Associations of diabesity with all-cause and cardiovascular disease mortality: Findings from the Mexico City Prospective Study.

AIM: To investigate the joint associations of diabetes and obesity with all-cause and cardiovascular disease (CVD) mortality in the Mexico City Prospective Study. MATERIALS AND METHODS: In total, 154 128 participants (67.2% women) were included in this prospective analysis. Diabetes was self-reported, while body mass index was used to calculate obesity. Using diabetes and obesity classifications, six groups were created: (a) normal (no diabetes and normal weight); (b) normal weight and diabetes; (c) overweight but not diabetes (overweight); (d) overweight and diabetes (prediabesity); (e) obesity but not diabetes (obesity); and (f) obesity and diabetes (diabesity). Associations between these categories and outcomes were investigated using Cox proportional hazard models adjusted for confounder factors. RESULTS: During 18.3 years of follow-up, 27 197 (17.6%) participants died (28.5% because of CV causes). In the maximally adjusted model, participants those with the highest risk {hazard ratio (HR): 2.37 [95% confidence interval (CI): 2.24-2.51]}, followed by those with diabesity [HR: 2.04 (95% CI: 1.94-2.15)]. Similar trends of associations were observed for CVD mortality. The highest CV mortality risk was observed in individuals with diabesity [HR: 1.80 (95% CI: 1.63-1.99)], followed by normal weight and diabetic individuals [HR: 1.78 (95% CI: 1.60-1.98)]. CONCLUSION: This large prospective study identified that diabetes was the main driver of all-cause and CVD mortality in all the categories studied, with diabesity being the riskiest. Given the high prevalence of both conditions in Mexico, our results reinforce the importance of initiating prevention strategies from an early age.

Associations of the 'weekend warrior' physical activity pattern with all-cause, cardiovascular disease and cancer mortality: the Mexico City Prospective Study.

OBJECTIVES: The objective was to investigate the benefits of the 'weekend warrior' physical activity pattern in Latin America, where many people take part in high levels of non-exercise physical activity. METHODS: Participants in the Mexico City Prospective Study were surveyed from 1998 to 2004 and resurveyed from 2015 to 2019. Those who exercised up to once or twice per week were termed weekend warriors. Those who exercised more often were termed regularly active. Analyses were adjusted for potential confounders. RESULTS: The main analysis included 26 006 deaths in 154 882 adults (67% female) aged 52±13 years followed for 18±4 years (mean±SD). Compared with those who reported no exercise, the HR (95% CI) was 0.88 (0.83 to 0.93) in the weekend warriors and 0.88 (0.84 to 0.91) in the regularly active. Similar results were observed for cardiovascular disease and cancer mortality, but associations were weaker. Stratified analyses showed that substantial reductions in all-cause mortality risk only occurred when the duration of exercise sessions was at least 30-60 min. The repeated-measures analysis included 843 deaths in 10 023 adults followed for 20±2 years. Compared with being inactive or becoming inactive, the HR was 0.86 (95% CI 0.65 to 1.12) when being a weekend warrior or becoming a weekend warrior and 0.85 (95% CI 0.70 to 1.03) when being regularly active or becoming regularly active. CONCLUSIONS: This is the first prospective study to investigate the benefits of the weekend warrior physical activity pattern in Latin America. The results suggest that even busy adults could benefit from taking part in one or two sessions of exercise per week.

Alcohol drinking in one's thirties and forties is associated with body mass index in men, but not in women: A longitudinal analysis of the 1970 British Cohort Study.

