Smoking vs other risk factors as the cause of smoking-attributable deaths: confounding in the courtroom. Multiple Health Behavior Changes and Co-variation in a Telephone Counseling Trial Cardiovascular Disease in Type 2 Diabetes From Population to Man to Mechanisms Behavior modification and risk perception in patients with nonmelanoma skin cancer. Effects of the mediterranean lifestyle program on multiple risk behaviors and psychosocial outcomes among women at risk for heart disease The epidemiology of Type 2 diabetes mellitus in Greek adults: the ATTICA study. Family predictors of disease management over one year in Latino and European American patients with type 2 diabetes. Evaluation of comorbidity in 9388 head and neck cancer patients: a national cohort study from the DAHANCA database. Outcomes from a Multiple Risk Factor Diabetes Self-Management Trial for Latinas: ¡Viva Bien! Biologic and quality-of-life outcomes from the Mediterranean Lifestyle Program: a randomized clinical trial. Body iron stores in relation to risk of type 2 diabetes in apparently healthy women. Long-term outcomes from a multiple-risk-factor diabetes trial for Latinas: ¡Viva Bien! Multiple behavioral risk factors among adolescent survivors of childhood cancer in the Survivor Health and Resilience Education (SHARE) program. Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. A Systematic Review of Loneliness and Common Chronic Physical Conditions in Adults Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. Lifestyle Intervention in Overweight Individuals With a Family History of Diabetes Risk association of HbA1c variability with chronic kidney disease and cardiovascular disease in type 2 diabetes: prospective analysis of the Hong Kong Diabetes Registry. Patterns of comorbidity and multimorbidity in the oldest old: the Octabaix study. Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Enhancing support for health behavior change among women at risk for heart disease: the Mediterranean Lifestyle Trial. Economic Analysis of the Mediterranean Lifestyle Program for Postmenopausal Women With Diabetes Higher HDL cholesterol levels are associated with a lower incidence of chronic kidney disease in patients with type 2 diabetes.
CONTEXT The surgeon general estimates that more than 400,000 deaths are attributable to smoking annually in the United States . The tobacco industry has criticized the surgeon general 's estimates because they do not control for the lower educational and socioeconomic status of modern-day smokers . OBJECTIVE To determine whether controlling for education , occupation , race , alcohol consumption , and various dietary factors , in addition to age and sex , substantially alters the relative and attributable risk estimates associated with tobacco smoking . DESIGN , SETTING , AND PARTICIPANTS Nationwide American Cancer Society prospect i ve cohort study of 974 , 150 US adults aged 30 years or older , enrolled in 1982 and followed up through 1988 . ( The same study is used for the surgeon general and Centers for Disease Control and Prevention [ CDC ] estimates of smoking-attributable deaths in the United States . ) MAIN OUTCOME MEASURES Death from each of the chronic diseases considered in the CDC 's estimate of smoking-attributable mortality ( cancers of the lung , oropharynx , larynx , esophagus , pancreas , kidney , bladder , and cervix ; ischemic heart disease , arterial disease , and other heart conditions ; stroke ; chronic obstructive pulmonary disease ; and other respiratory conditions ) . Estimates adjusted for multiple covariates were compared with those adjusted for age only among current and former vs never smokers . RESULTS Adjusting for multiple covariates slightly decreased the relative and attributable risk estimates for current smoking in both men and women , but slightly increased the estimates for former smoking in women . Multivariate adjustment decreased the overall estimate of deaths attributable to smoking in the United States by approximately 1 % , from 401,109 to 396,741 per year . CONCLUSIONS Our study suggests that federal estimates of deaths caused by smoking are not substantially altered by adjustment for behavioral and demographic factors associated with smoking beyond the current adjustment for age and sex . JAMA . 2000;284:706 - Background Delivering effective multiple health behavior interventions to large numbers of adults with chronic conditions via primary care setting s is a public health priority . Purpose Within a 12-month , telephone-delivered diet and physical activity intervention with multiple behavioral outcomes , we examined the extent and co-variation of multiple health behavior change . Methods A cluster-r and omized trial with 434 patients with type 2 diabetes or hypertension were recruited from 10 general practice s , which were r and omized to receive telephone counseling or usual care .  Results Those receiving telephone counseling were significantly more likely than those in usual care to make greater reductions in multiple behaviors after adjusting for baseline risk behaviors ( OR 2.42 ; 95%CI 1.43 , 4.11 ) . Controlling for baseline risk and group allocation , making changes to either physical activity , fat , vegetable , or fiber intake was associated with making significantly more improvements in other behaviors . Conclusions For patients with chronic conditions , telephone counseling can significantly improve multiple health behaviors , with behavioral changes tending to co-vary Epidemic of diabetes , affecting about 3–5 % of Western population s , is one of the main threats to human health in the 21st century ( 1 ) . Changes in the human environment , behavior , and lifestyle have result ed in a dramatic increase in the incidence and prevalence of diabetes in people with genetic susceptibility to diabetes . The global number of people with diabetes was 151 million in 2000 , and it is projected to increase to 221 million in 2010 ( an increase of 46 % ) both in developed and developing countries ( 2 ) . Chronic hyperglycemia leads to many long-term complications in the eyes , kidneys , nerves , heart , and blood vessels .  