Andrea Bellavia

Fruit and vegetable consumption and all-cause mortality: a dose-response analysis

BACKGROUND The association between fruit and vegetable (FV) consumption and overall mortality has seldom been investigated in large cohort studies. Findings from the few available studies are inconsistent. OBJECTIVE The objective was to examine the dose-response relation between FV consumption and mortality, in terms of both time and rate, in a large prospective cohort of Swedish men and women. DESIGN FV consumption was assessed through a self-administrated questionnaire in a population-based cohort of 71,706 participants (38,221 men and 33,485 women) aged 45-83 y. We performed a dose-response analysis to evaluate 10th survival percentile differences (PDs) by using Laplace regression and estimated HRs by using Cox regression. RESULTS During 13 y of follow-up, 11,439 deaths (6803 men and 4636 women) occurred in the cohort. In comparison with 5 servings FV/d, a lower consumption was progressively associated with shorter survival and higher mortality rates. Those who never consumed FV lived 3 y shorter (PD: -37 mo; 95% CI: -58, -16 mo) and had a 53% higher mortality rate (HR: 1.53; 95% CI: 1.19, 1.99) than did those who consumed 5 servings FV/d. Consideration of fruit and vegetables separately showed that those who never consumed fruit lived 19 mo shorter (PD: -19 mo; 95% CI: -29, -10 mo) than did those who ate 1 fruit/d. Participants who consumed 3 vegetables/d lived 32 mo longer than did those who never consumed vegetables (PD: 32 mo; 96% CI: 13, 51 mo). CONCLUSION FV consumption <5 servings/d is associated with progressively shorter survival and higher mortality rates. The Swedish Mammography Cohort and the Cohort of Swedish Men were registered at clinicaltrials.gov as NCT01127698 and NCT01127711, respectively.

Sleep Duration and Survival Percentiles Across Categories of Physical Activity

The association between long sleep duration and death is not fully understood. Long sleep is associated with low physical activity, which is a strong predictor of death. Our aim was to investigate the association between sleep duration and death across categories of total physical activity in a large prospective cohort of Swedish men and women. We followed a population-based cohort of 70,973 participants (37,846 men and 33,127 women), aged 45-83 years, from January 1998 to December 2012. Sleep duration and physical activity levels were assessed through a questionnaire. We evaluated the association of interest in terms of mortality rates by estimating hazard ratios with Cox regression and in terms of survival by evaluating 15th survival percentile differences with Laplace regression. During 15 years of follow-up, we recorded 14,575 deaths (8,436 men and 6,139 women). We observed a significant interaction between sleep duration and physical activity in predicting death (P < 0.001). Long sleep duration (>8 hours) was associated with increased mortality risk (hazard ratio = 1.24; 95% confidence interval: 1.11, 1.39) and shorter survival (15th percentile difference = -20 months; 95% confidence interval: -30, -11) among only those with low physical activity. The association between long sleep duration and death might be partly explained by comorbidity with low physical activity.

Fruit and Vegetable Intake and Risk of Hip Fracture: A Cohort Study of Swedish Men and Women

Dietary guidelines recommend a daily intake of 5 servings of fruits and vegetables. Whether such intakes are associated with a lower risk of hip fracture is at present unclear. The aim of the present study was to investigate the dose‐response association between habitual fruit and vegetable intake and hip fracture in a cohort study based on 40,644 men from the Cohort of Swedish Men (COSM) and 34,947 women from the Swedish Mammography Cohort (SMC) (total n = 75,591), free from cardiovascular disease and cancer, who answered lifestyle questionnaires in 1997 (age 45 to 83 years). Intake of fruits and vegetables (servings/day) was assessed by food frequency questionnaire and incident hip fractures were retrieved from the Swedish Patient Register (1998 to 2010). The mean follow‐up time was 14.2 years. One‐third of the participants reported an intake of fruits and vegetables of >5 servings/day, one‐third reported >3 to ≤5 servings/day, 28% reported >1 to ≤3 servings/day, and 6% reported ≤1 serving/day. During 1,037,645 person‐years we observed 3644 hip fractures (2266 or 62% in women). The dose‐response association was found to be strongly nonlinear (p < 0.001). Men and women with zero consumption had 88% higher rate of hip fracture compared with those consuming 5 servings/day; adjusted hazard ratio (HR) was 1.88 (95% CI, 1.53 to 2.32). The rate was gradually lower with higher intakes; adjusted HR for 1 versus 5 servings/day was 1.35 (95% CI, 1.21 to 1.58). However, more than 5 servings/day did not confer additionally lower HRs (adjusted HR for 8 versus 5 servings/day was 0.96; 95% CI, 0.90 to 1.03). Similar results were observed when men and women were analyzed separately. We conclude that there is a dose‐response association between fruit and vegetable intake and hip fracture such that an intake below the recommended five servings/day confers higher rates of hip fracture. Intakes above this recommendation do not seem to further lower the risk.