Our objective was to investigate longitudinal associations between alcohol drinking and body mass index (BMI). Alcohol drinking (exposure), BMI (outcome), smoking habit, occupation, longstanding illness, and leisure time physical activity (potential confounders) were assessed at ages 30, 34, 42, and 46 in the 1970 British Birth Cohort Study. Multilevel models were used to cope with the problem of correlated observations. There were 15,708 observations in 5931 men and 14,077 observations in 5656 women. Drinking was associated with BMI in men. According to the regression coefficients, BMI was expected to increase by 0.36 (95% confidence interval: 0.11, 0.60) kg/m2 per year in men who drank once a week and by 0.40 (0.14, 0.15) kg/m2 per year in men who drank most days. In ten years, BMI was expected to increase by 5.4 kg/m2 in men who drank and by 2.9 kg/m2 in men who drank and were physically active. Drinking was not associated with BMI in women. Rather, BMI was expected to increase by 0.25 (0.07, 0.43) kg/m2 per year in women who were former smokers. In ten years, BMI was expected to increase by 4.3 kg/m2 in women who were former smokers and by 0.8 kg/m2 in women who were former smokers and who were physically active. Associations between drinking and BMI were similar after further adjustment for problematic drinking and diet. These longitudinal data suggest that drinking is associated with BMI in men and that drinking is not associated with BMI in women independent of other lifestyle risk factors.

Estimated cardiorespiratory fitness in childhood and cardiometabolic health in adulthood: 1970 British Cohort Study.

BACKGROUND: Associations of cardiorespiratory fitness in childhood and adulthood with adult cardiometabolic risk factors are poorly understood, not least because of the paucity of studies. OBJECTIVES: We investigated associations between nonexercise testing cardiorespiratory fitness (NETCRF) in childhood/adulthood and cardiometabolic risk factors in adulthood. METHODS: Based on an established algorithm comprising gender, age, body mass index, resting heart rate, and self-reported physical activity at age 10, we computed NETCRF. Risk factors were assessed at age 46 in 5009 participants when NETCRF was again calculated. Linear regression was used to summarize associations between NETCRF in childhood and risk factors in adulthood and, additionally, the relationship between NETCRF in adulthood and risk factors in adulthood after adjusting for childhood NETCRF. RESULTS: Inconsistent associations were observed between childhood NETCRF and adult risk factors. NETCRF in adulthood was associated with blood pressure [-5.8 (-6.7, -4.9)], glycated hemoglobin [-3.41 (-4.06, -2.76)], total cholesterol [-0.16 (-0.24, -0.08)], HDL cholesterol [0.19 (0.16, 0.22)], triglycerides [-0.68 (-0.85, -0.50)], and C-reactive protein [-0.29 (-0.35, -0.22)] in adult males. Similar associations were observed in adult females. Compared to those with low estimated fitness in both childhood and adulthood, participants with low fitness in childhood and high fitness in adulthood had a lower risk of two or more cardiometabolic risk factors (odds ratio: 0.25; 95% confidence interval: 0.19, 0.31). CONCLUSION: Associations between estimated fitness and risk factors are stronger in adulthood than from childhood to adulthood. Adults with previously sedentary childhoods may still gain benefits from improving their fitness.

High-Density Lipoprotein Cholesterol and Mortality: Too Much of a Good Thing?

OBJECTIVE: The objective of this study was to examine the shape of the association between high-density lipoprotein cholesterol (HDL-C) and mortality in a large general population sample. APPROACH AND RESULTS: Adult participants (n=37 059; age=57.7±11.9 years; 46.8% men) were recruited from general population household-based surveys (Health Survey for England and Scottish Health Survey). Individual participant data were linked with the British National Health Service Central Registry to record mortality. There were 2250 deaths from all causes during 326 016 person-years of follow-up. When compared with the reference category (HDL-C=1.5-1.99 mmol/L), a U-shaped association was apparent for all-cause mortality, with elevated risk in participants with the lowest (hazard ratio=1.23; 95% confidence interval, 1.06, 1.44) and highest (1.25; 0.97, 1.62) HDL-C concentration. Associations for cardiovascular disease were linear, and elevated risk was observed in those with the lowest HDL-C concentration (1.49; 1.15, 1.94). CONCLUSIONS: A U-shaped association was observed between HDL-C and mortality in a large general population sample.