Individuals with pre-diabetes , undiagnosed type 2 diabetes , and long-lasting type 2 diabetes are at high risk of all complications of macrovascular disease , coronary heart disease ( CHD ) , stroke , and peripheral vascular disease . More than 70 % of patients with type 2 diabetes die of cardiovascular causes ( 3 ) . Therefore , the epidemic of type 2 diabetes will be followed by an epidemic of diabetes-related cardiovascular disease ( CVD ) . Over the years , epidemiological studies have produced important information on the prevalence and incidence of diabetes complications in different population s. They have also given important information on different risk factors determining susceptibility to diabetes complications ( Fig. 1 ) . This information is crucial for mechanistic studies in physiology at the tissue level and for molecular biology studies at the cellular level . A good example is glycated hemoglobin . Several studies have indicated that glycated hemoglobin is associated with diabetes complications in prospect i ve epidemiological studies . That information has been crucial for the planning of clinical trials to test the hypothesis that the treatment of chronic hyperglycemia leads to reduction in long-term diabetes complications . Moreover , information from epidemiology has led to several mechanistic studies and the elucidation of molecular level insights how insulin resistance and hyperglycemia lead to diabetes complications . CONTEXT Nonmelanoma skin cancer ( NMSC ) is the most common cancer among humans , yet risk perceptions and preventive health behaviors in those who survive this cancer are relatively unknown . OBJECTIVES To assess the impact of the disease and its treatment on sun-protective behaviors , general preventive health behaviors , and risk perception in NMSC patients , and to determine factors associated with behavioral change . DESIGN AND SETTING A prospect i ve study was conducted of 211 consecutive NMSC patients presenting to a dermatologic surgery clinic at a tertiary care university medical center from February 2005 to March 2006 . These patients were all adults , were fluent in English , and had NMSC of the head and neck . Of the 211 eligible patients , complete data was obtained for 183 ( 87 % ) . The most common reasons for dropout were voluntary withdrawal and incompletely answered surveys . INTERVENTION AND OUTCOME MEASURES Surveys that assessed disease-specific quality of life ( QoL ) , preventive health behaviors , sun-protective behaviors , and risk perception were administered before and after surgical treatment of NMSC . RESULTS Sun-protective behaviors improved postsurgery even after controlling for seasons ( P<0.001 ) . Predictor factors associated with increased sun-protective behavior included poor skin tanning ability , summer season , no employment , less comorbid conditions , and previous NMSC treatment . Baseline QoL was not predictive of behavioral change . As for risk perception , respondents thought they were more likely than someone similar to themselves to develop future NMSCs but thought they had similar risks of developing melanoma or other non-skin cancers ( P<0.001 ) . NMSC patients demonstrated disease-specific behavior modifications by selectively improving their sun habits but showed no significant improvement in other preventive health behaviors . This finding is consistent with patients ' specific perception of increased risk for future NMSCs , but surprisingly , not for melanoma . Increased patient education of associated cancer risks with NMSC is warranted . CONCLUSIONS NMSC patients demonstrated disease-specific behavior modifications by selectively improving their sun habits but showed no significant improvement in other preventive health behaviors . This finding is consistent with patients ' specific perception of increased risk for future NMSCs , but surprisingly , not for melanoma . Increased patient education of associated cancer risks with NMSC is warranted Background : The Mediterranean Lifestyle Program was evaluated for its effects on multiple behavioral risk factors for coronary heart disease ( CHD )  among postmenopausal women with diabetes . Purpose : Our purpose is to test a comprehensive lifestyle management intervention to reduce CHD risk in postmenopausal women with type 2 diabetes . Methods : Participants ( N = 279 ) were r and omized to usual care ( UC ) or Mediterranean Lifestyle Program , a lifestyle change intervention aim ed at the behavioral risk factors ( eating patterns , physical activity , stress management , and social support ) affecting risk for CHD in postmenopausal women with type 2 diabetes . Results : In original and intent-to-treat analyses ,  Mediterranean Lifestyle Program participants showed significantly greater improvement in dietary behaviors , physical activity , stress management , perceived support , and weight loss