Effect of lifestyle interventions on carotid arterial structure - The DR's EXTRA study.

No lifestyle-based interventions with medium-term duration on carotid atherosclerotic have been performed so far. We aimed to investigate whether guideline-based dietary and physical activity interventions slow the progression of atherosclerotic changes in the general elderly population. 1410 Finnish men and women from a representative population sample were randomly assigned to one of six groups in the four-year intervention study: 1) reference, 2) aerobic training, 3) resistance training, 4) Nordic Diet, 5) aerobic training + Nordic Diet, 6) resistance training + Nordic Diet. The primary outcome was mean common carotid artery intima-media thickness (cIMT). The lumen diameter of the common carotid artery (cLD) was also analyzed. 567 men and 565 women aged 57 to 78 years were included. None of the intervention groups significantly slowed cIMT progression compared to the reference group. A subgroup analysis showed that men in the diet group had significantly smaller cIMT progression than in the reference group (-0.078 mm, 95% CI: -0.146 to -0.009, p = 0.02) and no significant increase in cIMT (p = 0.23). No other group showed a slowed cIMT progression. Among guideline-based lifestyle interventions, only diet leads to a significantly smaller progression of cIMT in older men of a representative population sample. No other lifestyle intervention contributed to a slowing of the progression of structural carotid markers. It must be questioned whether the guideline-based recommendations for a lifestyle change that were in place until recently are adequate to decelerate the atherosclerotic process.

The Nordic diet and cognition--The DR's EXTRA Study.

The rapid increase in the prevalence of dementia associated with ageing populations has stimulated interest in identifying modifiable lifestyle factors that could prevent cognitive impairment. One such potential preventive lifestyle factor is the Nordic diet that has been shown to reduce the risk of CVD; however, its effect on cognition has not been studied. The aim of the present study was to estimate the cross-sectional and longitudinal associations of the baseline Nordic diet with cognitive function at baseline and after a 4-year follow-up in a population-based random sample (n 1140 women and men, age 57-78 years) as secondary analyses of the Finnish Dose-Responses to Exercise Training study. The Nordic diet score was created based on reported dietary components in 4-d food records. Cognition was assessed by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery and the Mini-mental State Examination (MMSE). The baseline Nordic diet score had been positively associated with Verbal Fluency (ß 0.08 (95% CI 0.00, 0.16), P = 0.039) and Word List Learning (ß 0.06 (95% CI 0.01, 0.10), P = 0.022) at 4 years but not with the Consortium to Establish a Registry for Alzheimer's Disease total score (CERAD-TS) or MMSE at 4 years, after adjustment for baseline cognitive scores, demographic factors and health-related factors. After excluding individuals with impaired cognition at baseline, the baseline Nordic diet score had also been positively associated with the CERAD-TS (ß 0.10 (95% CI 0.00, 0.20), P = 0.042) and MMSE (ß 0.03 (95% CI 0.00, 0.06), P = 0.039) at 4 years. These associations disappeared after further adjustment for energy intake. In conclusion, the Nordic diet might have a positive association with cognition in individuals with normal cognition.

Validation of metabolic syndrome score by confirmatory factor analysis in children and adults and prediction of cardiometabolic outcomes in adults.

AIMS/HYPOTHESIS: We validated the metabolic syndrome (MetS) score by confirmatory factor analysis (CFA) in children, middle-aged men, and older women and men and by investigating the relationships of the MetS score to incident type 2 diabetes, myocardial infarction, and cardiovascular and overall death in middle-aged men. METHODS: We assessed the core features of MetS, calculated the MetS score using z scores for waist circumference, insulin, glucose, triacylglycerols, HDL-cholesterol and blood pressure, and carried out CFA to investigate whether MetS represents a single entity in population samples of 491 children, 1,900 middle-aged men, 614 older women and 555 older men from Finland. We also followed-up incident type 2 diabetes for 11 years and other outcomes for 17-18 years in middle-aged men. RESULTS: We carried out second-order CFAs in which the MetS was represented by a second-order latent variable underlying four latent variables characterised by abdominal obesity, insulin resistance, dyslipidaemia and raised blood pressure in different age groups. These second-order factors and factors derived from first-order CFA using previously proposed models were strongly associated with a composite MetS score in all age groups (r = 0.84-0.94) and similarly predicted type 2 diabetes, cardiovascular outcomes and mortality in middle-aged men. The risk of type 2 diabetes, myocardial infarction, cardiovascular death and overall death increased 3.67-, 1.38-, 1.56- and 1.44-fold, respectively, for a 1 SD increase in the MetS score. CONCLUSIONS: The MetS can be described as a single entity in all age groups. The MetS score is a valid tool for research evaluating cardiometabolic risk in different age groups. Further research is needed to define cut-off points for risk estimation in clinical practice.

