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Beyond Established and Novel Risk Factors: Lifestyle Risk Factors for Cardiovascular Disease
Abstract
D yslipidemia, hypertension, and diabetes mellitus have been appropriately highlighted as established predictors of cardiovascular disease.These risk factors have become preeminent targets for influencing cardiovascular risk; their assessment, treatment, and monitoring are major emphases of clinical care, research investigation, treatment guidelines, organization position papers, and measures of physician and hospital performance.Notably, lifestyle risk factors, including dietary habits, physical inactivity, smoking, and adiposity, strongly influence the established cardiovascular risk factors and also affect novel pathways of risk such as inflammation/oxidative stress, endothelial function, thrombosis/coagulation, and arrhythmia.Furthermore, modest alterations of these lifestyle risk factors are achievable and have substantial effects on cardiovascular risk.Thus, basic lifestyle habits should be considered fundamental risk factors for cardiovascular disease.Although efforts to combat established and novel risk factors with pharmacological treatments are important and should continue, we call for a systematic rebalancing of current research, clinical care, and policy efforts to focus more on lifestyle.The rising costs of healthcare and the epidemics of overweight and obesity highlight the inadequacies of our current strategy.Substantially more resources should be directed toward research on lifestyle risk factors, their determinants, and effective interventions to change them.The clinical evaluation and treatment of dietary, physical activity, and smoking habits must become as routine and familiar as assessment of blood pressure, cholesterol, and glucose levels.Major policy initiatives and reimbursement guidelines must also be rebalanced to emphasize lifestyle risk factors.
Overview
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TL;DR
This review argues that lifestyle risk factors—diet, physical inactivity, smoking, and adiposity—are fundamental causes of cardiovascular disease and should be prioritized alongside established and novel risk factors. It calls for rebalancing research, clinical care, and policy toward lifestyle assessment and intervention.
Key findings
- Lifestyle factors account for most cardiovascular and diabetes burden: >70% of total cardiovascular events, 80% of CHD events, and 90% of new diabetes cases are attributable to a handful of basic lifestyle factors.
- Modest lifestyle changes have large effects: smoking cessation reduces total mortality by approximately one third; physical activity/fitness is associated with 30% to 50% lower cardiovascular event risk; oily fish (1–2 servings/week) reduces CHD death by 36% and total mortality by 17%; a Mediterranean-type diet reduced myocardial infarction or cardiac death by 72% over 4 years; lifestyle intervention reduced diabetes incidence by 58% versus placebo and 39% versus metformin.
- Population behavior can change: US per capita tobacco use fell nearly two thirds since the 1950s; from 1977 to 2000, average fat consumption declined from 36.4% to 32.8% of calories and carbohydrate increased from 44.3% to 50.3%, while total calories rose from 2000 to 2250 kcal/d.
- Adherence is imperfect for both lifestyle and drugs: in the Women’s Health Initiative, 40% stopped the study drug at an average 5.2 years and 54% at 6.8 years; in the Diabetes Prevention Project, 58% maintained the physical activity goal, 38% achieved the weight loss goal, and 67% were ≥80% adherent to drug therapy; lipid-lowering or antihypertensive adherence typically ranges from 65% to 85% in trials to <50% in practice.
Methods
- Design: narrative review/commentary, not original research; it synthesizes evidence from epidemiological studies and randomized controlled trials.
- Data or sample: no primary sample; it cites prior studies and trials (e.g., Framingham, DPP, WHI, Lyon Diet Heart Study, Look AHEAD) and MEDLINE publication counts as of December 2007.
- Main analysis: narrative synthesis and argument for rebalancing research, clinical care, and policy toward lifestyle risk factors.
Limitations
- The paper states that direct evidence comparing adherence to modest lifestyle changes versus lifelong drug use is scant; additional research is needed on optimal behavior-change strategies; and the quality of evidence for some cardiovascular drugs exceeds that for some lifestyle changes because of discrepancies in the sizes and numbers of large randomized trials.
- Evident from the text: as a narrative review, it lacks a systematic search, formal meta-analysis, risk-of-bias assessment, or primary data, and its evidence selection and emphasis reflect the authors’ perspective.
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In the paper
“Lifestyle behaviors can strongly affect the slopes of these changes, attenuating or even reversing the increases seen over time.55,56”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
What the sources say
- Not checked yetcites [55]
- Not checked yetcites [56] source
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In the paper
“large disparities in both the prevalence of established risk factors and the rates of cardiovascular events in genetically similar populations both over time and across regions confirm that genetic effects are subordinate to lifestyle and environmental influences.50 -52,57-59”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
What the sources say
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In the paper
“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”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
What the sources say
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In the paper
“a major advance in medicine has been confirmation in pharmaceutical trials that blood pressure and blood lipids are in the casual pathway for cardiovascular events”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > From Prediction to Treatment
What the sources say
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In the paper
“Nevertheless, measurement and treatment of blood lipids, blood pressure, and glucose levels have became the major emphases for cardiovascular risk reduction.”