at 6 months compared to UC . Conclusions : This study demonstrated the effectiveness of the Mediterranean Lifestyle Program in improving self-care among women with type 2 diabetes , showed that postmenopausal women could make comprehensive lifestyle changes , and provided evidence that a program using social-cognitive strategies and peer support can be used to modify multiple lifestyle behaviors AIMS Individuals with Type 2 diabetes are at high risk for coronary heart disease , and may benefit from aggressive lifestyle modification . We evaluated the prevalence of Type 2 diabetes , in a Greek adult population , in relation to physical activity and dietary habits . METHODS From May 2001 to December 2002 , we r and omly enrolled 1514 men and 1528 women , with no evidence of cardiovascular or any other chronic disease . The sampling was stratified by the age and gender distribution of the general population in the greater area of Athens ( census 2001 ) . Diabetes was defined according to the established American Diabetes Association criteria .  Dietary habits  were assessed through a vali date d food frequency question naire and a diet score  was developed , in which higher values suggest greater adherence to the Mediterranean diet . Weekly energy expenditure  was assessed by considering frequency , duration and intensity of sports-related physical activity during a usual week . RESULTS After age adjustment for the Greek adult population ( 2001 census ) , the projected prevalence of Type 2 diabetes was 7.6 % in men and 5.9 % in women . A significant proportion of diabetic subjects ( 24 % of men and 30 % of women ) were unaware of their condition . Moreover , a 10-unit increase in the diet score was associated with 21 % lower odds of diabetes ( P < 0.05 ) , while individuals taking light physical activity were at 35 % lower odds ratio of diabetes compared with sedentary individuals ( P < 0.05 ) . CONCLUSIONS Diabetes mellitus is common in our population , with approximately 1 in 5 individuals with Type 2 diabetes being unaware of their condition . The lifestyle approach described here may contribute significantly to the reduction in the prevalence of diabetes , at a population level Family context is thought to influence chronic disease management but few studies have longitudinally examined these relationships . Research on families and chronic illness has focused almost exclusively on European American families . In this prospect i ve study we tested a multidimensional model of family influence on disease management in type 2 diabetes in a bi-ethnic sample of European Americans and Latinos . Specifically , we tested how baseline family characteristics ( structure , world view , and emotion management ) predicted change in disease management over one year in 104 European American and 57 Latino patients with type 2 diabetes . We found that emotion management predicted change in disease management in both groups of patients as hypothesized , while family world view predicted change in both ethnic groups but in the predicted direction only for European Americans . Examining family context within ethnic groups is required to eluci date unique cultural patterns . Attending to culturally unique interpretations of constructs and measures is warranted . The import of family emotion management , specifically  conflict resolution  , in disease management deserves further study to support clinical intervention development . Examining multiple domains of family life and multidimensional health outcomes strengthens our capacity to develop theory about family context s and individual health BACKGROUND Comorbidity is common in head and neck squamous cell carcinoma ( HNSCC ) patients due to the etiology of the disease being primarily smoking . The aim of this study was to investigate the impact of comorbidity on survival in a national population -based cohort study on 9388 HNSCC- patients treated with radiotherapy ( RT )  , to re-evaluate the prognostic impact of individual diseases within the Charlson Comorbidity Index ( CCI ) , and to develop a revised head and neck comorbidity index ( HN-CCI ) . MATERIAL AND METHODS A national cohort of 9388 HNSCC- patients treated with curative intended RT diagnosed from 1992 to 2008 was identified from the DAHANCA- data base . Data on comorbidity prior to HNSCC-diagnosis was obtained from the National Patient Registry and adapted to the CCI . RESULTS By dividing the patients into two groups , we tested and vali date d which type of comorbidities within the CCI affected overall survival ( OS ) and cancer specific death ( CSD ) . In total , 36 % of patients had comorbidity . Six comorbid conditions within the CCI significantly reduced five-year OS probability : congestive heart failure , cerebrovascular disease , chronic pulmonary disease , peptic ulcer disease , liver disease , and diabetes , and based on these conditions the new head and neck specific comorbidity index was developed , the HN-CCI . Comorbidity according to HN-CCI had a highly significant impact on OS , whereas it was not associated with CSD . Chronological age was not associated with increased risk of CSD after controlling for comorbidity . CONCLUSIONS Comorbidity is frequent in HNSCC patients and negatively impacts OS . Therefore assessment of comorbidity will be of great importance , both in order to treat/optimize patient 's health before radiotherapy , but also in order to be able to stratify/control for comorbidity in r and omized trials to avoid bias . Re-evaluation of the CCI revealed that only six conditions had an impact on survival , and a new modified index to assess comorbidity for HNSCC- patients was developed . The performance of HN-CCI to stratify patients on survival was good and HN-CCI is highly recommended for future assessment of comorbidity and prognostic staging of radiotherapy-treated HNSCC- patients Background Culturally appropriate interventions are needed to assist Latinas in making multiple healthful lifestyle changes . Purpose The purpose of this study was to test a cultural adaptation of a successful multiple health behavior change program , ¡ Viva Bien ! Methods R and om assignment of 280 Latinas with type 2 diabetes to usual care only or to usual care + ¡ Viva Bien !  , which included group meetings for building skills to promote the Mediterranean diet , physical activity , stress management , supportive re sources , and smoking cessation . Results ¡ Viva Bien ! participants compared to usual care significantly improved psychosocial and behavioral outcomes ( fat intake , stress management practice , physical activity , and social – environmental support ) at 6 months , and some improvements were maintained at 12 months . Biological improvements included hemoglobin A1c and heart disease risk factors . Conclusions The ¡ Viva Bien ! multiple lifestyle behavior program was effective in improving psychosocial , behavioral , and biological/ quality of life outcomes related to heart health for Latinas with type 2 diabetes ( Clinical Trials.gov no : NCT00233259 ) OBJECTIVE Few multiple lifestyle behavior change programs have been design ed to reduce the risk of coronary heart disease in postmenopausal women with type 2 diabetes . This study tested the effectiveness of the Mediterranean Lifestyle Program ( MLP ) , a comprehensive lifestyle self-management program ( Mediterranean low-saturated fat diet , stress management training , exercise , group support , and smoking cessation ) , in reducing cardiovascular risk factors in postmenopausal women with type 2 diabetes . RESEARCH DESIGN AND METHODS Postmenopausal women with type 2 diabetes ( n = 279 ) were r and omized to either usual care ( control ) or treatment ( MLP ) conditions . MLP participants took part in an initial 3-day retreat , followed by 6 months of weekly meetings , to learn and practice program components . Biological end points were changes in HbA(1c ) , lipid profiles , BMI , blood pressure , plasma fatty acids , and flexibility . Impact on quality of life was assessed . RESULTS Multivariate ANCOVAs revealed significantly greater improvements in the MLP condition compared with the usual care group on HbA(1c ) , BMI , plasma fatty acids , and quality of life at the 6-month follow-up . Patterns favoring intervention were seen in lipids , blood pressure , and flexibility but did not reach statistical significance . CONCLUSIONS These results demonstrate that postmenopausal women with type 2 diabetes can make comprehensive lifestyle changes that may lead to clinical ly significant improvements in glycemic control , some coronary heart disease risk factors , and quality of life CONTEXT Type 2 diabetes is a common manifestation of hemochromatosis , a disease of iron overload . However , it is not clear whether higher iron stores predict the development of type 2 diabetes in a healthy population . OBJECTIVE To examine plasma ferritin concentration and the ratio of the concentrations of transferrin receptors to ferritin in relation to risk of type 2 diabetes . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve nested case-control study within the Nurses ' Health Study cohort . Of the 32 826 women who provided blood sample s during 1989 - 1990 and were free of diagnosed diabetes , cardiovascular disease , and cancer , 698 developed diabetes during 10 years of follow-up . The controls ( n = 716 ) were matched to cases on age , race , and fasting status ; and on body mass index ( BMI ) for cases in the top BMI decile . MAIN OUTCOME MEASURE Incident cases of type 2 diabetes . RESULTS Among cases , the mean ( SD ) concentration of ferritin was significantly higher ( 109 [ 105 ] vs 71.5 [ 68.7 ] ng/mL for controls ; P<.001 for difference ) and the mean ( SD ) ratio of transferrin receptors to ferritin was significantly lower ( 102 [ 205 ] vs 141 [ 340 ] , respectively ; P = .01 ) . In conditional logistic regression stratified on the matching factors and controlled for BMI and other diabetes risk factors , the multivariate relative risks [ RRs ] of incident type 2 diabetes across increasing quintiles of ferritin were 1.00 , 1.09 ( 95 % confidence interval [ CI ] , 0.70 - 1.70 ) , 1.26 ( 95 % CI , 0.82 - 1.95 ) , 1.30 ( 95 % CI , 0.83 - 2.04 ) , and 2.68 ( 95 % CI , 1.75 - 4.11 ) ( P<.001 for trend ) . The RRs across increasing quintiles of transferrin receptors to ferritin ratio were 2.44 ( 95 % CI , 1.61 - 3.71 ) , 1.00 ( 95 % CI , 0.64 - 1.56 ) , 1.13 ( 95 % CI , 0.73 - 1.74 ) , 0.99 ( 95 % CI , 0.64 - 1.53 ) , and 1.00 ( P = .01 for trend ) . Further adjustment for an inflammatory marker ( C-reactive protein ) did not change the results appreciably . The associations persisted within strata defined by levels of BMI , menopausal status , alcohol consumption , and C-reactive protein . CONCLUSION Higher iron stores ( reflected by an elevated ferritin concentration and a lower ratio of transferrin receptors to ferritin ) are associated with an increased risk of type 2 diabetes in healthy women independent of known diabetes risk factors Latinas with type 2 diabetes are in need of culturally sensitive interventions to make recommended long-term lifestyle changes and reduce heart disease risk . To test the longer-term ( 24-month ) effects of a previously successful , culturally adapted , multiple-health-behavior-change program , ¡ Viva Bien ! , 280 Latinas were r and omly assigned to usual care or ¡ Viva Bien!.  