Age, marital status and changes in dietary habits in later life: a 21-year follow-up among Finnish women.

OBJECTIVE: To examine 21-year longitudinal changes in dietary habits and their associations with age and marital status among women aged 50-60 years at baseline. DESIGN: Prospective, longitudinal study of a cohort in the FINMONICA population-based risk factor survey with clinical assessments in 1982, 1992 and 2003. Dietary habits were assessed via self-reported consumption of foods typically contributing to SFA, cholesterol and sugar intakes in the Finnish diet. A dietary risk score based upon five items was used. SETTING: Kuopio region, Finland. SUBJECTS: Complete data from all three assessments for 103 women of the original cohort of 299 were included for two age groups: 50-54 and 55-60 years at baseline. RESULTS: Dietary habits improved between 1982 and 1992 and showed continued but less pronounced improvement between 1992 and 2003: within the younger age group, 78 % of the women reduced the number of dietary risk points from the 1982 to 2003 scores, whereas 3 % increased them and 19 % reported no change. In the older age group these percentages were 61 %, 23 % and 16 %, respectively. Women who remained married showed a steadier decline in dietary risk points than single women or women who were widows at the beginning of the follow-up. CONCLUSIONS: Older women make positive changes to their dietary habits but the consistency of these changes may be affected by the ageing process, marital status and changes in the latter.

Adherence to Life's simple 7 is associated with better carotid properties.

BACKGROUND AND AIMS: Cardiovascular health scores have emerged as a simple way to assess the risk to suffer from a cardiovascular disease. The American Heart Association's Life's Simple 7 constitutes of modifiable lifestyle factors to reduce cardiovascular risk. Its association with carotid properties is yet inconclusive. The aim of this study is to determine the association between the adherence to Life's Simple 7 and carotid properties in middle-aged to elderly Finns. METHODS: A representative sample of Finnish men and women aged 55-74 years was included in the present study. Carotid intima-media thickness (cIMT), lumen diameter (cLD), and carotid distensibility were measured by transcutaneous ultrasound using state-of-the-art wall contour detection techniques. The Life's Simple 7 cardiovascular health score was calculated using seven categories (body mass index, cholesterol, systolic blood pressure, fasting plasma glucose, smoking status, physical activity, and diet). In accordance to the American Heart Association, for each category, an ideal score was given 2 points, intermediate scores 1 point, and poor scores 0 points. RESULTS: In total, 1400 (49.4% male) subjects were included in the analyses. After adjusting for age and sex, we found that subjects with a an ideal cardiovascular health score had lower cLD than those with an intermediate score (-0.21 mm, 95% CI: 0.37 to -0.05 mm, p=0.005) and a poor score (-0.39 mm, 95% CI: 0.65 to -0.12 mm, p=0.001). Similarly, subjects with an ideal health score had higher carotid distensibility than those with an intermediate score (0.0032 1/kPa, 95% CI: 0.009-0.0055 1/kPa, p=0.002) and a poor score (0.0018 1/kPa, 95% CI: 0.0005-0.0032 1/kPa, p=0.004). We found no differences regarding cIMT. CONCLUSIONS: In middle-aged to elderly Finns, higher adherence to the Life's Simple 7 is associated with lower cLD and higher distensibility, but not with cIMT. Adherence to healthy lifestyle habits is therefore associated with better carotid structure and carotid function in middle-aged to elderly Finns.

Exercise, diet, and cognition in a 4-year randomized controlled trial: Dose-Responses to Exercise Training (DR's EXTRA).

