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Cited by 840Cardiovascular Health and Risk FactorsHealth and Lifestyle StudiesNutritional Studies and Diet

Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study

Open access
Khaw, Kay-Tee, Wareham, Nicholas, Bingham, Sheila, Welch, Ailsa, Luben, Robert, Day, Nicholas·2008·PLoS Medicine
DOI 10.1371/journal.pmed.0050012PMC PMC2174962
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Abstract

BACKGROUND: There is overwhelming evidence that behavioural factors influence health, but their combined impact on the general population is less well documented. We aimed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community. METHODS AND FINDINGS: We examined the prospective relationship between lifestyle and mortality in a prospective population study of 20,244 men and women aged 45-79 y with no known cardiovascular disease or cancer at baseline survey in 1993-1997, living in the general community in the United Kingdom, and followed up to 2006. Participants scored one point for each health behaviour: current non-smoking, not physically inactive, moderate alcohol intake (1-14 units a week) and plasma vitamin C >50 mmol/l indicating fruit and vegetable intake of at least five servings a day, for a total score ranging from zero to four. After an average 11 y follow-up, the age-, sex-, body mass-, and social class-adjusted relative risks (95% confidence intervals) for all-cause mortality(1,987 deaths) for men and women who had three, two, one, and zero compared to four health behaviours were respectively, 1.39 (1.21-1.60), 1.95 (1.70--2.25), 2.52 (2.13-3.00), and 4.04 (2.95-5.54) p < 0.001 trend. The relationships were consistent in subgroups stratified by sex, age, body mass index, and social class, and after excluding deaths within 2 y. The trends were strongest for cardiovascular causes. The mortality risk for those with four compared to zero health behaviours was equivalent to being 14 y younger in chronological age. CONCLUSIONS: Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age.

AI snapshot

Written from the paper’s full text.

TL;DR

In EPIC-Norfolk, four simple health behaviours—nonsmoking, not physically inactive, moderate alcohol intake, and plasma vitamin C consistent with ≥5 fruit/vegetable servings/day—were combined into a 0–4 score. Over an average 11 years, adults with zero behaviours had about four times the all-cause mortality risk of those with all four, equivalent to roughly 14 years of chronological age.

Key findings

  • Among 20,244 men and women aged 45–79 without known cardiovascular disease or cancer at baseline, adjusted all-cause mortality relative risks versus a score of 4 were 1.39 (95% CI 1.21–1.60) for score 3, 1.95 (1.70–2.25) for score 2, 2.52 (2.13–3.00) for score 1, and 4.04 (2.95–5.54) for score 0; p < 0.001 for trend.
  • Cardiovascular mortality showed the strongest gradient: score 0 versus score 4 had RR 5.02 (95% CI 2.93–8.61). Cancer mortality score 0 versus 4 was RR 3.74 (2.34–5.98), and non-CVD/noncancer mortality was RR 3.56 (1.77–7.16).
  • Adjusted cumulative survival was about 75% for those scoring zero and 95% for those scoring four. The mortality risk difference between score 0 and score 4 was equivalent to approximately 14 years of chronological age.
  • Relationships were consistent in subgroups stratified by sex, age, BMI, and social class, and after excluding deaths within 2 years; similar trends were seen in 2,057 individuals with prevalent disease excluded from main analyses.

Methods

  • Prospective population study: EPIC-Norfolk, UK, baseline survey 1993–1997, follow-up to July 2006 (average 11 years). Of 22,301 with complete data, 2,057 with history of heart disease, stroke, or cancer were excluded, leaving 20,244 participants aged 45–79.
  • Health behaviour score: one point each for current nonsmoking, not physically inactive, moderate alcohol intake (1–14 units/week), and plasma vitamin C >50 mmol/l indicating at least five fruit/vegetable servings daily; total score 0–4.
  • Cox proportional hazards models estimated relative risks for all-cause and cause-specific mortality, adjusted for age, sex, body mass index, and social class; analyses included subgroup stratification and exclusion of deaths within 2 years.

Limitations

  • The paper states potential large measurement errors in exposure assessment, use of only one baseline measure without accounting for lifestyle changes over follow-up, no weighting of different behaviours, and dichotomizing physical activity as inactive versus not inactive, which may obscure gradients between moderately inactive and active people.
  • The paper states residual confounding cannot be excluded, and the analyses examined only mortality, not functional health or quality of life.
  • Evident from the text: the cohort was 99.5% white, resident in Norfolk, UK, and middle-aged/older, so findings may not generalize to other populations; the observational design cannot establish causality.