- Also stated in: § From Prediction to Treatment · plain
“Assessment and pharmacological treatment of elevated blood pressure, cholesterol, and glucose levels have become standards of cardiovascular care and the major emphases of practice guidelines, organization position papers, healthcare quality indicators, and reimbursement standards.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > From Prediction to Treatment
What the sources say
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § From Prediction to Treatment · plain
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In the paper
“suggesting that elevated glucose may at least partly signify more proximal pathology (eg, adipocyte stress and dysfunction) that increases macrovascular risk.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > From Prediction to Treatment
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These basic lifestyle habits-poor diet, physical inactivity, and smoking-are thus the most proximal risk factors for cardiovascular disease.”
- Also stated in: § Abstract · plain
“Thus, basic lifestyle habits should be considered fundamental risk factors for cardiovascular disease.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Sources of Funding
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Abstract · plain
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Furthermore, modest alterations of these lifestyle risk factors are achievable and have substantial effects on cardiovascular risk.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Abstract
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In the paper
“although diabetes mellitus and elevated glucose levels clearly predict CHD risk, lowering of glucose by drug treatment generally has not produced anticipated reductions in CHD events, 11,12,12a”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > From Prediction to Treatment
What the sources say
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In the paper
“Consistent with these pleiotropic benefits, physical activity and fitness are associated with 30% to 50% lower risk of cardiovascular events.38,40,67”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Cardiovascular Risk
What the sources say
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- It may state two separate claims as one. 15
- Probably not a substantial claim. 3
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In the paper
“Evaluated systematically, Ͼ70% of total cardiovascular events, 80% of CHD events, and 90% of new cases of diabetes mellitus appear to be attributable to just a handful of basic lifestyle factors.60,61”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
Strength:hedged· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
In the paper
“Conversely, prevalence of diabetes mellitus has risen steadily, largely because of an epidemic of adiposity 35”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
What the sources say
- Not checked yetcites [35] source
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In the paper
“Prediction models make no assumptions (and allow no inferences) about the presence or extent of confounding, magnitude of causal effects, or hierarchy of variables along causal pathways.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > From Prediction to Treatment
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In the paper
“In the United States, the prevalence of high cholesterol, hypertension, and smoking, together with age-adjusted cardiovascular deaths, has declined over several decades.35,36”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
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None of the sources cited for this claim have been checked yet.
In the paper
“Notably, lifestyle risk factors, including dietary habits, physical inactivity, smoking, and adiposity, strongly influence the established cardiovascular risk factors and also affect novel pathways of risk such as inflammation/oxidative stress, endothelial function, thrombosis/coagulation, and arrhythmia.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Abstract
What the sources say
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Furthermore, modest alterations of these lifestyle risk factors are achievable and have substantial effects on cardiovascular risk.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Abstract
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✗ Based: failsProbably not a substantial claim. The paper may give no reason why it holds.
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In the paper
“emphases on more downstream risk factors such as hypertension, dyslipidemia, and diabetes mellitus address neither the root causes of adiposity nor its full cardiovascular consequences.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
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In the paper
“Because adiposity is largely caused by poor diet (excess calories) and inadequate activity”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✗ Based: failsProbably not a substantial claim. The paper may give no reason why it holds.