BACKGROUND: Evidence for the effects of exercise and dietary interventions on cognition from long-term randomized controlled trials (RCTs) in large general populations remains insufficient. OBJECTIVE: The objective of our study was to investigate the independent and combined effects of resistance and aerobic exercise and dietary interventions on cognition in a population sample of middle-aged and older individuals. METHODS: We conducted a 4-y RCT in 1401 men and women aged 57-78 y at baseline. The participants were randomly assigned to the resistance exercise, aerobic exercise, diet, combined resistance exercise and diet, combined aerobic exercise and diet, or control group. Exercise goals were at least moderate-intensity resistance exercise ≥2 times/wk and at least moderate-intensity aerobic exercise ≥5 times/wk. Dietary goals were ≥400 g/d of vegetables, fruit, and berries; ≥2 servings of fish/wk; ≥14 g fiber/1000 kcal; and ≤10% of energy of daily energy intake from SFAs. The primary outcome was the change in global cognition measured by the total score of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological tests [CERAD total score (CERAD-TS)]. The data were analyzed using the intention-to-treat principle and linear mixed-effects models. RESULTS: There was a trend toward improved CERAD-TS over 4 y in the combined aerobic exercise and diet group compared with the control group (net increase: 1.4 points; 95% CI: 0.1, 2.7; P = 0.06) adjusted for age, sex, years of education, symptoms of depression, and waist circumference at baseline. No other differences in CERAD-TS changes were found across the 6 study groups. Diet did not potentiate the effect of aerobic or resistance exercise on CERAD-TS. CONCLUSIONS: A combination of at least moderate-intensity aerobic exercise and a healthy diet may improve cognition in older individuals over 4 y, but there was no effect of either of these interventions alone, resistance training alone, or resistance exercise with a healthy diet on cognition.

BDNF is a novel marker of cognitive function in ageing women: the DR's EXTRA Study.

Brain-derived neurotrophic factor (BDNF) is one of the key molecules modulating brain plasticity. While low circulating levels of BDNF have been suggested to predispose to Alzheimer's disease, very little data are available on its association with cognitive function in general population. We evaluated the association between plasma BDNF levels and cognition in a representative population sample of ageing men and women. The subjects (n=1389) were participants of the Dose-Responses to Exercise Training (DR's EXTRA) Study and represent a random sample of Eastern Finnish people (684 men and 705 women), 57-79 years of age at baseline of the study. Plasma BDNF levels were measured by enzyme-linked immunosorbent assay (ELISA). Cognitive function was evaluated using the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological test battery. Women had a higher mean (+/-SEM) plasma BDNF level than men (1721+/-55vs. 1495+/-54pg/ml, P<0.001). In women, 1 SD decrease in BDNF increased the risk for a low score in Naming Test by 53% (95% CI 1.21-1.92, P<0.001), in Mini-Mental State Examination by 63% (95% CI 1.21-2.20, P=0.001), in Word List Memory by 56% (95% CI 1.08-2.26, P=0.019), in Word List Recall by 50% (95% CI 1.10-2.05, P=0.010), in Word List Saving by 49% (95% CI 1.12-1.99, P=0.007), and in Word List Recognition by 64% (95% CI 1.19-2.25, P=0.002). Data were adjusted for age, education, depression, impaired glucose metabolism, cardiovascular disease, antihypertensive medication, lipid lowering medication, use of sex hormones, smoking, alcohol consumption, storing time of plasma in the freezer and platelet count. BDNF was not associated with cognition in men. Present data suggest that plasma BDNF is a biomarker of impaired memory and general cognitive function in ageing women.

Carotid intima-media thickness and cognitive function in elderly women: a population-based study.