Lifestyle risk factors, obesity and infectious disease mortality in the general population: Linkage study of 97,844 adults from England and Scotland.

We examined associations between lifestyle variables and infectious disease mortality in a large general population cohort. A sample of 97,844 men and women (aged 47.1 ±â€¯17.7 yrs.; 46.6% male) recruited from general population, household-based surveys were followed up over mean [SD] 9.4 ±â€¯4.5 years. Exposure measurements included self-reported physical activity, cigarette smoking, alcohol intake, and objective body mass index and waist to hip ratio. There were 9027 deaths, of which 14.1% were attributed to infectious diseases. Compared to physically inactive participants both insufficiently active (Hazard ratio = 0.61; 95% CI, 0.50, 0.75) and sufficiently active (at least 150 min/wk. moderate - vigorous activity) (0.60; 0.45, 0.78) was associated with reduced risk of infectious disease mortality in models mutually adjusted for other lifestyle factors. Ex-smokers and current smokers were at increased risk of infectious disease mortality compared with never smoker, with the strongest associations being observed for heavy smoking (>20 cigarettes/day) and pneumonia (3.30; 2.35, 4.63). Underweight was associated with increased risk of infectious disease mortality (3.65; 2.64, 5.06) compared with normal weight; the risk of viral infection was lower in overweight (0.56; 0.44, 0.72) and obesity (0.39; 0.26, 0.58). Central obesity was, however, related to higher risk of bacterial infections, but only in normal weight centrally obese participants (1.71; 1.10, 2.64). A physically active lifestyle and lifelong absence from cigarette smoking had protective associations against infectious disease mortality. Obesity has divergent associations dependent on peripheral and visceral fat depots, and the specific outcome.

Association between physical activity and sub-types of cardiovascular disease death causes in a general population cohort.

Physical activity is thought to be cardioprotective, but associations with different subtypes of cardiovascular disease (CVD) are poorly understood. We examined associations between physical activity and seven major CVD death causes. The sample comprised 65,093 adults (aged 58 ± 12 years, 45.4% men) followed up over mean [SD] 9.4 ± 4.5 years, recruited from The Health Survey for England and the Scottish Health Surveys. A CVD diagnosis was reported in 9.2% of the sample at baseline. Physical activity was self-reported. Outcomes were subtypes of CVD death; acute myocardial infarction; chronic ischaemic heart disease; pulmonary heart disease; a composite of cardiac arrest, arrhythmias, and sudden cardiac death; heart failure; cerebrovascular; composite of aortic aneurysm and other peripheral vascular diseases. There were 3050 CVD deaths (30.8% of all deaths). In Cox proportional hazards models adjusted for confounders, physical activity was associated with reduced relative risk of all CVD outcomes; compared with the lowest, the highest physical activity quintile was associated with reduced risk of acute myocardial infarction (Hazard ratio 0.66: 95% CI 0.50, 0.89), chronic ischaemic heart disease (0.49: 0.38, 0.64), pulmonary heart disease (0.48: 0.22, 1.07), arrhythmias (0.18: 0.04, 0.76); heart failure (0.35: 0.20, 0.63), cerebrovascular events (0.53: 0.38, 0.75); aneurysm and peripheral vascular diseases (0.54: 0.34, 0.93). Results were largely consistent across participants with and without existing CVD at baseline. Physical activity was associated with reduced risk of seven major CVD death causes. Protective benefits were apparent even at levels of activity below the current recommendations.

Does Strength-Promoting Exercise Confer Unique Health Benefits? A Pooled Analysis of Data on 11 Population Cohorts With All-Cause, Cancer, and Cardiovascular Mortality Endpoints.

