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Cited by 477Cardiovascular Health and Risk FactorsNutritional Studies and DietHealth Promotion and Cardiovascular Prevention

Healthy Lifestyle Factors in the Primary Prevention of Coronary Heart Disease Among Men: Benefits Among Users and Nonusers of Lipid-Lowering and Antihypertensive Medications

Open access
Chiuve, Stephanie E., McCullough, Marjorie L., Sacks, Frank M., Rimm, Eric B.·2006·Circulation
DOI 10.1161/circulationaha.106.621417
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Abstract

Background— Healthy lifestyle choices such as eating a prudent diet, exercising regularly, managing weight, and not smoking may substantially reduce coronary heart disease (CHD) risk by improving lipids, blood pressure, and other risk factors. The burden of CHD that could be avoided through adherence to these modifiable lifestyle factors has not been assessed among middle-aged and older US men, specifically men taking medications for hypertension or hypercholesterolemia. Methods and Results— We prospectively monitored 42 847 men in the Health Professionals Follow-up Study, 40 to 75 years of age and free of disease in 1986. Lifestyle factors were updated through self-reported questionnaires. Low risk was defined as (1) absence of smoking, (2) body mass index <25 kg/m 2 , (3) moderate-to-vigorous activity ≥30 min/d, (4) moderate alcohol consumption (5 to 30 g/d), and (5) the top 40% of the distribution for a healthy diet score. Over 16 years, we documented 2183 incident cases of CHD (nonfatal myocardial infarction and fatal CHD). In multivariate-adjusted Cox proportional hazards models, men who were at low risk for 5 lifestyle factors had a lower risk of CHD (relative risk: 0.13; 95% confidence interval [CI]: 0.09, 0.19) compared with men who were at low risk for no lifestyle factors. Sixty-two percent (95% CI: 49%, 74%) of coronary events in this cohort may have been prevented with better adherence to these 5 healthy lifestyle practices. Among men taking medication for hypertension or hypercholesterolemia, 57% (95% CI: 32%, 79%) of all coronary events may have been prevented with a low-risk lifestyle. Compared with men who did not make lifestyle changes during follow-up, those who adopted ≥2 additional low-risk lifestyle factors had a 27% (95% CI: 7%, 43%) lower risk of CHD. Conclusions— A majority of CHD events among US men may be preventable through adherence to healthy lifestyle practices, even among those taking medications for hypertension or hypercholesterolemia.

AI snapshot

Written from the paper’s full text.

TL;DR

In 42,847 US male health professionals followed for 16 years, adherence to five low-risk lifestyle factors was associated with substantially lower coronary heart disease (CHD) risk, and 62% of coronary events may have been preventable. The inverse association persisted among men taking antihypertensive or lipid-lowering medications, with a population-attributable risk of 57%.

Key findings

  • Over 16 years, 2,183 incident CHD cases occurred. Men at low risk for all 5 lifestyle factors had an RR of 0.13 (95% CI: 0.09, 0.19) compared with men at low risk for none; the population-attributable risk was 62% (95% CI: 49%, 74%).
  • Among users of lipid-lowering or antihypertensive medications, the population-attributable risk for all 5 low-risk factors was 57% (95% CI: 32%, 79%); among nonusers it was 66% (95% CI: 49%, 79%). By age, population-attributable risk was 79% (95% CI: 61%, 90%) for men <65 years and 47% (95% CI: 27%, 68%) for men ≥65 years.
  • Men who adopted ≥2 additional low-risk lifestyle factors during follow-up had an RR of 0.73 (95% CI: 0.57, 0.93) compared with men who did not change; men who reduced their score by ≥2 factors had an RR of 1.48 (95% CI: 1.15, 1.88).
  • In multivariate models including all lifestyle factors, low-risk categories were independently associated with lower CHD risk: not currently smoking RR 0.47 (95% CI: 0.42, 0.54), BMI <25 kg/m² RR 0.70 (95% CI: 0.64, 0.77), exercise ≥3.5 h/wk RR 0.83 (95% CI: 0.74, 0.92), diet score top 40% RR 0.84 (95% CI: 0.77, 0.92), and alcohol 5–30 g/d RR 0.79 (95% CI: 0.73, 0.87).