OBJECTIVE: Several vascular risk factors have been linked to cognitive decline. However, little is known about the association between the atherosclerotic process and cognitive impairment. We investigated whether carotid intima-media thickness (IMT) predicts the risk of cognitive impairment and whether the putative impairment is specific for some cognitive domains. METHODS: A 12-year population-based follow-up study was performed for a total of 91 women, aged 60-70 years at baseline. Ultrasonographically assessed carotid artery IMT and the Mini-Mental State Examination test were performed at baseline and 12-year follow-up. A detailed cognitive evaluation for memory and cognitive speed was performed in 2003. The mean of left and right carotid bifurcation IMT was used in the analyses for association with the risk for poor cognitive speed and memory. RESULTS: Increased IMT at baseline was an independent predictor for poor memory (beta = -5.004, 95% confidence interval = -7.74 to -2.27; p = 0.001) and cognitive speed (beta = 2.562, 95% confidence interval = 1.19-4.94; p = 0.035) at 12-year follow-up after adjustment for age, education, depression, plasma LDL cholesterol, systolic blood pressure, cardiovascular disease, hormone replacement therapy, smoking, alcohol consumption and physical activity. The risk for poor memory (p = 0.023 for linear trend) and cognitive speed (p = 0.070 for linear trend) increased with increasing IMT tertiles. CONCLUSIONS: Carotid IMT predicts an increased risk for cognitive impairment, particularly poor memory and cognitive speed, in elderly women.

Metabolic syndrome and the progression of carotid intima-media thickness in elderly women.

BACKGROUND: Although the metabolic syndrome can predict cardiovascular events in middle-aged individuals, data on its association with the progression of subclinical atherosclerosis, particularly in elderly women, are limited. We investigated the association of the metabolic syndrome with the progression of carotid intima-media thickness (IMT) in elderly women. METHODS: We performed a 12-year follow-up study in a population-based sample of 101 women (age range at baseline, 60-70 years). All study variables were measured at baseline and 12 years later. We used the National Cholesterol Education Program definition for metabolic syndrome (> or =3 of 5 risk factors) and quantified carotid IMT noninvasively by ultrasonography. RESULTS: The prevalence of metabolic syndrome increased from 13% at baseline to 46% after 12 years of follow-up (P<.001). The mean +/- SD IMT increased by 21% (from 1.05 +/- 0.31 mm to 1.27 +/- 0.38 mm) during 12 years (P<.001). Among the individuals without metabolic syndrome at baseline, the increase in carotid IMT was greater in 34 women who developed metabolic syndrome during 12 years (0.31 +/- 0.37 mm) than in 54 women who did not (0.16 +/- 0.25 mm) after adjustment for age, prevalent cardiovascular diseases, physical activity, smoking, alcohol intake, serum low-density lipoprotein cholesterol level, use of cholesterol-lowering medication, carotid IMT, and National Cholesterol Education Program metabolic risk score at baseline (P = .04 for difference). CONCLUSION: Incident metabolic syndrome is associated with accelerated progression of carotid IMT in elderly women.

Moderators of Maintained Increase in Aerobic Exercise Among Aging Men and Women in a 4-Year Randomized Controlled Trial: The DR's EXTRA Study.

BACKGROUND: Little is known about factors that modify the effectiveness of exercise interventions in increasing exercise. We aimed to identify moderators of the effectiveness of aerobic exercise intervention in maintaining increased aerobic exercise among older individuals. METHODS: The participants of a 4-year randomized controlled trial were a population sample of 1410 men and women aged 57 to 78 years. The aerobic exercise group included 185 individuals and the control group included 169 individuals who reported low aerobic exercise at baseline. Maintained increase in aerobic exercise was defined as at least 60-minute increase in moderate-to-heavy aerobic exercise per week from baseline to 2- and 4-year assessments. RESULTS: Individuals in the aerobic exercise group were 2.5 (95% CI 1.5 to 3.9) times more likely to maintain increased aerobic exercise than those in the control group. Individuals aged < 68.5 years but not older individuals succeeded in maintaining increased aerobic exercise in the intervention group (P = .02 for interaction). Individuals who were past smokers (P = .02 for interaction), were working (P = .05 for interaction), or had symptoms of depression (P = .05 for interaction) succeeded better in maintaining increased aerobic exercise in the intervention group than other individuals. CONCLUSIONS: These findings help in more precise targeting of future exercise interventions among older individuals.

Cardiopulmonary fitness is a function of lean mass, not total body weight: The DR's EXTRA study.