Public health guidance includes recommendations to engage in strength-promoting exercise (SPE), but there is little evidence on its links with mortality. Using data from the Health Survey for England and the Scottish Health Survey from 1994-2008, we examined the associations between SPE (gym-based and own-body-weight strength activities) and all-cause, cancer, and cardiovascular disease mortality. Multivariable-adjusted Cox regression was used to examine the associations between SPE (any, low-/high-volume, and adherence to the SPE guideline (≥2 sessions/week)) and mortality. The core sample comprised 80,306 adults aged ≥30 years, corresponding to 5,763 any-cause deaths (736,463 person-years). Following exclusions for prevalent disease/events occurring in the first 24 months, participation in any SPE was favorably associated with all-cause (hazard ratio (HR) = 0.77, 95% confidence interval (CI): 0.69, 0.87) and cancer (HR = 0.69, 95% CI: 0.56, 0.86) mortality. Adhering only to the SPE guideline was associated with all-cause (HR = 0.79, 95% CI: 0.66, 0.94) and cancer (HR = 0.66, 95% CI: 0.48, 0.92) mortality; adhering only to the aerobic activity guideline (equivalent to 150 minutes/week of moderate-intensity activity) was associated with all-cause (HR = 0.84, 95% CI: 0.78, 0.90) and cardiovascular disease (HR = 0.78, 95% CI: 0.68, 0.90) mortality. Adherence to both guidelines was associated with all-cause (HR = 0.71, 95% CI: 0.57, 0.87) and cancer (HR = 0.70, 95% CI: 0.50, 0.98) mortality. Our results support promoting adherence to the strength exercise guidelines over and above the generic physical activity targets.

The association between leisure-time physical activity and lung function in older adults: The English longitudinal study of ageing.

The longitudinal association between physical activity and lung function is unclear. Therefore, we examined said association over eight years. This study included data from 2966 participants in English Longitudinal Study of Ageing (63±7years [mean±SD]), a prospective study of initially healthy, community dwelling adults. Physical activity was assessed using an interview and lung function using a spirometer at baseline (2004-5) and follow-up (2012-13). General linear regression was used to assess associations between activity and lung function. Logistic regression was used to assess the odds of new cases of abnormal lung function. Some 14% of participants were defined as physically inactive at baseline, 50% were classified into the moderate group, and 36% into the vigorous group. In comparison with remaining inactive at follow-up, remaining active was positively associated with forced vital capacity (FVC) (ß=0.09, 95% confidence interval [CI]: 0.01, 0.17; p=0.02) and forced expiratory volume in one second (FEV-1) (ß=0.09, 95% CI: 0.02, 0.15; p=0.01) after adjustment for baseline lung function score and other covariates. Using the fifth centile to define the lower limit of normal (that is, -1.64 z scores), there were lower odds of incident abnormal lung function in participants who remained physically active compared to those who remained inactive (FVC odds ratio=0.31, 95% CI: 0.17, 0.55. FEV-1 odds ratio=0.43, 95% CI: 0.26, 0.72). Similar associations were observed in those who became active. This study suggests that remaining physically active or becoming active in older age is positively associated with lung function and reduced odds of abnormal lung function.

Associations between alcohol and obesity in more than 100 000 adults in England and Scotland.

The objective of this cross-sectional study was to clarify the association between alcohol and obesity using data from 106 182 adults in England and Scotland (46·7 % male; mean 46·9 (sd 16·9) years). Trained interviewers asked participants about alcohol intake. Obesity was defined as BMI≥30 kg/m2. Potential confounders included age, sex, smoking, physical activity, longstanding illness, psychological distress and socioeconomic status. Compared with those who drank at least five times a week, obesity risk was 1·21 (95 % CI 1·15, 1·27) in those who drank one to four times a week, 1·53 (95 % CI 1·43, 1·62) in those who drank one to two times a month, 1·61 (95 % CI 1·52, 1·71) in those who drank less than once every couple of months, 1·34 (95 % CI 1·23, 1·47) in those who were former drinkers, and 1·03 (95 % CI 0·95, 1·11) in those who were never drinkers. Compared with those who drank a harmful volume, obesity risk was 0·78 (95 % CI 0·68, 0·90) in those who drank within guidelines, 0·69 (95 % CI 0·54, 0·88) in former drinkers and 0·50 (95 % CI 0·40, 0·63) in never drinkers; and, these associations were biased away from the null after adjustment for drinking volume. Abstinence was associated with increased risk of obesity in women. These data suggest that the association between drinking frequency and obesity is bell-shaped, with obesity risk not significantly different in those who drink most often and never drinkers. Drinking volume has a positive confounding effect on the association between drinking frequency and obesity, which may help explain the conflicting findings of other studies.