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

Integrity signals

Registry

Crossref · 10.1371/journal.pmed.0050012

Cites

36 of 36 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 22 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The relationships between health behaviour score and mortality were consistent in subgroups stratified by sex, age, body mass index, and social class, and after excluding deaths within 2 y.

    “The relationships were consistent in subgroups stratified by sex, age, body mass index, and social class, and after excluding deaths within 2 y.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.
  • Findingown data

    The trends in mortality by health behaviour score were strongest for cardiovascular causes.

    “The trends were strongest for cardiovascular causes.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.
  • Findingown data

    Current smoking was the most consistent and strongest risk factor among the individual health behaviours.

    “As might be expected, there were some differentials in the observed risk reductions observed for different health behaviours and cause-specific mortality in men and women; current smoking was the most consistent and strongest risk factor.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.
  • Findingown data

    None of the interaction terms for health score with sex, age, body mass index, and social class were significant in multivariate analyses.

    “None of the interaction terms for health score with sex, age, body mass index, and social class were significant in multivariate analyses.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.
  • Findingown data

    From the Cox model, the beta coefficient for mortality associated with each year increase in chronological age was 0.10 (standard error 0.004).

    “From the Cox model, the beta coefficient for mortality associated with each year increase in chronological age was 0.10 (6 standard error 0.004).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.
  • May combine two claims. 14
  • The quote only partly states this claim. 4
  • Classified as probably not a substantial claim. 15

  • May combine two claims.

    Findingown data

    Each of the health behaviours-smoking, being physically inactive, not having a moderate alcohol intake, and a low fruit and vegetable intake as indicated by plasma vitamin C level <50 mmol/l-was associated with significantly higher risks of mortality from all causes.

    “Each of the health behaviours: smoking, being physically inactive, not having a moderate alcohol intake, and a low fruit and vegetable intake as indicated by plasma vitamin C level ,50 mmol/l.were associated with significantly higher risks of mortality from all causes.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.

  • May combine two claims.

    Findingcitation

    In this cohort, vitamin supplement use was not associated with mortality, and results were similar after adjusting for vitamin supplement use or excluding vitamin users from the analyses.

    “In this cohort, vitamin supplement use was not associated with mortality, and results were similar after adjusting for vitamin supplement use or excluding vitamin users from the analyses (unpublished data and [19]).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Khaw, 2001, Lancet

      Not checked in the free run.

    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.

  • The quote only partly states this claim.

    Findingown data

    Alcohol intake of <1 or >14 units/week was independently associated with higher all-cause mortality (RR 1.26, 95% CI 1.14-1.38) compared with moderate intake, after adjustment for age, sex, BMI, and social class.

    “All Cause | RR (95% CI) | n ¼ 1,977 events | 1.77 (1.55-2.01) | 1.24 (1.13-1.36) | 1.26 (1.14-1.38) | 1.44 (1.31-1.59)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

  • The quote only partly states this claim.

    Findingown data

    Plasma vitamin C level <50 mmol/l was independently associated with higher all-cause mortality (RR 1.44, 95% CI 1.31-1.59), after adjustment for age, sex, BMI, and social class.

    “All Cause | RR (95% CI) | n ¼ 1,977 events | 1.77 (1.55-2.01) | 1.24 (1.13-1.36) | 1.26 (1.14-1.38) | 1.44 (1.31-1.59)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

  • May combine two claims.

    Findingown data

    In EPIC-Norfolk men and women aged 45-79 without known cardiovascular disease or cancer, all-cause mortality risk increased with decreasing health behaviour score, with adjusted relative risks compared with score 4 of 1.39 (95% CI 1.21-1.60) for score 3, 1.95 (1.70-2.25) for score 2, 2.52 (2.13-3.00) for score 1, and 4.04 (2.95-5.54) for score 0.

    “All cause | 1,977/20,244 | 1 | 1.39 (1.21-1.60) | 1.95 (1.70-2.25) | 2.52 (2.13-3.00) | 4.04 (2.95-5.54)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    The four health behaviours were within the usual range found in a free-living population.

    “The four health behaviours were within the usual range found in a free-living population.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Physical inactivity was independently associated with higher all-cause mortality (RR 1.24, 95% CI 1.13-1.36) compared with not being inactive, after adjustment for age, sex, BMI, and social class.