Methods

  • Prospective cohort study of 42,847 men in the Health Professionals Follow-up Study, aged 40–75 years and free of disease in 1986, followed through January 31, 2002. Lifestyle factors were updated through biennial questionnaires, with diet assessed every 4 years by a 131-item food frequency questionnaire.
  • Low risk was defined as not currently smoking, BMI <25 kg/m², moderate-to-vigorous activity ≥30 min/d, moderate alcohol intake (5–30 g/d), and a diet score in the top 40% of the cohort’s Alternate Healthy Eating Index distribution. A healthy lifestyle score summed the number of low-risk factors (0–5).
  • Cox proportional hazards models estimated relative risks, adjusted for age, calendar year, parental history of MI, history of hypertension, history of hypercholesterolemia, aspirin use, and antihypertensive medication use. Population-attributable risks were calculated, and change in lifestyle was analyzed among 33,759 men who completed baseline and at least one follow-up questionnaire.

Limitations

  • The paper states it was observational, not a clinical trial; self-reported measurement error is inevitable and likely nondifferential, which would attenuate true relative risks. It also notes that only 4% of men adopted all healthy practices, that the healthiest men could not increase their score by 2 factors, and that the cohort was healthier than the general US male population.
  • Evident from the text and tables: the medication subgroup analyses had few cases, especially for lipid-lowering medication users at low risk for all 5 factors (3 cases; RR 0.31, 95% CI: 0.07, 1.30), making those estimates imprecise.
  • Evident from the text: the cohort consisted of highly educated male health professionals, so findings may not generalize to other populations.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1161/circulationaha.106.621417

Cites

49 of 49 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 30 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    For each lifestyle factor, there was an inverse association with risk of CHD that remained significant when all 5 lifestyle factors were included in the same model.

    “For each lifestyle factor, we observed an inverse association with risk of CHD, which remained significant when all 5 lifestyle factors were included in the same model (Table 1).”
    Quote in the paperSubstantial claim
  • Findingown data

    Men at low risk for 5 lifestyle factors had a lower risk of CHD (RR 0.13; 95% CI 0.09, 0.19) compared with men at low risk for no lifestyle factors.

    “In multivariate-adjusted Cox proportional hazards models, men who were at low risk for 5 lifestyle factors had a lower risk of CHD (relative risk: 0.13; 95% confidence interval [CI]: 0.09, 0.19) compared with men who were at low risk for no lifestyle factors.”
    Quote in the paperSubstantial claim
  • Findingown data

    Among medication users and nonusers, the healthy lifestyle score was significantly inversely associated with risk of CHD.

    “Among these medication users (and also among nonusers), the healthy lifestyle score was significantly inversely associated with risk of CHD (Figure 2).”
    Quote in the paperSubstantial claim
  • Findingown data

    Being at low risk for each lifestyle factor was significantly and independently associated with lower risk of CHD.

    “When categorized as a dichotomous variable, being at low risk for each lifestyle factor was still significantly and independently associated with lower risk.”
    Quote in the paperSubstantial claim
  • Findingown data

    Overall, the healthy lifestyle score was significantly inversely associated with risk of CHD (P for trend <0.0001).

    “Overall, the healthy lifestyle score was significantly inversely associated with risk of CHD (P for trend, Ͻ0.0001) (Figure 1).”
    Quote in the paperSubstantial claim
  • The quote only partly states this claim. 3
  • Classified as probably not a substantial claim. 11
  • May combine two claims. 7

  • The quote only partly states this claim.

    Findingown data

    Over 16 years, 2183 incident cases of CHD (nonfatal myocardial infarction and fatal CHD) were documented among 42,847 men in the Health Professionals Follow-up Study.

    “Over 16 years, we documented 2183 incident cases of CHD (nonfatal myocardial infarction and fatal CHD).”
    • Also stated in: § Results · plain
      “After 16 years of follow-up, we documented 2183 incident coronary events.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The average HEI score of 68.3 within this cohort is slightly higher than the mean HEI score of 65.2 among US men 51 years or older.

    “The average HEI score of 68.3, within this cohort, 45 is slightly higher than the mean HEI score of 65.2 among US men 51 years or older.46”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [45] source

      Not checked in the free run.

    • cites [46]

      Not checked in the free run.

  • The quote only partly states this claim.