Relationships between exercise, smoking habit and mortality in more than 100,000 adults.

Exercise is associated with reduced risks of all-cause, cardiovascular disease (CVD) and cancer mortality; however, the benefits in smokers and ex-smokers are unclear. The aim of this study was to investigate associations between exercise, smoking habit and mortality. Self-reported exercise and smoking, and all-cause, CVD and cancer mortality were assessed in 106,341 adults in the Health Survey for England and the Scottish Health Survey. There were 9149 deaths from all causes, 2839 from CVD and 2634 from cancer during 999,948 person-years of follow-up. Greater amounts of exercise were associated with decreases and greater amounts of smoking were associated with increases in the risks of mortality from all causes, CVD and cancer. There was no statistically significant evidence of biological interaction; rather, the relative risks of all-cause mortality were additive. In the subgroup of 26,768 ex-smokers, the all-cause mortality hazard ratio was 0.70 (95% CI 0.60, 0.80), the CVD mortality hazard ratio was 0.71 (0.55, 092) and the cancer mortality hazard ratio was 0.66 (0.52, 0.84) in those who exercised compared to those who did not. In the subgroup of 28,440 smokers, the all-cause mortality hazard ratio was 0.69 (0.57, 0.83), the CVD mortality hazard ratio was 0.66 (0.45, 0.96) and the cancer mortality hazard ratio was 0.69 (0.51, 0.94) in those who exercised compared to those who did not. Given that an outright ban is unlikely, this study is important because it suggests exercise reduces the risks of all-cause, CVD and cancer mortality by around 30% in smokers and ex-smokers.

The association between leisure-time physical activity, low HDL-cholesterol and mortality in a pooled analysis of nine population-based cohorts.

The objective of this study was to investigate associations between leisure-time physical activity, low high-density lipoprotein cholesterol (HDL-C) and mortality. Self-reported leisure-time physical activity, HDL-C concentration, and mortality were assessed in 37,059 adults in Health Survey for England and Scottish Health Survey. Meeting physical activity guidelines was defined as ≥150 min wk-1 of moderate-intensity activity, ≥75 min wk-1 of vigorous-intensity activity, or equivalent combinations. Low HDL-C was defined as <1.03 mmol L-1. Cox proportional hazard models were adjusted for age, sex, smoking, total cholesterol, systolic blood pressure, body mass index, longstanding illness, and socioeconomic status. There were 2250 deaths during 326,016 person-years of follow-up. Compared with those who met physical activity guidelines and whose HDL-C was normal (reference group), all-cause mortality risk was not elevated in those who met physical activity guidelines and whose HDL-C concentration was low (hazard ratio: 1.07; 95% confidence interval: 0.75, 1.53). Compared with the reference group, all-cause mortality risk was elevated in those who did not meet physical activity guidelines and whose HDL-C was normal (1.37; 1.16, 1.61), and in those who did not meet physical activity guidelines and whose HDL-C was low (1.65; 1.37, 1.98). Cardiovascular disease mortality hazard ratios were similar, although confidence intervals were wider. There was no statistically significant evidence of biological interaction between physical inactivity and low HDL-C. This novel study supports the notion that leisure-time physical activity be recommended in those with low HDL-C concentration who may be resistant to the HDL-raising effect of exercise training.

Physical Inactivity and the Economic and Health Burdens Due to Cardiovascular Disease: Exercise as Medicine.