Treatment included group meetings to promote a culturally adapted Mediterranean diet , physical activity , supportive re sources , problem solving , stress-management practice s , and smoking cessation . ¡ Viva Bien ! participants achieved and maintained some lifestyle improvements from baseline through 24 months , including significant improvements for psychosocial outcomes , fat intake , social – environmental support , body mass index , and hemoglobin A1c . Effects tended to diminish over time . The ¡ Viva Bien ! multiple-behavior program was effective in improving and maintaining some psychosocial , behavioral , and biological outcomes related to heart health across 24 months for Latinas with type 2 diabetes , a high-risk , underserved population ( Clinical Trials.gov number , NCT00233259 ) BACKGROUND Health-compromising behaviors among survivors of childhood cancer may increase their risks of cancer recurrence and the onset of chronic disease in adulthood . Regardless of whether such behaviors occur singly or in combination with one another , multiple behavioral risk factors must be identified and addressed early to promote better health outcomes within this special population . Adolescent survivors may be especially vulnerable , as reported rates of smoking and other risky behaviors are at or near levels of their healthy peers . The psychological literature suggests stress may play a role in risk behavior initiation and maintenance , including multiple behavioral risks , and that adolescent survivors are stress-prone . This report focuses on the prevalence and co-occurrence of three behavioral risk factors ( cigarette use , insufficient physical activity , and non-adherence to sun protection recommendations ) and describes stress-health behavior relationships in this special population . PROCEDURE All patients in this study ( n = 75 ) were adolescent survivors of childhood cancer and completed a baseline assessment of their  health behaviors and stress  as part of a r and omized controlled trial of health promotion . RESULTS Twenty-eight percent of the patients reported one of three risk factors , 12 % reported two of three risk factors , and 7 % reported all three risk factors . Non-adherence to sun protection was the single most common risk factor ; physical inactivity and non-adherent sun protection were the most common co-occurring risk factors . Greater age and stress were significantly associated with the presence of more behavioral risk factors . CONCLUSIONS The evidence suggests interventions to reduce multiple health-compromising behaviors in these patients are warranted , and that efforts to address these patients ' personal and family stress levels are important as well CONTEXT Current public health campaigns to reduce obesity and type 2 diabetes have largely focused on increasing exercise , but have paid little attention to the reduction of sedentary behaviors . OBJECTIVE To examine the relationship between various sedentary behaviors , especially prolonged television ( TV ) watching , and risk of obesity and type 2 diabetes in women . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study conducted from 1992 to 1998 among women from 11 states in the Nurses ' Health Study . The obesity analysis included 50 277 women who had a body mass index ( BMI ) of less than 30 and were free from diagnosed cardiovascular disease , diabetes , or cancer and completed questions on physical activity and sedentary behaviors at baseline . The diabetes analysis included 68 497 women who at baseline were free from diagnosed diabetes mellitus , cardiovascular disease , or cancer . MAIN OUTCOME MEASURES Onset of obesity and type 2 diabetes mellitus . RESULTS During 6 years of follow-up , 3757 ( 7.5 % ) of 50 277 women who had a BMI of less than 30 in 1992 became obese ( BMI > or = 30 ) . Overall , we documented 1515 new cases of type 2 diabetes .  Time spent watching TV was positively associated with risk of obesity and type 2 diabetes . In the multivariate analyses adjusting for age , smoking , exercise levels , dietary factors , and other covariates , each 2-h/d increment in TV watching was associated with a 23 % ( 95 % confidence interval [ CI ] , 17%-30 % ) increase in obesity and a 14 % ( 95 % CI , 5%-23 % ) increase in risk of diabetes ; each 2-h/d increment in sitting at work was associated with a 5 % ( 95 % CI , 0%-10 % ) increase in obesity and a 7 % ( 95 % CI , 0%-16 % ) increase in diabetes . In contrast , st and ing or walking around at home ( 2 h/d ) was associated with a 9 % ( 95 % CI , 6%-12 % ) reduction in obesity and a 12 % ( 95 % CI , 7%-16 % ) reduction in diabetes . Each 1 hour per day of brisk walking was associated with a 24 % ( 95 % CI , 19%-29 % ) reduction in obesity and a 34 % ( 95 % CI , 27%-41 % ) reduction in diabetes . We estimated that in our cohort , 30 % ( 95 % CI , 24%-36 % ) of new cases of obesity and 43 % ( 95 % CI , 32%-52 % ) of new cases of diabetes could be prevented by adopting a relatively active lifestyle ( < 10 h/wk of TV watching and > or = 30 min/d of brisk walking ) . CONCLUSIONS Independent of exercise levels , sedentary behaviors , especially TV watching , were associated with significantly elevated risk of obesity and type 2 diabetes , whereas even light to moderate activity was associated with substantially lower risk . This study emphasizes the importance of reducing prolonged TV watching and other sedentary behaviors for preventing obesity and diabetes Loneliness is a prevalent and global problem for adult population s and has been linked to multiple chronic conditions in quantitative studies . This paper presents a systematic review of quantitative studies that examined the links between  loneliness  and common chronic conditions including : heart disease , hypertension , stroke , lung disease , and metabolic disorders . A comprehensive literature search process guided by the PRISMA statement led to the inclusion of 33 articles that measure loneliness in chronic illness population s.  Loneliness is a significant biopsychosocial stressor that is prevalent in adults with heart disease , hypertension , stroke , and lung disease . The relationships among loneliness , obesity , and metabolic disorders are understudied but current research indicates that loneliness is associated with obesity and with psychological stress in obese persons . Limited interventions have demonstrated long-term effectiveness for reducing loneliness in adults with these same chronic conditions . Future longitudinal r and omized trials that enhance knowledge of how diminishing loneliness can lead to improved health outcomes in persons with common chronic conditions would continue to build evidence to support the translation of findings to recommendations for clinical care OBJECTIVE To assess the association between sleep problems and chronic disease in older adults . METHODS Self-reported st and ardized question naire data from 1506 community-dwelling men and women aged 55 - 84 years in the continental United States who completed a 20-min telephone interview when contacted from lists of r and omly selected telephone numbers . RESULTS A majority of the participants ( 83 % ) reported one or more of 11 medical conditions and nearly one in four elderly respondents ( age 65 - 84 years ) had major comorbidity ( i.e. four or more conditions ) . Depression , heart disease , bodily pain and memory problems were associated with more prevalent symptoms of insomnia . Other conditions such as obesity , arthritis , diabetes , lung diseases , stroke and osteoporosis were associated with other sleep-related problems such as breathing pauses , snoring , daytime sleepiness , restless legs or insufficient sleep ( < 6 h nightly ) . CONCLUSIONS Poll findings are consistent with epidemiological studies of sleep , aging and chronic disease . These results suggest that the sleep complaints common in older adults are often secondary to their comorbidities and not to aging per se . These types of studies may be useful in promoting sleep awareness among health professionals and among older adults , especially those with heart disease , depression , chronic bodily pain or major comorbidity OBJECTIVE To assess the effect of lifestyle intervention over 2 years on changes in weight , coronary heart disease ( CHD ) risk factors , and incidence of diabetes in overweight individuals with a parental history of diabetes . RESEARCH DESIGN AND METHODS Participants ( n = 154 ) , who were 30–100 % over ideal body weight , had one or both parents with diabetes , and were currently nondiabetic , were r and omly assigned to 2-year treatments focused on diet ( decreasing calories and fat intake ) , exercise ( goal of 1,500 kcal/week of moderate activity ) , or the combination of diet plus exercise or to a no-treatment control group . Subjects were reassessed at 6 months , 1 year , and 2 years . RESULTS At 6 months , the groups differed significantly on measures of eating , exercise , and fitness ; weight losses in the diet and diet-plus-exercise groups were significantly > in the exercise and control conditions . Weight losses were associated with positive changes in CHD risk factors . After 6 months , there was gradual deterioration of behavioral and physiological changes , so that at 2 years , almost no between-group differences were maintained . Differences between groups in risk of developing diabetes were of borderline significance ( P = 0.08 ) . Strongest predictors were impaired glucose tolerance at baseline , which was positively related to risk of developing diabetes , and weight loss from baseline to 2 years , which was negatively related ; in all treatment groups , a modest weight loss of 4.5 kg reduced the risk of type 2 diabetes by ∼ 30 % compared with no weight loss . CONCLUSIONS Although initially successful , the interventions studied here were not effective in producing long-term changes in behavior , weight , or physiological parameters . However , weight loss from 0 to 2 years reduced the risk of developing type 2 diabetes . Since modest weight loss significantly reduced risk of type 2 diabetes , further research is needed to determine how best to increase the percentage of subjects achieving at least a modest weight loss BACKGROUND In type 2 diabetes , tight glycaemic control lowers the risk of diabetic complications , but it remains uncertain whether variability of glycaemia influences outcomes . We examined the association of glycated haemoglobin ( HbA1c ) variability with incident chronic kidney disease and cardiovascular disease in a prospect i ve cohort of 8439 Chinese patients with type 2 diabetes recruited from 1994 