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In the paper
“these unfortunate changes will likely mitigate further improvements in cardiovascular mortality and even reverse the decline in cardiovascular disease incidence.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Lifestyle Risk Factors
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
In the paper
“For example, in a trial among 5145 diabetics, lifestyle advice lowered systolic blood pressure, diastolic blood pressure, triglycerides, fasting glucose, hemoglobin A 1c , and proteinuria; in-creased high-density lipoprotein cholesterol; increased weight loss and physical fitness; and reduced use of diabetic, antihypertensive, and lipid-lowering medications.103”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Changing Behavior
What the sources say
- Not checked yetcites [103] source
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
In the paper
“In another trial, modest lifestyle recommendations (advice to consume a healthy low-calorie diet and be moderately active, such as walking briskly Ϸ20 min/d) reduced incidence of diabetes mellitus by 58% compared with placebo and by 39% compared with metformin.55”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Cardiovascular Risk
What the sources say
- Not checked yetcites [55]
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In the paper
“Ironically, a large proportion of healthcare expenditures, including costs to individuals, businesses, and society, is attributable to poor lifestyle behaviors, 114 -117 and these costs are lowered by initiatives that promote healthy lifestyles. 118”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > The Need for Balance
What the sources say
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In the paper
“Major gaps remain, but strategies to lessen smoking in the United States have been effective, reducing per capita tobacco use by nearly two thirds since the 1950s.34”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Changing Behavior
What the sources say
- Not checked yetcites [34] source
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In the paper
“In patients with established cardiovascular disease, physical activity reduces angina symptoms, benefits heart failure, decreases claudication, and lowers mortality after myocardial infarction.38”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Cardiovascular Risk
What the sources say
- Not checked yetcites [38] source
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
In the paper
“Modest consumption of oily fish (1 to 2 servings per week) reduces CHD death by 36%, with 17% reduction in total mortality in randomized controlled trials of fish oil in higher-risk populations.46”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Cardiovascular Risk
What the sources say
- Not checked yetcites [46] source
Strength:plain· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
In the paper
“Although both lifestyle and metformin lowered glucose levels (lessening the nominal diagnosis of diabetes mellitus), only the lifestyle intervention improved multiple other established cardiovascular risk factors related to inactivity, adiposity, and poor dietary habits.56”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Cardiovascular Risk
What the sources say
- Not checked yetcites [56] source
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In the paper
“The funding sources had no role in study design; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.”
§ Beyond Established and Novel Risk Factors Lifestyle Risk Factors for Cardiovascular Disease > Sources of Funding
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“Providers should recognize that while patient compliance with both lifestyle and medications is similarly imperfect, such strategies, even imperfectly implemented, improve clinical outcomes.397”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [397]
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“According to the DASH guidelines and the Dietary Guidelines for Americans 2015 – 2020 , consuming no N 2300 mg of sodiumperdayis recommended,with1500 mgbeingconsideredbetter for lowering blood pressure (Mozaffarian et al., 2008).”
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“Methods We used three key approaches to identifying national diet surveys: (1) contacting authors of surveys, (2) systematic literature review and (3) general web-based searches.”
BackgroundMethodInfluentialChild maltreatment and cardiovascular disease: quantifying mediation pathways using UK Biobank
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“The more proximal risk factors include dyslipidaemia, hypertension, and diabetes which are often related to lifestyle behaviours such as smoking and physical activity [1].”
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“However, the prevalence of diabetes mellitus has increased steadily, mostly because of an epidemic of adiposity [13].”
BackgroundFoods, obesity, and diabetes—are all calories created equal?
Mozaffarian, D. (2017) · Nutrition Reviews · doi:10.1093/nutrit/nuw024 · Cited by 70
Self-citationNeighborhood Environmental Burden and Cardiovascular Health in the US
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“Education, n (%) High school 2 (5) Technical school/some college 3 (8)”
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“However, the number of scientific publications dealing with lifestyle control and diet in cardiovascular prevention is much lower than those addressing risk factors, which probably reflects the lower interest in this aspect of treatment.(24) Obesity forms the pathophysiological basis underlying most cardiovascular ris…”
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“(i.e., cardiovascular disease; Mozaffarian et al., 2008), obesity is a major public health concern.”
BackgroundHaba‐Rubio, J., Marques-Vidal, P. M., Andries, D., Tobback, N., Preisig, M., Vollenweider, P., Waeber, G., Luca, G., Tafti, M., & Heinzer, R. C. (2015) · SLEEP · doi:10.5665/sleep.4496 · Cited by 55
Importance of Lifestyle Modification on Cardiovascular Risk Reduction
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Pathogenesis and Management of the Dyslipidemia of the Metabolic Syndrome
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“31 The diet should be low in saturated fat, transfats, and cholesterol, and an increased intake of foods containing mono-and polyunsaturated fatty acids should be encouraged.”
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Concurrent and Convergent Validity of the Simple Lifestyle Indicator Questionnaire
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“Lifestyle issues including physical activity [1, 2], diet [3– 5], smoking [6], alcohol consumption [7], and self-reported stress [8] have all been shown to predispose people to higher risk of cardiovascular disease [9].”
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“Obtaining adequate sleep, consuming enough fruits and vegetables, and engaging in sufficient PA are 3 lifestyle behaviors that significantly reduce all-cause mortality(20) 22 and have a positive effect on physical and mental health.(23,24) Good sleep health facilitates the ability to maintain attentive wakefulness and…”
Black tea lowers the rate of blood pressure variation: a randomized controlled trial
Hodgson, J. M., Croft, K. D., Woodman, R. J., Puddey, I. B., Fuchs, D., Draijer, R., Lukoshkova, E. V., & Head, G. A. (2013) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.112.051375 · Cited by 47
Dietary Phylloquinone Intakes and Metabolic Syndrome in US Young Adults
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“These covariates were chosen based on the genetic component underlying MetS [19] and the established influence of lifestyle factors on cardiovascular health [20].”