Leisure time physical activity, or exercise, has been described as today's best buy in public health. Physical inactivity is responsible for around 10% of all deaths and physical inactivity costs global healthcare systems billions of dollars each year. Here, we describe the human and economic costs of cardiovascular disease. Then, we explain that physical inactivity is a major modifiable risk factor for cardiovascular disease. The evidence of the role of physical activity in the primary prevention of cardiovascular disease is reviewed and we make the case that exercise is medicine.

Long terms trends of multimorbidity and association with physical activity in older English population.

BACKGROUND: Multimorbidity has become one of the main challenges in the recent years for patients, health care providers and the health care systems globally. However, literature describing the burden of multimorbidity in the elderly population, especially longitudinal trends is very limited. Physical activity is recommended as one of the main lifestyle changes in the prevention and management of multiple chronic diseases worldwide; however, the evidence on its association with multimorbidity remains inconclusive. Therefore, we aimed to assess the longitudinal trends of multimorbidity and the association between multimorbidity and physical activity in a nationally representative cohort of the English population aged ≥50 years between 2002 and 2013. METHODS: We used data on 15,688 core participants from six waves of the English Longitudinal Study of Ageing, with complete information on physical activity. Self-reported physical activity was categorised as inactive, mild, moderate and vigorous levels of physical activity. We calculated the number of morbidities and the prevalence of multimorbidity (more than 2 chronic conditions) between 2002 and 2013 overall and by levels of self-reported physical activity. We estimated the odds ratio (OR) and 95% confidence intervals (CI) for multimorbidity by each category of physical activity, adjusting for potential confounders. RESULTS: There was a progressive decrease over time in the proportion of participants without any chronic conditions (33.9% in 2002/2003 vs. 26.8% in 2012/2013). In contrast, the prevalence of multimorbidity steadily increased over time (31.7% in 2002/2003 vs. 43.1% in 2012/2013). Compared to the physically inactive group, the OR for multimorbidity was 0.84 (95% CI 0.78 to 0.91) in mild, 0.61 (95% CI 0.56 to 0.66) in moderate and 0.45 (95% CI 0.41 to 0.49) in the vigorous physical activity group. CONCLUSION: This study demonstrated an inverse dose-response association between levels of physical activity and multimorbidity, however, given the increasing prevalence of multimorbidity over time, there is a need to explore causal associations between physical activity and multimorbidity and its impact as a primary prevention strategy to prevent the occurrence of chronic conditions later in life and reduce the burden of multimorbidity.

A non-exercise testing method for estimating cardiorespiratory fitness: associations with all-cause and cardiovascular mortality in a pooled analysis of eight population-based cohorts.

AIMS: Cardiorespiratory fitness (CRF) is a key predictor of chronic disease, particularly cardiovascular disease (CVD), but its assessment usually requires exercise testing which is impractical and costly in most health-care settings. Non-exercise testing cardiorespiratory fitness (NET-F)-estimating methods are a less resource-demanding alternative, but their predictive capacity for CVD and total mortality has yet to be tested. The objective of this study is to examine the association of a validated NET-F algorithm with all-cause and CVD mortality. METHODS AND RESULTS: The participants were 32,319 adults (14,650 men) aged 35-70 years who took part in eight Health Survey for England and Scottish Health Survey studies between 1994 and 2003. Non-exercise testing cardiorespiratory fitness (a metabolic equivalent of VO2max) was calculated using age, sex, body mass index (BMI), resting heart rate, and self-reported physical activity. We followed participants for mortality until 2008. Two thousand one hundred and sixty-five participants died (460 cardiovascular deaths) during a mean 9.0 [standard deviation (SD) = 3.6] year follow-up. After adjusting for potential confounders including diabetes, hypertension, smoking, social class, alcohol, and depression, a higher fitness score according to the NET-F was associated with a lower risk of mortality from all-causes (hazard ratio per SD increase in NET-F 0.85, 95% confidence interval: 0.78-0.93 in men; 0.88, 0.80-0.98 in women) and CVD (men: 0.75, 0.63-0.90; women: 0.73, 0.60-0.92). Non-exercise testing cardiorespiratory fitness had a better discriminative ability than any of its components (CVD mortality c-statistic: NET-F = 0.70-0.74; BMI = 0.45-0.59; physical activity = 0.60-0.64; resting heart rate = 0.57-0.61). The sensitivity of the NET-F algorithm to predict events occurring in the highest risk quintile was better for CVD (0.49 in both sexes) than all-cause mortality (0.44 and 0.40 for men and women, respectively). The specificity for all-cause and CVD mortality ranged between 0.80 and 0.82. The net reclassification improvement of CVD mortality risk (vs. a standardized aggregate score of the modifiable components of NET-F) was 27.2 and 21.0% for men and women, respectively. CONCLUSION: The CRF-estimating method NET-F that does not involve exercise testing showed consistent associations with all-cause and cardiovascular mortality, and it had good discrimination and excellent risk reclassification improvement. As such, it merits further attention as a practical and potentially and useful risk prediction tool.