    “All Cause | RR (95% CI) | n ¼ 1,977 events | 1.77 (1.55-2.01) | 1.24 (1.13-1.36) | 1.26 (1.14-1.38) | 1.44 (1.31-1.59)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

  • The quote only partly states this claim.

    Findingown data

    Current smoking was independently associated with higher all-cause mortality (RR 1.77, 95% CI 1.55-2.01) compared with nonsmoking, after adjustment for age, sex, BMI, and social class.

    “All Cause | RR (95% CI) | n ¼ 1,977 events | 1.77 (1.55-2.01) | 1.24 (1.13-1.36) | 1.26 (1.14-1.38) | 1.44 (1.31-1.59)”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

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

    Premisecitation

    There is a large body of experimental and epidemiologic evidence indicating a high intake of fruit and vegetables is beneficially associated with health.

    “Nevertheless, there is a large body of experimental and epidemiologic evidence indicating a high intake of fruit and vegetables is beneficially associated with health [5,7,11,32]”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [5] Joshipura, 2001, Ann Intern Med

      Not checked in the free run.

    • cites [7] Law, 1998, Eur J Clin Nutr

      Not checked in the free run.

    • cites [11] Ness, 1997, Int J Epidemiol

      Not checked in the free run.

    • cites [32] Rimm, 1996, JAMA

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Individuals with a history of heart disease, stroke, or cancer at the baseline visit were excluded from the main analyses.

    “Of the 22,301 with available data, 2,057 had a history of heart disease, stroke, or cancer at the baseline visit and were excluded from the main analyses, leaving 20,244 individuals.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    A huge body of evidence indicates that lifestyles such as smoking, diet, and physical activity have a major influence on health.

    “A huge body of evidence indicates that lifestyles such as smoking, diet, and physical activity have a major influence on health [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [1]

      Not checked in the free run.

    • cites [2] Chiuve, 2006, Circulation

      Not checked in the free run.

    • cites [3] Doll, 2004, BMJ

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Plasma vitamin C is a good biomarker of plant food intake; a blood value of 50 mmol/l or more indicates an intake of at least five servings of fruit and vegetables daily.

    “Because humans do not manufacture vitamin C and have to rely on exogenous sources, plasma vitamin C is a good biomarker of plant food intake; previous studies have reported that a blood value of 50 mmol/l or more indicates an intake of at least five servings of fruit and vegetables daily [19;26].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] Khaw, 2001, Lancet

      Not checked in the free run.

    • cites [26] Bingham, 1995, Br J Nutr

      Not checked in the free run.

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

    Study design and conductnone given

    The simple health behaviour score was based on instruments that have been extensively previously validated.

    “The score, though simple, was based on instruments that have been extensively previously validated.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    A recent report from 2,339 men and women aged 70-90 y in 11 European countries indicated that adherence to a Mediterranean diet, nonsmoking, any alcohol use, and moderate physical activity were associated with more than 50% lower rate of all-cause and cause-specific mortality.

    “Nevertheless, a recent report from 2,339 men and women aged 70-90 y in 11 European countries indicated that adherence to a Mediterranean diet, nonsmoking, any alcohol use, and moderate physical activity were associated with more than 50% lower rate of all-cause and cause-specific mortality [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Knoops, 2004, JAMA

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The Norfolk cohort was comparable to national population samples with respect to characteristics including anthropometry, blood pressure, and lipids, but with a lower prevalence of current smokers.

    “The Norfolk cohort was comparable to national population samples with respect to characteristics including anthropometry, blood pressure, and lipids, but with a lower prevalence of current smokers [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Day, 1999, Br J Cancer

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age.

    “Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Death certification at the Office of National Statistics, United Kingdom, is virtually complete.

  • May combine two claims.

    Premisecitation

    Low work and leisure-time physical activity predicts all-cause mortality and cardiovascular disease incidence.

    “We have also previously shown that low work and leisure-time physical activity predicts all-cause mortality and cardiovascular disease incidence [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Khaw, 2006, Int J Epidemiol

      Not checked in the free run.

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

    Study design and conductnone given

    The authors declared no competing interests.

    “The authors have declared that no competing interests exist.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    We used only a measure at one point in time to characterize individuals and did not take into account likely changes in lifestyles over the follow-up period.

