07) and comorbidity (HR = 1.09, 95% CI 1.02-1.17) were associated with mortality while female gender (HR = 0.61, 95% CI 0.43-0.86), taking exercise (HR = 0.80, 95% CI 0.64-1.01) and higher MMSE scores (HR = 0.96, 95% CI 0.94-0.99) showed a positive effect on survival.

CONCLUSION

In Chinese nonagenarians and centenarians, age, gender, taking exercise, cognitive impairment and comorbidity at baseline show predictive power of oldest old mortality.

A Systematic Literature Review of Studies Analyzing Inequalities in Health Expectancy among the Older Population

Aim

To collect, organize and appraise evidence of socioeconomic and demographic inequalities in health and mortality among the older population using a summary measure of population health: Health Expectancy.

Methods

A systematic literature review was conducted. Literature published in English before November 2014 was searched via two possible sources: three electronic databases (Web of Science, Medline and Embase), and references in selected articles. The search was developed combining terms referring to outcome, exposure and participants, consisting in health expectancy, socioeconomic and demographic groups, and older population, respectively.

Results

Of 256 references identified, 90 met the inclusion criteria. Six references were added after searching reference lists of included articles. Thirty-three studies were focused only on gender-based inequalities; the remaining sixty-three considered gender along with other exposures. Findings were organized according to two leading perspectives: the type of inequalities considered and the health indicators chosen to measure health expectancy. Evidence of gender-based differentials and a socioeconomic gradient were found in all studies. A remarkable heterogeneity in the choice of health indicators used to compute health expectancy emerged as well as a non-uniform way of defining same health conditions.

Conclusions

Health expectancy is a useful and convenient measure to monitor and assess the quality of ageing and compare different groups and populations. This review showed a general agreement of results obtained in different studies with regard to the existence of inequalities associated with several factors, such as gender, education, behaviors, and race. However, the lack of a standardized definition of health expectancy limits its comparability across studies. The need of conceiving health expectancy as a comparable and repeatable measure was highlighted as fundamental to make it an informative instrument for policy makers.

Physical Activity Protects the Human Brain against Metabolic Stress Induced by a Postprandial and Chronic Inflammation

In recent years, it has become clear that chronic systemic low-grade inflammation is at the root of many, if not all, typically Western diseases associated with the metabolic syndrome. While much focus has been given to sedentary lifestyle as a cause of chronic inflammation, it is less often appreciated that chronic inflammation may also promote a sedentary lifestyle, which in turn causes chronic inflammation. Given that even minor increases in chronic inflammation reduce brain volume in otherwise healthy individuals, the bidirectional relationship between inflammation and sedentary behaviour may explain why humans have lost brain volume in the last 30,000 years and also intelligence in the last 30 years. We review evidence that lack of physical activity induces chronic low-grade inflammation and, consequently, an energy conflict between the selfish immune system and the selfish brain. Although the notion that increased physical activity would improve health in the modern world is widespread, here we provide a novel perspective on this truism by providing evidence that recovery of normal human behaviour, such as spontaneous physical activity, would calm proinflammatory activity, thereby allocating more energy to the brain and other organs, and by doing so would improve human health.

Predictors of Adherence in a Community-Based Tai Chi Program

Cette étude a examiné les facteurs qui influent l'adhésion dans un programme de de tai-chi à 16 semaines parmi les adultes multi-ethniques d'âge moyen et plus âgés qui vivent dans un environnement faible socio-économique à Toronto. L'analyse a été basée sur des données recueillies auprès de trois cohortes du programme de tai-chi qui ont eu lieu à partir d'août 2009 à mars 2012. La variable principale de résultat, l'adhésion, a été mesurée par le nombre total de sessions suivies par chacun des participants. L'échantillon total était de 210 participants, avec un âge moyen de 68,1 ± 8,6. Basé sur le modèle de régression, l'adhésion a été associée de façon significative à l'âge plus avancé, au stress plus perçu, à l'enseignement supérieur, et aux scores mentales et physiques plus élevés de composants sur le Questionnaire Abrégée 36. Inversement, une faible observance était significativement associée à une activité physique hebdomadaire de base plus élevée. Nos résultats suggèrent que nous devrions cibler les personnes les moins instruites, à la santé mentale et physique médiocre, pour optimiser l'adhésion aux futurs programmes de tai-chi communautaires.

Cognition and health in African American men

OBJECTIVE

Despite high rates of poor health outcomes, little attention has been focused on associations between prominent health factors and cognitive function in African American men, exclusively. The objective was to examine relationships between cardiovascular and pulmonary health, and cognitive function in African American men.

METHOD

Data from 257 men were pooled from two studies of African American aging. The mean age of participants was 58.15 and mean educational attainment was 11.78 years. Participants provided self-reported health and demographic information, completed cognitive measures, and had their blood pressure and peak expiratory flow assessed.

RESULTS

After adjustment, significant relationships were found between average peak expiratory flow rate (APEFR) and cognitive performance measures.

DISCUSSION

Results suggest that lung function is important to consider when examining cognitive function in African American men. Understanding the role of health in cognition and implications for quality of life in this population will be critical as life expectancies increase.