besity Research & Clinical Practice (2013) xxx, xxx.e1—xxx.e9
RIGINAL ARTICLE
ody mass index gain between ages 20nd 40 years and lifestyle characteristicsf men at ages 40—60 years: Thedventist Health Study-2
laudio Japasa, Synnøve Knutsenb, Salem Dehomb,ildemar Dos Santosa, Serena Tonstada,∗
Department of Health Promotion and Education, School of Public Health, Lomainda University, Loma Linda, CA 92350, United StatesDepartment of Epidemiology, Biostatistics & Population Medicine, School of Publicealth, Loma Linda University, Loma Linda, CA 92350, United States
eceived 2 July 2013; received in revised form 25 November 2013; accepted 28 November 2013
SummaryBackground: Obesity increases risk of premature disease, and may be associated withunfavorable lifestyle changes that add to risk. This study analyzed the associationof midlife BMI change with current lifestyle patterns among multiethnic men.Methods: Men aged 40—60 years (n = 9864) retrospectively reported body weightbetween ages 20—40 years and current dietary, TV, physical activity and sleep prac-tices in the Adventist Health Study II, a study of church-goers in the US and Canada. Inmultivariate logistic regression analysis, odds ratios for BMI gain were calculated foreach lifestyle practice controlling for sociodemographic and other lifestyle factorsand current BMI.Results: Men with median or higher BMI gain (2.79 kg/m2) between ages 20—40 yearswere more likely to consume a non-vegetarian diet, and engage in excessive TVwatching and little physical activity and had a shorter sleep duration compared tomen with BMI gain below the median (all p < 0.001). In multivariate logistic analysis
current BMI was significantly associated with all lifestyle factors (all p ≤ 0.005). BMI
th lower odds of vegetarian diet (odds ratio [OR] 0.939; 95%
gain was associated wi
Please cite this article in press as: Japas C, et al. Body mass index gain between ages 20 and 40 years andlifestyle characteristics of men at ages 40—60 years: The Adventist Health Study-2. Obes Res Clin Pract (2013),http://dx.doi.org/10.1016/j.orcp.2013.11.007
confidence interval [CI] 0.921—0.957) and of physical activity ≥150 min/week (OR0.979, 95% CI 0.960—0.999).Conclusions: These findings imply that diet and less physical activity are associatedwith both gained and attained BMI, while inactivity (TV watching) and short sleep
with attained BMI. Unhealthy lifestyle may add risk to thatgitudinal and intervention studies are needed to infer causal
ssociation for the Study of Obesity. Published by Elsevier Ltd.
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Tfwtltdfviidiet. Participants ranged from 30—112 years old,and were composed of 26.9% blacks and 63.5% non-Hispanic whites with the remaining consisting of
Weight gain tends to be experienced in early tomiddle adulthood and is associated with severallifestyle practices including diet and lack of ade-quate physical activity. On the other hand smokingand high alcohol consumption may limit weightgain. Lifestyle habits may not only lead to weightgain, but may also be a consequence of weightgain. Sugary and fatty foods are highly palatableand provide little satiety [1]. A mirror image ofthis association is that the liking of sweets and fatincreases with increasing BMI [2]. Conversely, veg-etarian diets rich in legumes, vegetables and fruitsmay be protective against weight gain [3,4]. In onestudy, participants consuming a vegan diet had amean BMI that was ∼5 units lower than observedin non-vegetarians [5]. Whether people who gainweight favor non-vegetarian diets has not beenstudied, to our knowledge.
While lack of physical activity is an establisheddeterminant of obesity [6], the converse is alsotrue, that obesity hinders physical activity. Further-more, underlying genetic dispositions may lead toboth obesity and inactivity [7].
Sedentary behavior is defined as an immobilestate resulting in energy expenditure close to theresting metabolic rate [8], and is associated withobesity, independent of physical activity [9,10]. TVwatching is a major component of sedentarinessassociated with obesity. A doubling in risk of obesitywas seen among those who watch more than 8 h/day[11]. Again, the converse may be true, with obe-sity leading to more TV time, because of barriersto physical or social activities among the obese.