    “We used only a measure at one point in time to characterize individuals and did not take into account likely changes in lifestyles over the follow-up period.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationown data

    These results may provide further support for the idea that even small differences in lifestyle may make a big difference to health in the population and encourage behaviour change.

    “These results may provide further support for the idea that even small differences in lifestyle may make a big difference to health in the population and encourage behaviour change.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The EPIC-Norfolk cohort is representative of middle-aged and older people in the general population.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The relative risks of mortality by health behaviour score were adjusted for age, sex, body mass index, and social class.

    “Mortality Rates and Relative Risk of All-Cause Mortality by Number of Health Behaviours, Adjusted by Age, Sex, and Body Mass Index, and Stratified by Cause, Sex, Age, Body Mass Index, and Social Class in 20,244 Men and Women Aged 45-79 y without Known Cardiovascular Disease or Cancer in EPIC-Norfolk 1993-2006, Cox Regression Model”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation

    The proportions of the population with some or all positive health behaviours were relatively high since the definitions for health behaviours were not necessarily optimal, for example, for physical activity, and dichotomizing behaviours between inactive and not inactive may have obscured the gradient in mortality between those who were moderately inactive and those who were active.

    “Thirdly, the proportions of the population with some or all positive health behaviours were relatively high since the definitions for health behaviours were not necessarily optimal, for example, for physical activity [20], and dichotomizing behaviours between inactive and not inactive may have obscured the gradient in mortality between those who were moderately inactive and those who were active.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Khaw, 2006, Int J Epidemiol

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Random measurement error is likely to attenuate any associations observed, so the estimated differences in risk are likely to be larger than those observed.

    “Nevertheless, random measurement error is likely to attenuate any associations observed, so the estimated differences in risk are likely to be larger than those observed.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    The sponsors had no role in the design, conduct, collection, management, analysis, interpretation, or preparation of the manuscript.

    “The sponsors had no role in the design and conduct of the study, collection, management, analysis and interpretation of the data, and preparation, review, or approval of the manuscript.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    We cannot exclude residual confounding.

    “Though we cannot exclude residual confounding, our results are consistent with the existing evidence indicating these behavioural factors are beneficial for health.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The combined impact of the four health behaviours was associated with an estimated 4-fold difference in mortality risk, equivalent to 14 years in chronological age.

    “their combined impact was associated with an estimated 4-fold difference in mortality risk, equivalent to 14 y in chronological age.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

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

    Study design and conductreasoning

    The lead author had full access to all data and takes responsibility for the integrity and accuracy of the data analysis.

    “KTK conducted the data analyses, wrote the paper with coauthors, had full access to all of the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Subjective functional health is predictive of mortality.

    “subjective functional health is also predictive of mortality [36]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Myint, 2006, Ann Epidemiol

      Not checked in the free run.

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

    Premisecitation

    In the UK, the recommendations are up to 21 drinks weekly for men and 14 drinks weekly for women.

    “In the UK, the recommendations are up to 21 drinks weekly for men and 14 drinks weekly for women [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33]

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The physical activity measures and scales were developed and validated.

    “NW developed and validated the physical activity measures and scales.”
    Quote in the paperSubstantial claim
30 of 30

  • The paper relies on this without support.

    Health behaviours such as smoking, diet, and physical activity are highly correlated.

    “Many health behaviours such as smoking habit, diet, and physical activity are highly correlated and, in aetiologically focused papers, treated as covariates.”

  • The paper relies on this without support.

    Death certification at the Office of National Statistics, United Kingdom, is virtually complete.

    “All participants are flagged for death certification at the Office of National Statistics, United Kingdom which is virtually complete.”

  • The paper relies on this without support.

    The observed associations between health behaviour score and mortality are not explained by unmeasured or residual confounding.

    “After allowing for other factors that might have affected their likelihood of dying (for example, age)”

  • The paper relies on this without support.

    The EPIC-Norfolk cohort is representative of middle-aged and older people in the general population.

    “These findings indicate that the combination of four simply defined health behaviors predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older people.”

  • The paper relies on this without support.

    Mortality follow-up via record linkage was complete and accurate.

    “Deaths among the participants were then recorded until 2006.”
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?

  • Regular physical activity protects against premature death independent of obesity.

    “Moreover, regular physical activity appears to protect against premature death independent of obesity [10, 11].”