Physical activity and mortality in a prospective cohort of middle-aged and elderly men – a time perspective

BackgroundHigher physical activity (PA) levels are known to be associated with lower risk of death. Less attention, however, has been paid to directly evaluate the effect of PA on the time by which a certain fraction of the population has died.MethodsA population-based cohort of 29,362 men 45 to 79 years of age was followed from January 1998 to December 2010. A total of 4,570 men died. PA was assessed through a self-administrated questionnaire. Adjusted differences in the number of months by which 10% (10th percentile) of the cohort has died, according to levels of total PA (TPA) and different domains of PA were estimated using Laplace regression.ResultsOverall, the 10th survival percentile was 9.6 years, that is, 90% of the cohort lived longer than 9.6 years. We found a strong evidence of non-linearity between TPA and the 10th survival percentile (P-value < 0.001). Compared to men with the lowest TPA (29 metabolic equivalents (MET)-hrs/day), men with a median TPA (41 MET-hrs/day) had 30 months longer survival (95% CI: 25–35). Below the median TPA, every increment of 4 MET-hrs/day, approximately a 30 minutes brisk pace daily walk, was associated with a longer survival of 11 months (95% CI: 8–15). Above the median TPA additional activity was not significantly associated with better survival.ConclusionsWe found that a physically active lifestyle is associated with a substantial improvement in survival time, up to 2.5 years over 13 years of follow-up.

Mediterranean Diet and Hip Fracture in Swedish Men and Women

A Mediterranean diet, known to have beneficial effects on cardiovascular health, may also influence the risk of hip fracture although previous studies present discrepant results. We therefore aimed to determine whether the rate of hip fracture was associated with degree of adherence to a Mediterranean diet. We combined two Swedish cohort studies consisting of 37,903 men and 33,403 women (total n = 71,333, mean age 60 years) free of previous cardiovascular disease and cancer who answered a medical and a food‐frequency questionnaire in 1997. A modified Mediterranean diet score (mMED; range, 0 to 8 points) was created based on high consumption of fruits and vegetables, legumes and nuts, whole grains, fermented dairy products, fish, and olive/rapeseed oil, moderate intake of alcohol, and low intake of red and processed meat. Incident hip fractures between January 1, 1998, and December 31, 2012, were retrieved from the National Patient Register. Hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for potential confounders were calculated using Cox proportional hazards regression. Differences in age at hip fracture were calculated using multivariable Laplace regression. During follow‐up, 3175 hip fractures occurred at a median age of 73.3 years. One unit increase in the mMED was associated with 6% lower hip fracture rate (adjusted HR = 0.94; 95% CI, 0.92 to 0.96) and with a 3‐month higher median age at hip fracture (50th percentile difference = 2.8 months; 95% CI, 1.4 to 4.2). Comparing the highest quintile of adherence to the mMED (6 to 8 points) with the lowest (0 to 2 points) conferred an adjusted HR of hip fracture of 0.78 (95% CI, 0.69 to 0.89) and a 12‐month higher median age of hip fracture (50th percentile difference = 11.6 months; 95% CI, 4.2 to 19.0). Results were similar in men and women. We conclude that higher adherence to a Mediterranean‐like diet is associated with lower risk of future hip fracture.

Fruit and Vegetable Intake and Hip Fracture Incidence in Older Men and Women : The CHANCES Project

The role of fruit and vegetable intake in relation to fracture prevention during adulthood and beyond is not adequately understood. We investigated the potential association between fruit and vegetable intake and hip fracture incidence in a large sample of older adults from Europe and the United States. A total of 142,018 individuals (116,509 women) aged ≥60 years, from five cohorts, were followed up prospectively for 1,911,482 person‐years, accumulating 5552 hip fractures. Fruit and vegetable intake was assessed by validated, cohort‐specific, food‐frequency questionnaires (FFQ). Ηip fractures were ascertained through national patient registers or telephone interviews/questionnaires. Adjusted hazard ratios (HRs) derived by Cox proportional hazards regression were estimated for each cohort and subsequently pooled using random effects meta‐analysis. Intake of ≤1 serving/day of fruit and vegetables combined was associated with 39% higher hip fracture risk (pooled adjusted HR, 1.39; 95% confidence interval [CI], 1.20 to 1.58) in comparison with moderate intake (>3 and ≤5 servings/day) (pfor heterogeneity = 0.505), whereas higher intakes (>5 servings/day) were not associated with lower risk in comparison with the same reference. Associations were more evident among women. We concluded that a daily intake of 1 or <1 servings of fruits and vegetables was associated with increased hip fracture risk in relation to moderate daily intakes. Older adults with such low fruit and vegetable consumption may benefit from raising their intakes to moderate amounts in order to reduce their hip fracture risk.