BACKGROUND: Division by total body weight is the usual way to standardise peak oxygen uptake (peak VO2) for body size. However, this method systematically underestimates cardiopulmonary fitness in obese individuals. Our aim was to analyse whether lean-mass is a better base for a body mass-independent standard of cardiopulmonary fitness. METHODS: A population based sample of 578 men (body mass index (BMI) 19-47 kg/m(2)) and 592 women (BMI 16-49 kg/m(2)) 57-78 years of age. Peak VO2 was assessed by respiratory gas analysis during a maximal exercise test on a cycle ergometer. We studied the validity of the weight-ratio and the lean mass-ratio standards in a linear regression model. RESULTS: The weight-ratio standard implies an increase of peak VO2 per additional kg body weight with 20.7 ml/min (95% confidence interval (CI): 20.3-21.1) in women and 26.9 ml/min (95% CI: 26.4-27.5) in men. The observed increase per kg is only 8.5 ml/min (95% CI: 6.5-10.5) in men and 10.4 ml/min (95% CI: 7.5-13.4) in women. For the lean mass-ratio standard expected and observed increases in peak VO2 per kg lean mass were 32.3 (95% CI: 31.8-32.9) and 34.6 (95% CI: 30.0-39.1) ml/min for women and 36.2 (95% CI: 35.6-36.8) and 37.3 (95% CI: 32.1-42.4) ml/min in men. The lean mass-ratio standard is a body mass-independent measure of cardiopulmonary fitness in 100% of women and 58% of men; corresponding values for the weight-ratio standard were 11% and 16%. CONCLUSIONS: For comparisons of cardiopulmonary fitness across different categories of body mass, the lean mass-ratio standard should be used.

The impact of time cost of physical exercise on health outcomes by older adults: the DR's EXTRA Study.

When the motivation for exercise is high and people are retired, the cost of time used for physical exercise may be lower and individuals may exercise more compared to individuals with a low motivational level and in working life. The aim was to study the effect of time cost of physical exercise on the amount of physical exercise and on health-related quality of life. We used 2-year data (n = 1,292) from a 4-year randomised controlled trial in a population-based sample of Eastern Finnish men and women, 57-78 years of age at baseline, in 2005-2006. In the statistical analysis, physical exercise and health outcomes were assumed to be endogenous variables explained with a set of exogenous variables. The statistical modelling was done by panel data instrumental variable regressions. Health-related quality of life was evaluated by the RAND 36-item survey and motives for exercise with a questionnaire. Joy as the motivation for physical exercise and retirement increased the amount of physical exercise per week (p < 0.001). A higher amount of exercise was associated with physical (p < 0.001) and mental (p < 0.001) components of quality of life. Moreover, a higher amount of physical exercise decreased the metabolic risk factor score (p < 0.001). The motivation and extra time, i.e. retirement, have a significant impact on the time spent on physical exercise (p < 0.001). Our data agree with the theory that high motivation and retirement lower the time cost of physical exercise. The results emphasise that motivation and the labour market position are important in determining the cost of physical exercise.

Cardiorespiratory fitness and metabolic syndrome in older men and women: the dose responses to Exercise Training (DR's EXTRA) study.

OBJECTIVE: We studied the association of maximum oxygen uptake (Vo(2max)) with the development and resolution of metabolic syndrome (MetS) for 2 years in older individuals. RESEARCH DESIGN AND METHODS: Subjects were a population sample of 1,226 men and women aged 57-78 years. We assessed Vo(2max) directly by respiratory gas analysis during maximum exercise testing and used dichotomous and continuous variables for MetS. RESULTS: One SD increase in baseline Vo(2max) associated with 44% (95% CI 24-58) decreased risk of developing MetS. Individuals in the highest third of baseline Vo(2max) were 68% (37-84) less likely to develop MetS than those in the lowest third. One SD increase in Vo(2max) increased the likelihood to resolve MetS 1.8 (1.2-2.8) times. Individuals in the highest Vo(2max) third were 3.9 (1.5-9.9) times more likely to resolve MetS than those in the lowest third. CONCLUSIONS: Higher levels of cardiorespiratory fitness protect against MetS and may resolve it in older individuals.

Cardiorespiratory fitness as a feature of metabolic syndrome in older men and women: the Dose-Responses to Exercise Training study (DR's EXTRA).