Sleep duration may play a role in the pathophy-siology of obesity. Short sleep duration may leadto obesity, and obesity impair sleep time [12]. Thisloss of sleep duration may be attributed to subjec-tive sleep disturbances, emotional stress, and sleepapnea [13,14].
Among men, being overweight or obese solic-its special attention since many men do not seean urgent concern with being overweight or obese.
Please cite this article in press as: Japas C, et al. Body
lifestyle characteristics of men at ages 40—60 years: The
http://dx.doi.org/10.1016/j.orcp.2013.11.007
Men tend to consider ‘bigness’ with being healthy orphysically attractive [15]. However, risks of obesityin men are considerable. Men tend to accumulate
otB
bdominal fat, the origin of metabolic syndrome,iabetes type 2, and cardiovascular disease [15].estosterone levels decrease from as early as 30ears of age and are correlated with fat-free massoss and increases in fat mass [16].
The aim of the current study was to estimatessociations of weight gain in men with majorifestyle habits including diet, sedentary behav-or, physical activity and sleep. While a numberf studies have looked at the individual or com-ined impact of lifestyle factors on body weighthange [17,18; reviewed in 19], few have consid-red the association of previous weight gain withurrent lifestyle including not only nutrition andctivity, but also sedentary habits and sleep andompared to the effect of lifestyle on currentMI. Thus, we analyzed the association of retro-pectively reported weight change between theges of 20 and 40 years with reported lifestyleharacteristics, among men between the ages of0 and 60 years in the Adventist Health Study-
(AHS-2). Seventh-day Adventist church membersre encouraged to consume vegetarian diets andost members avoid tobacco and alcohol. This pro-
ided a unique ‘‘healthy’’ population in which totudy the above associations.
ethods
his investigation was based on data collectedrom the Adventist Health Study-2 (AHS-2). AHS-2as an epidemiological research study of Adven-
ists from Canada and the US, designed to identifyifestyle factors, foods, and metabolic risk indica-ors associated with cancer [20] as well as identifyeterminants of health and diseases between dif-erent ethnic and socioeconomic groups [21]. Eacholunteer completed a 48-page questionnaire thatncluded a wide array of questions regarding med-cal history, demographics, and lifestyle including
mass index gain between ages 20 and 40 years andAdventist Health Study-2. Obes Res Clin Pract (2013),
ther ethnicities [21]. This study obtained commit-ee review and approval by the Institutional Reviewoard of Loma Linda University.
ARTICLEody mass index gain and lifestyle characteristics
ecruitment and subject selection
ubjects were recruited among church membersiving in the US and Canada who were 30 years orlder, and sufficiently fluent in English to completehe questionnaire. Churches were divided into tworoups, black (n = 1000) and non-black (n = 3500)ongregations and recruited church-by-church [21].n the pursuit to include more black participants,he recruitment process was intensified for blackhurches [21]. Between February 2002 and May007, a total of about 96 000 individuals turned inhe questionnaire. There were 15 506 men betweenhe ages of 40—60 years. Exclusions included 135ho did not indicate race/ethnicity, 273 who wereurrent smokers, 1504 for outlying weight or BMIalues (weight <50 kg, BMI <16 or >60 kg/m2), 152or missing sleep duration, 289 for missing phys-cal activity, and 1931 for missing TV watching.hose with missing compared to nonmissing vari-bles were more likely to be Black (37.5% vs 20.9%),ess likely to be married (79.8% vs 87.2%), and lessikely to be college graduates (38.5% vs 55.1%).e also excluded 1358 participants who reported
onditions associated with weight change (type 2iabetes mellitus and/or non-skin cancer). Thus ournal analytic population consisted of 9864 malesged 40—60 years.
uestionnaire
ubjects were queried about their weight changes follows: ‘‘What was your weight at each ofhe following ages (answer for each age beforeour present age)?’’ These ages included 20, 30,nd 40 years of age. Height was self-reportedt the time of questionnaire completion and thessumption made that height did not change duringhe previous decades. Validation of self-reportednthropometrics in this population was publishedreviously [22]. BMI was calculated for the presentge and when participants were ages of 20, 30, and0 years.