    Findingown data

    Relative risk of CHD decreased with increasing healthy lifestyle score (P for trend <0.0001).

    “P for trend, Ͻ0.0001.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    Relative risk of CHD decreased with increasing healthy lifestyle score among both users and nonusers of antihypertensive and lipid-lowering medication (P for trend <0.0001 for both).

    “P for trend, Ͻ0.0001 for both users and nonusers of medication.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Relative risks and 95% CIs were estimated by using Cox proportional hazards models adjusted for age, calendar year, parental history of MI, history of hypertension, history of hypercholesterolemia, aspirin use, and antihypertensive medication use.

    “Relative risks (RRs) and 95% confidence intervals (CIs) were estimated by using Cox proportional hazards models adjusted for age, calendar year, parental history of MI, history of hypertension, history of hypercholesterolemia, aspirin use, and antihypertensive medication use.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Little is known about the relation between combined healthy lifestyle choices and incident CHD among middle-aged and older men, especially those who are reducing their risk by using drugs for hypertension or hypercholesterolemia.

    “Little is known about the relation between combined healthy lifestyle choices and incident CHD among middle-aged and older men, especially those who are reducing their risk by using drugs for hypertension or hypercholesterolemia.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Pharmacological therapies, including lipid-lowering and antihypertensive medications, are efficacious in lowering some of these risk factors, typically reducing cardiovascular disease risk by 20% to 30%.

    “Pharmacological therapies, including lipidlowering and antihypertensive medications, are efficacious in lowering some of these risk factors, 2,3 typically reducing cardiovascular disease risk by 20% to 30%.2,4”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [2] source

      Not checked in the free run.

    • cites [3] source

      Not checked in the free run.

    • cites [4] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    We stopped updating dietary information after new diagnoses of diabetes, angina, hypertension, hypercholesterolemia, or revascularization surgery because these diagnoses may lead to changes in diet.

    “Because diagnosis of diabetes, angina, hypertension, hypercholesterolemia, or revascularization surgery may lead to changes in diet, we stopped updating dietary information after new diagnoses of these outcomes during follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Healthy diet and other lifestyle practices, including not smoking, maintaining a healthy weight, and exercising daily, improve clinical risk factors and reduce inflammation, homocysteine, glucose intolerance, and arrhythmias.

    “Healthy diet and other lifestyle practices, including not smoking, maintaining a healthy weight, and exercising daily, also improve these clinical risk factors as well as reduce inflammation, homocysteine, glucose intolerance, and arrhythmias.[5][6][7][8][9][10][11]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5][6][7][8][9][10][11]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A healthy lifestyle has been associated with lower risk of incident coronary events among middle-aged women and lower risk of CHD mortality in a population of elderly men and women.

    “A healthy lifestyle has been associated with lower risk of incident coronary events among middle-aged women 13 and lower risk of CHD mortality in a population of elderly men and women.14”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [13] source

      Not checked in the free run.

    • cites [14] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    We used the cumulative average of the AHEI-based diet score from repeated dietary assessments to represent long-term dietary information and minimize within-person variation.

    “We used the cumulative average of the AHEI-based diet score from repeated dietary assessments to represent long-term dietary information and minimize within-person variation.29”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [29] source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    We used both confirmed and probable CHD cases because results were similar when probable cases (17% of cases) were excluded.

    “We used both confirmed and probable cases, as results were similar when we excluded probable cases (17% of cases).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Higher amounts of alcohol intake are associated with lower risk of CHD.

    “This is consistent with guidelines for moderate alcohol consumption, 26 although higher amounts of alcohol intake are associated with lower risk of CHD.27”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The activity questionnaire used to assess physical activity was previously validated within a subset of this cohort.

    “Participants reported the average time engaged in specific activities biennially, using an activity questionnaire previously validated within a subset of this cohort.17”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The observational design and repeated measures of diet and lifestyle allowed us to assess the consequences of changes in multiple lifestyle factors, which generally occur in free-living populations.

    “The observational design and repeated measures of diet and lifestyle allowed us to assess the consequences of changes in multiple lifestyle factors, which generally occur in free-living populations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    For missing lifestyle factor information, we carried forward information from the previous questionnaire when available, and placed men with residual missing values in the high-risk category to give the most conservative estimate.