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“The differences in results may be explained by the diversity of factors influencing CVD mortality [71].”
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“Lifestyle interventions have been effective in ameliorating risk factors for cardiovascular disease, by promoting smoking cessation and weight loss (12,13), with substantial effects on cardiovascular risk reduction (14).”
BackgroundEffects of Light Intensity Activity on CVD Risk Factors: A Systematic Review of Intervention Studies
Batacan, R. B., Duncan, M. J., Dalbo, V. J., Tucker, P. S., & Fenning, A. S. (2015) · BioMed Research International · doi:10.1155/2015/596367 · Cited by 52
“Notably, these lifestyle risk factors strongly influence the established biological CVD risk factors and also affect novel pathways of risk such as inflammation [4].”
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Are You Targeting Non–High-Density Lipoprotein Cholesterol?
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Early onset of type 2 diabetes among visible minority and immigrant populations in Canada
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“It is thus not surprising that a plethora of research has identified lifestyle and other behavioral risk factors as important determinants of diabetes risks in Canada and elsewhere (Johnson et al. 2001; Kriska et al. 2003; Mozaffarian, Wilson, and Kannel 2008; Hu 2011; Chiu et al. 2015).”
BackgroundPreventing Exercise-Related Cardiovascular Events
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“fore their interplay with menopause and chronic disease risk need to be considered.(21) Therefore, the purpose of this study was to comprehensively evaluate body composition derived”
BackgroundConsequences of ionizing radiation exposure to the cardiovascular system
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“After 70 years of follow-up, significant associations were identified between radiation dose and morbidity or mortality related to hypertension 24 , IHD 20 , CeVD 18,22 and lower-extremity arterial disease 21 .”
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“…the conventional thinking at the time that atherosclerosis was an inevitable process of aging and established that prevalence and severity of atherosclerosis among certain individuals and populations is related to the presence of various atherosclerotic risk factors (Mozaffarian et al., 2008).”
BackgroundAssociation of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk
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“Hence, this study shows that CR is able to generate an incremental benefit in contemporary patients with CHD, which had been questioned before.5 Results of this study underscore the importance of lifestyle and nonpharmacological intervention in the treatment scenario of CHD.23 So far, CR regimes are not standardized a…”
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“The development of CVD is associated with risk factors such as smoking, age, sex and hypertension (Mozaffarian et al. 2008).”
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“Although improving healthy diets and exercise can have substantial benefits (Loef & Walach, 2012; Mozaffarian et al., 2008), they also are difficult to initiate and maintain over time (Forman & Butryn, 2015).”
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A Smart Service Platform for Cost Efficient Cardiac Health Monitoring
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“, high blood pressure, high cholesterol levels, obesity, diabetes mellitus, and stress [40,41].”
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Sedentary Behaviour—A Target for the Prevention and Management of Cardiovascular Disease
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Cardiovascular Risk Assessment
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Plasma fetuin-A concentrations in young and older high- and low-active men
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Metadata
- Authors
- Mozaffarian, D., Wilson, P. W. F., & Kannel, W. B.
- Affiliations
- Boston University (US)
- Venue
- Circulation
- Published
- 2008-06-10
- Volume
- 117
- Issue
- 23
- Pages
- 3031-3038
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2080422716
- Semantic Scholar
- 44db2926f62498cbf063abbef4a9ea753762de82
- Cited by
- 456
- References
- 124
- Citations by year
- 2026: 19 · 2025: 41 · 2024: 30 · 2023: 33 · 2022: 39 · 2021: 24 · 2020: 27 · 2019: 19 · 2018: 15 · 2017: 12 · 2016: 28 · 2015: 21 · 2014: 36 · 2013: 26 · 2012: 25
- FWCI
- 3.08
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc25195-41-0-1, 1k08hl075628-01)
- National Heart, Lung, and Blood Institute (K08-HL-075628, N01‐HC25195)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- cardiovascular risk factors, lifestyle risk factors, dyslipidemia, hypertension, diabetes mellitus, physical inactivity, smoking, adiposity, inflammation, oxidative stress, endothelial function, thrombosis, cardiac arrhythmias, dietary habits, lifestyle intervention, healthcare policy, reimbursement guidelines
- MeSH terms
- Cardiovascular Diseases, Humans, Life Style, Risk Factors, Risk Reduction Behavior
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