Yearly household income was grouped from theisted options in the questionnaire to <$31 000,31 000-$50 000, $51 000-$75 000, and ≥$76 000).arital status was grouped into married, which
ncluded ‘‘first marriage,’’ ‘‘remarried,’’ and‘common law marriage’’, never married,nd a third category including ‘‘separated,’’‘divorced,’’ and ‘‘widowed.’’ Educational levelas grouped as high school or less, some college,
Please cite this article in press as: Japas C, et al. Body
lifestyle characteristics of men at ages 40—60 years: The
http://dx.doi.org/10.1016/j.orcp.2013.11.007
nd college graduate or higher.Dietary data was obtained from the food fre-
uency questionnaire for foods consumed in theast year. The section listed 130 hard-coded food
elnu
PRESSxxx.e3
r food groups of which participants selected orrote-in those items not listed. Vegetarian sta-
us was categorized by defining vegans as thoseho reported consuming no animal products (redeat, poultry, fish, eggs, milk, and dairy products
1/month), lacto-ovo vegetarians as consumingairy products and/or eggs equal to or greater thanne time per month, but not fish or meat (redeat, poultry <1 time/month), semi-vegetarians
s consuming dairy products and/or eggs andeat (red meat and poultry >1 time/month and
1 time/week), and non-vegetarians as consumingnimal products (red meat, poultry, fish, eggs, milk,nd dairy products >1 time/week) [5]. Validationf the questionnaire was shown previously [23].egans and lacto-ovo vegetarians were groupedogether in the current study as the proportion ofegans was small.
The questionnaire queried typical physical activ-ty during the previous year, by asking ‘‘how manyimes per week do you usually engage in regularigorous activities, such as brisk walking, jogging,icycling, etc., long enough or with enough inten-ity to work up a sweat, get your heart thumping oret out of breath?’’ Duration was based on the ques-ion stating ‘‘on average, how many minutes do youxercise each session?’’ A cutoff of ≥150 min/weekas chosen for this activity based on the rec-mmendation of 30 min daily. The questions werealidated previously in this population [24].
Sleep duration was based on a question of ‘‘Howany hours do you usually sleep each night?’’ Six
ours or more was chosen as a cut-off. Sedentari-ess was queried according to how many hours a dayere spent on watching TV listed as; none, <1, 1,, 3—4, and ≥5 h with <2 h/day chosen as a cut-off.
ata analysis
escriptive and univariate analyses (Chi-square andtudent t-tests) were applied to compare the socio-emographic characteristics and current lifestyleractices between men whose BMI changed equalo or above the median (2.79 kg/m2) versus belowhe median between ages 20 and 40 years.
Univariate and multivariate logistic regressionsstimated the association of BMI change withach of the lifestyle variables (diet, TV watching,hysical activity and sleep). In the multivariatenalysis we controlled for socio-demographic char-
mass index gain between ages 20 and 40 years andAdventist Health Study-2. Obes Res Clin Pract (2013),
thnicity and income), current BMI and otherifestyle practices. Alpha was set at a p = 0.05 sig-ificance level. Statistical analyses were performedsing SAS (Version 9.3: SAS Institute Inc.).
BMI change ranged from −14.09 kg/m2 to31.53 kg/m2. Descriptive characteristics accordingto change ≥the median (2.79 kg/m2) or <themedian are shown in Table 1. Men with a BMIchange ≥ the median were less likely to have com-pleted some or more college, and more likely tobe Black, non-vegetarian, watch ≥2 h of TV daily,engage in <150 min/week of physical activity, andto sleep 6 h or less/night than their counterparts.Marital status and income were not associatedwith BMI change. A small minority reported anyalcohol consumption (7.7%). This proportion did notdiffer according to BMI change (data not shown).Less than 2% of participants currently smokedcigarettes.