OBJECTIVE: We studied the associations of cardiorespiratory fitness with metabolic syndrome in older men and women, because such data are limited in representative population samples. RESEARCH DESIGN AND METHODS: We studied a population sample of 671 men and 676 women aged 57-79 years at baseline of a randomized controlled intervention study. We assessed maximal oxygen uptake (Vo(2max)) by respiratory gas analysis during a maximal bicycle exercise test. RESULTS: Vo(2max) had a strong, inverse, and graded association with the risk of having metabolic syndrome as defined by the National Cholesterol Education Program criteria. Men and women in the lowest third of Vo(2max) had 10.2- and 10.8-fold higher risks and those in the middle third had 2.9- and 4.7-fold higher risks (P < 0.001 all) of metabolic syndrome than those with the highest Vo(2max) after multivariable adjustments. Factor analysis generated a principal factor that was strongly loaded by the main components of metabolic syndrome and Vo(2max) (-0.68 in men and -0.70 in women). CONCLUSIONS: Low cardiorespiratory fitness is associated with metabolic syndrome in older men and women. Our findings suggest that low cardiorespiratory fitness could be considered a feature of metabolic syndrome.

Metabolic syndrome and cognitive function: a population-based follow-up study in elderly women.

OBJECTIVE: To test the hypothesis that metabolic syndrome predicts cognitive impairment, and to examine the association of single metabolic risk factors with cognitive functioning. METHODS: We performed a 12-year follow-up study in a population-based sample of 101 women aged 60-70 years at baseline. Metabolic syndrome was defined by the National Cholesterol Education Program criteria (> or =3 out of 5 risk factors). Global cognitive function was measured by the Mini-Mental State Examination both at baseline and follow-up. A detailed neuropsychological evaluation for memory and cognitive speed was performed at follow-up. RESULTS: The prevalence of metabolic syndrome increased from 13% at baseline to 49% at follow-up (p < 0.001). Women with metabolic syndrome at baseline had a 4.27 (95% confidence interval: 1.02-17.90; p = 0.047) times higher risk of poor memory at follow-up after adjustment for age, education and depression. The increasing number of metabolic risk factors was associated with worsening of memory at follow-up (p = 0.034 for linear trend). Women with low baseline levels of high-density lipoprotein (HDL) cholesterol were more likely to have poor memory at follow-up than those with higher HDL levels (p = 0.028). The risk of having poor memory increased by 46.5% (95% confidence interval: 15-66%; p = 0.008) with 1 SD decrease in HDL cholesterol level. CONCLUSION: In elderly women, metabolic syndrome may be an important contributor to worsening of memory, which is an essential part of mild cognitive impairment.

Serum high sensitivity C-reactive protein and cognitive function in elderly women.

BACKGROUND: Inflammation has been linked to cognitive impairment. However, limited data are available on the association between inflammatory markers and cognitive function. OBJECTIVES: We tested the hypothesis that elevated serum concentration of high sensitivity C-reactive protein (hs-CRP), an established marker of low-grade inflammation, predicts cognitive impairment in elderly women. DESIGN: A 12-year population-based follow-up study. PARTICIPANTS: A total of 97 women between 60 and 70 years of age at baseline. METHODS: Serum hs-CRP concentration was measured by a high sensitivity assay. Global cognitive function was measured with the Mini-Mental State Examination (MMSE), and memory and cognitive speed were measured with a detailed cognitive test battery. RESULTS: Higher baseline hs-CRP was associated with poorer memory at 12-year follow-up without adjustment and after adjustment for age, education and depression (standardised regression coefficient beta -0.842, 95% confidence interval -1.602 to -0.083, P = 0.030), and further adjustment for the use of hormone replacement therapy, smoking, serum LDL cholesterol and body mass index (standardised regression coefficient beta -0.817, 95% confidence interval -1.630 to -0.004, P = 0.049). Memory at 12-year follow-up worsened linearly with increasing hs-CRP at baseline (P = 0.048 for linear trend). There was no association between hs-CRP at baseline and cognitive speed or MMSE score at 12-year follow-up. CONCLUSIONS: High serum hs-CRP concentration predicts poorer memory 12 years later in elderly women. Hs-CRP may be a useful biomarker to identify individuals at an increased risk for cognitive decline.