Tombstone cost and longevity: The San Pedro Cemetery Museum in Medellín in Colombia.

BACKGROUND: Studies in the West suggest that tombstone cost is associated with longevity. The objective of this observational study was to investigate the association between tombstone cost and longevity in a large cemetery in Latin America. METHODS: Age at death was obtained from 2,273 consecutive death certificates held at the San Pedro Cemetery Museum in Medellín in Colombia. Subjects died in 2022, 2021, or 2020. Tombs are arranged in galleries in the cemetery and tombstone cost was based on the material from which the tombstone was made, its position in the gallery, and its ornamentation. Analysis of variance was used and the assumption of equal variance was not violated. RESULTS: Approximately 77% of tombstones were of low cost, 21% of medium cost, and 2% of high cost. Data from 1,751 subjects were used to investigate differences in longevity according to tombstone cost while adjusting for sex, civil status, violent death, and year of death. Longevity was similar in the low-cost group and medium-cost group: 64.3 years (63.2, 65.3) versus 63.3 years (61.3, 65.3) [estimated mean (95% confidence interval)]. Longevity was lower in the high-cost group: 47.0 years (40.1, 53.9). CONCLUSIONS: The inverse association between tombstone cost and longevity would suggest that people in Medellín are inclined to spend more on tombstones when commemorating the tragic death of a young person.

Lifestyle risk factors and all-cause and cause-specific mortality in the Mexico City prospective study: Assessing the influence of reverse causation.

BACKGROUND: We examined the association between individual lifestyle risk factors with all-cause and cause-specific mortality. METHODS: Prospective cohort study including 155,002 participants from the Mexico City Prospective Study. Cox regression models were used to estimate the association between individual lifestyle risk factors and all-cause and cause-specific mortality. Participants with prevalent diseases at baseline and participants who died during the first 2, 5, 10, and 15 years of follow-up were excluded to account for reverse causation. RESULTS: 27,469 people died during 18.3 years of follow-up years. Overweight and moderate alcohol consumption were inversely associated with all-cause mortality, while low physical activity and smoking were positively associated when all participants were included, regardless of prevalent disease or duration of follow-up. The direction of the association of overweight with all-cause mortality changed from inverse to positive after excluding the first 10 years of follow-up. Compared with normal weight, the hazard ratio (95 % confidence interval) was 1.17 (1.13,1.22) for obesity after excluding those who died in the first 5 years of follow-up and 1.71 (1.59,1.84) after excluding the first 15 years of follow-up. The magnitude of the association of alcohol intake, low physical activity, and smoking with mortality attenuated, whereas for fruits and vegetables increased, after excluding longer periods of follow-up. LIMITATIONS: The data were collected exclusively in Mexico City; lifestyle risk factors were self-reported and thus prone to misclassification bias. CONCLUSIONS: Reverse causation may influence both the magnitude and the direction of the associations between lifestyle risk factors and mortality.