In univariate logistic regression analyses,
Please cite this article in press as: Japas C, et al. Body
lifestyle characteristics of men at ages 40—60 years: The
http://dx.doi.org/10.1016/j.orcp.2013.11.007
median or higher change in BMI was associatedwith lower odds of a vegetarian diet (OR = 0.861,95% CI = 0.848—0.874, p-value <0.0001), aswell as TV watching <2 h/day (OR = 0.912, 95%
cwt
Table 1 Descriptive characteristics according to BMI changbetween ages 20 and 40 years in men aged 40—60 years (n =
Variable Median or above n =
Age, years (SD) 49.45 (5.80)
Marital status (%)
Never married 221 (4.5)
Married 4248 (86.9)
Separated/divorced/widowed 421 (8.6)
Education (%)
High school or less 710 (14.5)
Some college 1621 (33.1)
College graduate or more 2572 (52.4)
Ethnicity (%) <0.001Other 3687 (74.7)
Black 1252 (25.3)
Personal income (%)
<$31 000 1418 (28.7)
$31 000—50 000 1462 (29.6)
$51 000—75 000 1011 (20.5)
≥$76 000 1048 (21.2)
Diet (%)
Vegan/lacto-ovo vegetarian 1431 (32.6)
Non-vegetarian 2954 (67.4)
TV watching (%)
<2 h/day 2763 (55.9)
≥2 h/day 2176 (44.1)
Physical activity (%)
<150 min/week 3861 (78.2)
≥150 min/week 1078 (21.8)
Sleep per night (%)
6 h or less 1894 (38.3)
More than 6 h 3045 (61.7)
Age was compared using an independent t-test, while the other var
PRESSC. Japas et al.
I = 0.900—0.924, p-value <0.0001), physical activ-ty of 150 min or more per week (OR = 0.967, 95%I = 0.953—0.983, p-value <0.0001) and sleep timef more than 6 h (OR = 0.942, 95% CI = 0.930—0.954,-value <0.0001).
Results of the multivariate logistic regressionnalyses are shown in Tables 2—5. Current BMIas associated with less healthy lifestyle factors
ncluding nonvegetarian diet (Table 2), more TVatching (Table 3), less physical activity (Table 4)nd shorter sleep duration (Table 5). Median origher change in BMI was associated with lowerdds of consuming a vegetarian diet (Table 2).dds of vegetarian diet consumption increasedith age, education, less TV watching and more
leep, but decreased with Black ethnicity, beingeparated/divorced/widowed, higher income andurrent BMI.
mass index gain between ages 20 and 40 years andAdventist Health Study-2. Obes Res Clin Pract (2013),
Median or higher change in BMI was not asso-iated with TV watching (Table 3). Odds ofatching <2 h/day of TV increased with consump-
ion of vegetarian diet and higher education and
e median or above (≥2.79 kg/m2) vs below the median 9864).
Marital status (reference: married)Never married 0.691
Separated/divorced/widowed 1.012
Education (reference: college graduate or more education)Some college 0.730
High school or less 0.668
Ethnicity — black vs other 0.568
Diet — vegan/lacto-ovo vegetarian vs other 1.830
Personal income (reference: <$31 000/year)$31 000—50 000 1.128
$51 000—75 000 1.228
≥$76 000 1.527
Sleeping>6 h/night vs less 1.048
Physical activity≥150 min/week vs less 1.048
Current BMI 0.929
All variables are controlled for the other variables in the table.
0.911 0.937 <0.0001
ctivity weekly, as were being married and cur-
mass index gain between ages 20 and 40 years andAdventist Health Study-2. Obes Res Clin Pract (2013),
ent BMI (Table 4). Odds of engaging in ≥150 minf physical activity weekly were greater with Blackthnicity, higher education and income of $76 000early.
dds ratios of TV watching <2 h/day versus ≥2 h/day in
TV watching<2 h/day vs more 1.052 0.951 1.163 0.324Diet — vegan/lacto-ovo vegetarian vs other 1.265 1.142 1.401 <0.0001Physical activity
≥150 min/week vs less 1.049 0.937 1.175 0.4064
.