Burden of hip fracture using disability-adjusted life-years : a pooled analysis of prospective cohorts in the CHANCES consortium

BACKGROUND No studies have estimated disability-adjusted life-years (DALYs) lost due to hip fractures using real-life follow-up cohort data. We aimed to quantify the burden of disease due to incident hip fracture using DALYs in prospective cohorts in the CHANCES consortium, and to calculate population attributable fractions based on DALYs for specific risk factors. METHODS We used data from six cohorts of participants aged 50 years or older at recruitment to calculate DALYs. We applied disability weights proposed by the National Osteoporosis Foundation and did a series of sensitivity analyses to examine the robustness of DALY estimates. We calculated population attributable fractions for smoking, body-mass index (BMI), physical activity, alcohol intake, type 2 diabetes and parity, use of hormone replacement therapy, and oral contraceptives in women. We calculated summary risk estimates across cohorts with pooled analysis and random-effects meta-analysis methods. FINDINGS 223 880 men and women were followed up for a mean of 13 years (SD 6). 7724 (3·5%) participants developed an incident hip fracture, of whom 413 (5·3%) died as a result. 5964 DALYs (27 per 1000 individuals) were lost due to hip fractures, 1230 (20·6%) of which were in the group aged 75-79 years. 4150 (69·6%) DALYs were attributed to disability. Current smoking was the risk factor responsible for the greatest hip fracture burden (7·5%, 95% CI 5·2-9·7) followed by physical inactivity (5·5%, 2·1-8·5), history of diabetes (2·8%, 2·1-4·0), and low to average BMI (2·0%, 1·4-2·7), whereas low alcohol consumption (0·01-2·5 g per day) and high BMI had a protective effect. INTERPRETATION Hip fracture can lead to a substantial loss of healthy life-years in elderly people. National public health policies should be strengthened to reduce hip fracture incidence and mortality. Primary prevention measures should be strengthened to prevent falls, and reduce smoking and a sedentary lifestyle. FUNDING European Communitys Seventh Framework Programme.

Physical Activity and Heart Failure Risk in a Prospective Study of Men

OBJECTIVES This study investigated if total physical activity, as well as different types of physical activity, were associated with heart failure risk. BACKGROUND Physical activity has shown to be associated with reduced risks of coronary heart disease and stroke. Studies have also suggested that physical activity is associated with heart failure development. METHODS A study population of 33,012 men was followed from beginning of 1998 until the end of 2012. First event of heart failure was ascertained through linkage to the Swedish National Patient Register and Cause of Death Register. The data were analyzed by using Cox proportional hazards regression and Laplace regression. RESULTS During a mean follow-up of 13 years, we ascertained a total of 3,609 first events of heart failure. The average age at study baseline was 60 ± 9 years of age. When examining the entire study population, a U-shaped association between total physical activity and heart failure risk was detected, with both extremely high (57 metabolic equivalent [MET] h/day) and extremely low (38 MET h/day) levels of total physical activity associated with an increased risk of heart failure. When investigating different types of physical activity, we found that walking/bicycling at least 20 min/day was associated with 21% lower risk of heart failure (95% confidence interval: 0.72 to 0.87); corresponding to a median age at heart failure 8 months later for those who had actively walked or biked daily. When looking at long-term behavior of walking/bicycling, the results suggested a trend toward more recent active behavior being more related to heart failure protection than past physical activity levels. CONCLUSIONS This study suggests that both low levels and high levels of total physical activity, in comparison with moderate levels, could increase heart failure risk in men and that certain types of physical activity are associated with a protective effect on heart failure in men. When examining different types of physical activity, walking/bicycling at least 20 min per day was associated with the largest risk reduction of heart failure.

Differences in survival associated with processed and with nonprocessed red meat consumption

BACKGROUND High red meat consumption is associated with an increased mortality risk. This association is partly explained by the negative effect of processed meat consumption, which is widely established. The role of nonprocessed meat is unclear. OBJECTIVE The objective was to examine the combined association of processed and nonprocessed meat consumption with survival in a Swedish large prospective cohort. DESIGN In a population-based cohort of 74,645 Swedish men (40,089) and women (34,556), red meat consumption was assessed through a self-administered questionnaire. We estimated differences in survival [15th percentile differences (PDs), differences in the time by which the first 15% of the cohort died] according to levels of total red meat and combined levels of processed and nonprocessed red meat consumption. RESULTS During 15 y of follow-up (January 1998 to December 2012), we documented 16,683 deaths (6948 women; 9735 men). Compared with no consumption, consumption of red meat >100 g/d was progressively associated with shorter survival--up to 2 y for participants consuming an average of 300 g/d (15th PD: -21 mo; 95% CI: -31, -10). Compared with no consumption, high consumption of processed red meat (100 g/d) was associated with shorter survival (15th PD: -9 mo; 95% CI: -16, -2). High and moderate intakes of nonprocessed red meat were associated with shorter survival only when accompanied by a high intake of processed red meat. CONCLUSIONS We found that high total red meat consumption was associated with progressively shorter survival, largely because of the consumption of processed red meat. Consumption of nonprocessed red meat alone was not associated with shorter survival.

Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project

Hip fractures are associated with diminished quality of life and survival especially amongst the elderly.