to 2007 . METHODS Intrapersonal mean and SD of serially measured HbA1c were calculated . Chronic kidney disease was defined as estimated glomerular filtration rate < 60 ml/min per 1.73 m² . Cardiovascular disease was defined as events of ischemic heart disease , heart failure , ischemic stroke or peripheral vascular disease . RESULTS Over a median follow-up period of 7.2 years , 19.7 and 10.0 % of patients developed chronic kidney disease and cardiovascular disease , respectively . Patients who progressed to chronic kidney disease had higher mean HbA1c ( 7.8 ± 1.3 % vs 7.4 ± 1.2 % , p < 0.001 ) and SD ( 1.0 ± 0.8 % vs 0.8 ± 0.6 % , p < 0.001 ) than nonprogressors . Similarly , patients who developed cardiovascular disease had higher mean HbA1c ( 7.7 ± 1.3 % vs 7.4 ± 1.2 % , p < 0.001 ) and SD ( 1.4 ± 1.1 % vs 1.1 ± 0.8 % , p < 0.001 ) than patients who did not develop cardiovascular disease . By using multivariate-adjusted Cox regression analysis , adjusted SD was associated with incident chronic kidney disease and cardiovascular disease with corresponding hazard ratios of 1.16 ( 95 % CI 1.11 - 1.22 ) , p < 0.001 ) and 1.27 ( 95 % CI 1.15 - 1.40 , p < 0.001 ) , independent of mean HbA1c and other confounding variables . CONCLUSIONS Long-term glycaemic variability expressed by SD of HbA1c predicted development of renal and cardiovascular complications BACKGROUND Multimorbidity is associated with higher mortality , increased disability , a decline in functional status and a lower quality of life . The objective of the study is to explore patterns of multimorbidity in an elderly population . METHODS 328 community inhabitants aged 85 years were included .  Socio-demographic variables and data from the global geriatric assessment were evaluated . Information on the presence of sixteen common chronic conditions was collected : hypertension , diabetes mellitus , dyslipidemia , ischemic cardiomyopathy , heart failure , stroke , chronic obstructive pulmonary disease , ( COPD ) , atrial fibrillation , peripheral arterial disease , Parkinson 's disease , cancer , dementia , anemia , chronic kidney disease ( CKD ) , visual impairment and deafness . Hierarchical cluster analysis was performed . RESULTS The rate of multimorbidity ( > 1 disease ) was 95.1 % . Men had a higher percentage of COPD and malignancy . Four main clusters were identified . The highest value of the bivariate correlation matrix was that between heart failure and visual impairment . These two diseases were included in a cluster with atrial fibrillation , CKD , heart failure , stroke , high blood pressure and diabetes mellitus . CONCLUSIONS The large majority of oldest old subjects had multimorbidity . The results confirm the non-r and om co-occurrence of certain diseases in this age group BACKGROUND It has been suggested that the inverse association between alcohol and type 2 diabetes could be explained by moderate drinkers ' healthier lifestyles . OBJECTIVE We studied whether moderate alcohol consumption is associated with a lower risk of type 2 diabetes in adults with combined low-risk lifestyle behaviors . DESIGN We prospect ively examined 35,625 adults of the Dutch European Prospect i ve Investigation into Cancer and Nutrition ( EPIC-NL ) cohort aged 20 - 70 y , who were free of diabetes , cardiovascular disease , and cancer at baseline ( 1993 - 1997 ) . In addition to moderate alcohol consumption ( women : 5.0 - 14.9 g/d ; men : 5.0 - 29.9 g/d ) , we defined low-risk categories of 4 lifestyle behaviors : optimal weight [ body mass index ( in kg/m(2 ) ) < 25 ] , physically active ( > or = 30 min of physical activity/d ) , current nonsmoker , and a healthy diet [ upper 2 quintiles of the Dietary Approaches to Stop Hypertension ( DASH ) diet ] . RESULTS During a median of 10.3 y , we identified 796 incident cases of type 2 diabetes . Compared with teetotalers , hazard ratios of moderate alcohol consumers for risk of type 2 diabetes in low-risk lifestyle strata after multivariable adjustments were 0.35 ( 95 % CI : 0.17 , 0.72 ) when of a normal weight , 0.65 ( 95 % CI : 0.46 , 0.91 ) when physically active , 0.54 ( 95 % CI : 0.41 , 0.71 ) when nonsmoking , and 0.57 ( 95 % CI : 0.39 , 0.84 ) when consuming a healthy diet . When > or =3 low-risk lifestyle behaviors were combined , the hazard ratio for incidence of type 2 diabetes in moderate alcohol consumers after multivariable adjustments was 0.56 ( 95 % CI : 0.32 , 1.00 ) . CONCLUSION In subjects already at lower risk of type 2 diabetes on the basis of multiple low-risk lifestyle behaviors , moderate alcohol consumption was associated with an approximately 40 % lower risk compared with abstention This paper describes a r and omized study to evaluate the effects of a comprehensive lifestyle management intervention for 279 postmenopausal women with type 2 diabetes who are at elevated risk for coronary heart disease ( CHD ) . The intervention , called the Mediterranean Lifestyle Trial , is focused on dietary factors , physical activity , social support and stress management . The Mediterranean Lifestyle Trial relies on a synthesis of Social Cognitive Theory and Social Ecologic Theory , as well as goal -systems theory , to explicitly inform the lifestyle intervention and to address maintenance . Thus , the trial should help illuminate the theoretical mechanisms responsible for lifestyle change . Primary outcome variables are dietary , stress management and physical activity behavior change , quality of life , and CHD-related biological risk factors . Hypothesized mediating variables include self-efficacy , coping , and social and environmental support . Following the initial 6-month intervention , participants in the intervention condition are r and omized to one of two groups design ed to enhance maintenance of effects : either a peer-led support group or a personalized multilevel community re sources maintenance condition . Unlike the peer group , the personalized approach focuses on multiple levels of community re sources to promote healthful lifestyle change . Because this research focuses on issues of generalization and translation to practice , the RE- AIM evaluation framework is being used to evaluate Reach , Effectiveness , Adoption , Implementation and Maintenance . This framework will help to translate research into practice by directing research ers ' attention to important but seldom-investigated strategies for enhancing longer-term maintenance . Specifically , the study tests how long-term maintenance may be improved through the use of existing community re sources , an intervention based on multiple environmental factors and multiple lifestyle behaviors , and lay leaders versus personalized professional support PURPOSE The purpose of this study was to evaluate costs associated with the primary intervention of the Mediterranean Lifestyle Program ( MLP ) , which targeted postmenopausal women with type 2 diabetes at risk for coronary heart disease . METHODS Using retrospective data collected during MLP development and implementation , the authors estimated costs for the first 6 months relative to the usual care condition and incremental costs per behavioral , biologic , and quality -of-life change . Sensitivity analyses were conducted using variations in inflation rates , implementation setting s , labor and nonlabor inputs , and market wage rates . RESULTS Of the sample of 279 study participants , 163 were r and omized into the MLP condition .  Total intervention costs were estimated at $ 211 061 ( $ 148 022 direct costs ) or $ 1295 per MLP participant relative to usual care ( $ 908 direct costs ) . This translates to $ 3808 per average change in coronary heart disease risk as measured by an average 1-point reduction in hemoglobin A1C . Relative to other measured improvements , this corresponds to $ 2345 per unit reduction in body mass index and $ 644 per unit improvement in Problem Areas in Diabetes Quality -of-Life Self-care Summary score , and a $ 196 per-gram reduction in intake of saturated fatty acids as noted by the Food Frequency Question naire . A significant portion of the direct costs were related to the re sources used during the recruitment phase . CONCLUSIONS Providing a relatively intensive lifestyle self-management program for this high-risk group is associated with modest incremental costs compared with usual care , making the program potentially appealing to policy makers BACKGROUND AND AIMS Type 2 diabetes is one of the most important risk factor for the development of chronic kidney disease ( CKD ) . Recently , it has been shown that lower high-density lipoprotein cholesterol ( HDL-C ) levels predicted the development of microalbuminuria in type 2 diabetic individuals . We have prospect ively assessed the effects of plasma HDL-C levels on the incidence of CKD in a large cohort of type 2 diabetic patients . METHODS AND RESULTS We followed 1987 type 2 diabetic out patients with normal or near-normal kidney function at baseline for 5 years for the occurrence of incident CKD defined as glomerular filtration rate < or = 60 mL/min/1.73 m(2 ) ( as estimated by the abbreviated Modified Diet and Renal Disease Study equation ) . Cox proportional hazards models were used to examine the independent relationship between plasma HDL-C levels and incident CKD . During a median follow-up of 5 years , 11.8 % ( n=234 ) of participants developed incident CKD . In multivariate regression analysis , higher HDL-C levels were associated with a lower risk of incident CKD ( multiple-adjusted hazard ratio 0.76 ; 95 % coefficient intervals 0.61 - 0.96 ; p=0.025 ) independently of age , gender , body mass index , hypertension , smoking history , diabetes duration , hemoglobin A1c , plasma triglycerides , LDL-cholesterol , presence of diabetic retinopathy , baseline albuminuria , and current use of medications ( anti-hypertensive , anti-platelet , lipid-lowering and hypoglycemic drugs ) . CONCLUSIONS Higher plasma levels of HDL-C are associated with a lower risk of incident CKD in a large cohort of type 2 diabetic adults independently of numerous confounding factors
Preliminary evidence suggests that sequentially changing smoking alongside other risk behaviors was more effective than simultaneous change .
Follow-up period and intervention characteristics impacted effectiveness for some outcomes .
Interventions comprising education ( e.g. , providing information about behaviors associated with health risks ) and skills training ( e.g. , teaching skills that equip participants to engage in less risky behavior ) and targeting multiple risk behaviors concurrently are associated with small changes in diet and physical activity .
Although on average smoking was reduced , it appeared changes in smoking were negatively associated with changes in other behaviors , suggesting it may not be optimal to target smoking simultaneously with other risk behaviors
CONTEXT Multiple risk behaviors are common and associated with developing chronic conditions such as heart disease , cancer , or Type 2 diabetes .