D
Current BMI 0.96
All variables are controlled for the other variables in the table
Finally, median or higher change in BMI was notassociated with amount of sleep (Table 5). Odds
Please cite this article in press as: Japas C, et al. Body
lifestyle characteristics of men at ages 40—60 years: The
http://dx.doi.org/10.1016/j.orcp.2013.11.007
of sleeping 6 h or more/night increased with con-sumption of a vegetarian diet, but decreased withincreased education, Black ethnicity and currentBMI.
Ts2o
0.952 0.977 <0.0001
iscussion
mass index gain between ages 20 and 40 years andAdventist Health Study-2. Obes Res Clin Pract (2013),
he main findings of this study were that retro-pectively reported gain in BMI among men ages0—40 years was associated with greater likelihoodf consuming a non-vegetarian diet and physical
ARTICLEody mass index gain and lifestyle characteristics
ctivity of <150 min weekly. This suggests that menho gain more weight are likely to be engaged in
ifestyle behaviors that are likely to promote fur-her increase in BMI. These findings are concerningn light of evidence indicating that obesity leadso increased vulnerability to risk factors that causebesity [25]. Diet and activity were also associatedith attained BMI. On the other hand, TV watch-
ng and sleep duration were only associated withttained BMI and not BMI gain in multivariate anal-ses controlling for all other factors.
This study addressed weight gain between ages0 and 40, a time of life that is susceptible tohanges in lifestyle leading to weight gain. Someuthors have suggested that gaining weight dur-ng adult years is inevitable, even in individualsho actively engage in physical activity [26]. Menain an average of 2.4% of body weight every-year period [27], which adds 7—8 kg over 20ears, a substantial gain when considering risksf disease related to obesity. Men in the currenttudy gained nearly 5 kg over 20 years. Contribu-ors to weight gain with aging include reduction inesting metabolic rate [28], sarcopenia [29], andeductions in total energy expenditure and phys-cal activity levels [30]. While weight gain withging may be not entirely avoidable, men whoained lesser weight were more likely to reporthat they ate a plant based diet and engaged inhysical activity. These associations were small, butdjusted for current BMI and sociodemographic andifestyle characteristics, adjustments that weak-ned associations compared to the univariatenalyses.
Participants in the current study were aboutvenly divided between vegan/lacto-ovo vegetar-ans and non-vegetarians. Plant based diets areecommended by the Adventist church. Otherhurch tenets include avoiding trivial entertain-ent and adequate rest. In line with this,
onsumption of vegetarian diets was associatedith less TV watching and more sleep, though notith physical activity. A number of studies have
ound that weight gain is attenuated in people fol-owing vegetarian diets, mostly due to lower energyntakes, higher fiber content, and lower intake ofnimal fats [4,31]. This study found that both BMIain and current BMI were less likely to be asso-iated with a vegetarian diet and suggested thatncreases in BMI are associated with diets that mayurther increase BMI.
Obesity may restrict activities of daily living
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lifestyle characteristics of men at ages 40—60 years: The
http://dx.doi.org/10.1016/j.orcp.2013.11.007
nd produces cardiovascular and respiratory stressesponses that may further promote sedentaryehavior [32,33]. In this study current BMI was inde-endently associated with more TV watching while
s
ofi
PRESSxxx.e7
MI gain was not associated with TV watching in theultivariate analysis — only in the univariate analy-
is. Adjustment for other lifestyle factors includingiet, sleep time and physical activity may over-ontrol for the association between BMI gain andther factors, however, our purpose was to iden-ify lifestyle factors independently associated withMI gain. Lifestyle factors tend to be interrelateds they were in this study (data not shown). Forxample, the association between TV watching andbesity is partially explained by food and beveragesonsumed during TV watching [34].
Both change in BMI and current BMI weressociated with less physical activity though thessociation with change in BMI was small. Maintain-ng high amounts of physical activity is a predictorf smaller increases in BMI with age [26]. Our studyesults are in line with longitudinal studies show-ng that obesity predicts lower amounts of activityndependently of other lifestyle factors [10,35].he lower activity level associated with increasedMI may stem from mechanical, psychosocial andther barriers to activity. We measured only vig-rous activity in the current study. More moderatemounts of activity may be maintained or increasedn obesity [36].