    “For individuals missing information on any lifestyle factor, we carried forward information from the previous questionnaire, when available.Men with residual missing values were placed in the high-risk category, to give the most conservative estimate.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Study design and conductreasoning

    In our analysis, we estimated the impact of multiple lifestyle factors simultaneously, which would be difficult if not impossible to study in a trial with 16 years of follow-up.

    “In our analysis, we estimated the impact of multiple lifestyle factors simultaneously, which would be difficult if not impossible to study in a trial with 16 years of follow-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    Because of the prospective design of the study, misclassification should be nondifferential with respect to disease status and would attenuate the true relative risk.

    “Because of the prospective design of the study, this misclassification should be nondifferential with respect to disease status and would attenuate the true relative risk.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Measurement error in self-reported variables is inevitable.
18 of 18

  • The authors state this as an assumption.

    A causal relation exists between low-risk lifestyle practices and risk of CHD.

    “assuming a causal relation between the low-risk lifestyle practices and risk of CHD.”

  • The paper relies on this without support.

    A combination of healthy lifestyle choices has a greater impact than any single lifestyle factor.

    “but a combination of healthy lifestyle choices has a greater impact than any single lifestyle factor.”

  • The paper relies on this without support.

    Coronary disease remains elevated among users of antihypertensive and lipid-lowering medications.

    “but coronary disease remains elevated in this population.”

  • The paper relies on this without support.

    Measurement error in self-reported variables is inevitable.

    “measurement error in selfreported variables is inevitable.”

  • The paper relies on this without support.

    The observed associations between low-risk lifestyle factors and CHD are causal.

    “A randomized clinical trial is ideal to establish causality of these lifestyle factors on risk of CHD.”
    “We still conclude that a majority of cases of CHD among this low-risk population of men may have been prevented through a healthy lifestyle.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Among populations with traditional healthy lifestyle behaviors, the prevalences of obesity, dyslipidemia, hypertension, and diabetes mellitus are far less than in industrialized populations, even after adjustment for age.

    “Among populations with traditional healthy lifestyle behaviors, the prevalences of obesity, dyslipidemia, hypertension, and diabetes mellitus are far less than in industrialized populations, even after adjustment for age.49 -52”

    From Beyond Established and Novel Risk Factors: Lifestyle Risk Factors for Cardiovascular Disease (2008) · cites this paper as [49]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • The older age subgroup has conflicting boundaries

    Minor

    The table labels the older subgroup as over 65, while the Results describe it as 65 or older. These definitions differ for men aged exactly 65.

1 of 1

Cites

Flagged first, then by citations

1 of the 50 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. 10.1161/atvb.16.12.1509 · DOI
  2. US Department of Agriculture US Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans Fifth Edition. Washington DC: US Government Printing Office; 2000.
  3. 10.1161/circ.99.6.779 · DOI

Cited by

Sorted by citations

Related

Authors
Chiuve, S. E., McCullough, M. L., Sacks, F. M., & Rimm, E. B.
Affiliations
Brigham and Women's Hospital (US)
ORCID
Venue
Circulation
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2006-07-11
Volume
114
Issue
2
Pages
160-167
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
DOI
10.1161/circulationaha.106.621417
OpenAlex
W2000745019
Semantic Scholar
b513e2a44d4288b1919efb6b7438116f4d21ab0a
Cited by
477
References
50
Citations by year
2026: 7 · 2025: 13 · 2024: 12 · 2023: 59 · 2022: 30 · 2021: 17 · 2020: 23 · 2019: 16 · 2018: 29 · 2017: 19 · 2016: 23 · 2015: 13 · 2014: 27 · 2013: 20 · 2012: 35
FWCI
18.26
Type
journal article
Language
en
Open access
Locations
  • Circulation (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Heart, Lung, and Blood Institute (HL07575, R01HL035464, HL35464, T32HL007575)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
Keywords
coronary artery disease, primary prevention, healthy lifestyle, men, middle-aged and older adults, antihypertensive drugs, smoking, physical activity, alcohol consumption, body mass index, diet, myocardial infarction, modifiable risk factors, Health Professionals Follow-up Study
MeSH terms
Antihypertensive Agents, Hypolipidemic Agents, Coronary Disease, Drug Therapy, Combination, Health Personnel, Humans, Life Style, Male, Myocardial Infarction, Risk, United States, Incidence

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