In this study BMI gain was not related to sleepuration, though current BMI was associated withewer hours of sleep. Obesity increases risk of sleeppnea and other sleep disorders. Conversely, a num-er of studies have shown inadequate sleep to be aisk factor for obesity [12,37,38], however, causa-ion has not been determined. We chose a cut-offf <6 h/night, shown earlier to be associated withbesity [39].
We found BMI gain to be associated with Blackthnicity, in line with previous studies [40,41].lack ethnicity was associated with other obe-ogenic factors including non-vegetarian diet, TVatching and less sleep, though notably, higher
evels of physical activity were reported by Blackhurch members. BMI gain was not associated witharital status in the current study, though mar-
ied men watched more TV and were less physicallyctive than their single counterparts. In previoustudies [42,43], it was found that married menxperienced a greater increase in BMI than singler divorced men. Putative explanations includedore regular meals and larger, less time for leisure
ctivities, and less interest in maintaining a fig-re that would attract a mate. We have no readyxplanation for the divergent finding in the current
mass index gain between ages 20 and 40 years andAdventist Health Study-2. Obes Res Clin Pract (2013),
tudy.Education and income are primary determinants
f lifestyle and weight gain — and this was con-rmed in the present study. A highly cited study
[44] showed that higher education may lead tobetter health decision-making, a higher sense ofpersonal control over health, and less socioeco-nomic stresses permitting better lifestyles. Mostof our findings indicated healthier lifestyles amongthose with higher education and income, with anotable exception. While education increased theodds of a vegetarian diet, higher income decreasedthose odds.
Limitations
The data was cross sectional and causality cannotbe inferred. We did not assess lifestyle habits atage 20, at the onset of the study’s timeline, thuswe cannot address changes in lifestyle, or whetherthe lifestyle habits were present at baseline. Bloodtests were not available to examine metabolic vari-ables or chronic viral infection that could affectbody weight nor was use of laxatives or diureticsrecorded.
Recall bias may distort the results. It remainspossible that men with greater weight gain reportedhealthier lifestyles than the actual ones, however,this seems unlikely given our results. Anthropomet-rics and lifestyle variables were self-reported. Wedid not study nonlinear associations. While moststudies show that less than 6 h of sleep is not theideal for optimal health, some studies have foundthat a U-shaped correlation between sleep and BMIindicated risks associated with too many hours ofsleep [12].
The study was conducted among church adher-ents, and the church promotes a vegetarian diet,rest and avoidance of entertainment. Respondentsmay have reported healthier lifestyles than theactual ones. Respondents with missing data tendedto have lower education and were more likely to beBlack, thus, the sample was not representative ofthe entire population. An advantage of this popu-lation is the absence of smoking and heavy alcoholdrinking, both factors that may confound the asso-ciations observed. We chose as the comparatorgroup to those with high BMI gain, those who hada BMI gain below the median. This group couldbe heterogenous including men with stable weight,lesser BMI gain and BMI loss; cut-offs for thesegroups are not readily apparent nor were causesof changes in BMI (intentional vs nonintentional)delineated in the questionnaire. The sample was
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lifestyle characteristics of men at ages 40—60 years: The
http://dx.doi.org/10.1016/j.orcp.2013.11.007
relatively young, and chronic disease that affectsbody weight including cancer and diabetes wasexcluded, though not thyroid disease, as weightloss is limited following thyroid treatment forhypothyroidism [44].
[
PRESSC. Japas et al.
onclusion
n conclusion, BMI gain between the ages of 20—40ears in men was associated with less healthful cur-ent lifestyle practices including diet and physicalctivity. These practices are likely to result in fur-her BMI increases.
onflict of interest
here are no conflicts of interest, financial or oth-rwise.
cknowledgments
he data for this study received funding from theational Cancer Institutefrom 2001 to 2008, grantumber R01 CA094594.
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