    From Exercise as a Mean to Control Low‐Grade Systemic Inflammation (2008) · cites this paper as [10]

  • Regular exercise offers protection against all causes of mortality, primarily by protection against atherosclerosis and insulin resistance.

    “regular exercise offers protection against all causes of mortality, primarily by protection against atherosclerosis and insulin resistance”

    From Exercise as a Mean to Control Low‐Grade Systemic Inflammation (2008) · cites this paper as [10]

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.

  • Physical-activity scoring rule differs between Table 1 and Methods

    Major

    Table 1 requires at least half an hour of daily leisure activity for someone with a sedentary occupation to score a point. The Methods define inactivity as a sedentary job with no recreational activity, so someone with less than half an hour but more than none would receive a point under the Methods rule.

  • Women's alcohol-category percentage does not match its count

    Minor

    The 254 women in this category are about 2.3% of the 11,063 women, not 1.2%.

    Reported 1.2 · recomputed 2.295941

  • Women's social-class percentage exceeds 100%

    Minor

    The table reports 119.9% for 2,145 women in social class III nonmanual. That count is about 19.39% of the 11,063 women.

    Reported 119.9 · recomputed 19.388954

  • The 14-unit alcohol boundary differs between scoring rules

    Minor

    Table 1 says the qualifying intake is less than 14 units a week, while the Methods include intake of up to and including 14 units. The rules disagree for someone drinking exactly 14 units.

4 of 4

Cites

Flagged first, then by citations

Research works printed but not linked: 34

  1. Chiuve, 2006, Circulation, 114, 160
  2. Doll, 2004, BMJ, 328, 1519
  3. Hu, 2000, Am J Clin Nutr, 72, 912
  4. Joshipura, 2001, Ann Intern Med, 134, 1106
  5. Knoops, 2004, JAMA, 292, 1433
  6. Law, 1998, Eur J Clin Nutr, 52, 549
  7. Manson, 1996, N Engl J Med, 334, 1325
  8. McCullough, 2002, Am J Clin Nutr, 76, 1261
  9. Mukamal, 2006, Arch Intern Med, 166, 2145
  10. Ness, 1997, Int J Epidemiol, 26, 1
  11. Oguma, 2002, Br J Sports Med, 36, 162
  12. Sesso, 1999, Am J Epidemiol, 150, 408
  13. Stampfer, 2000, N Engl J Med, 343, 16
  14. Thompson, 2003, Circulation, 107, 3109
  15. Trichopoulou, 2003, N Engl J Med, 348, 2599
  16. Alonso, 2005, JAMA, 293, 674
  17. Craighead, 2005, JAMA, 293, 674
  18. Khaw, 2001, Lancet, 357, 657
  19. Khaw, 2006, Int J Epidemiol, 35, 1034
  20. Day, 1999, Br J Cancer, 80, 95
  21. Wareham, 2002, Int J Epidemiol, 31, 168
  22. Wareham, 2003, Public Health Nutr, 6, 407
  23. Shohaimi, 2004, Eur Respir J, 24, 157
  24. Riemersma, 1990, Eur J Clin Nutr, 44, 143
  25. Bingham, 1995, Br J Nutr, 73, 531
  26. Liese, 2000, Am J Epidemiol, 152, 884
  27. Rimm, 2004, JAMA, 292, 1490
  28. Anderson, 2006, JAMA, 295, 693
  29. Howard, 2006, JAMA, 295, 655
  30. Prentice, 2006, JAMA, 295, 629
  31. Rimm, 1996, JAMA, 275, 447
  32. Myint, 2006, Prev Med, 44, 109
  33. Myint, 2007, Public Health Nutr, 10, 34
  34. Myint, 2006, Ann Epidemiol, 16, 492

Cited by

Sorted by citations

Related

Authors
Khaw, K.-T., Wareham, N., Bingham, S., Welch, A., Luben, R., & Day, N.
Affiliations
  • University of Cambridge (GB)
  • MRC Epidemiology Unit (GB)
  • Medical Research Council (GB)
Corresponding author
Khaw, Kay-Tee
ORCID
Venue
PLoS Medicine
Publisher
Public Library of Science (PLoS)
Published
2008-01-08
Volume
5
Issue
1
Pages
e12
ISSN
  • 1549-1277 (ISSN-L)
  • 1549-1676
DOI
10.1371/journal.pmed.0050012
PMC
PMC2174962
OpenAlex
W2109585014
Cited by
840
References
36
Citations by year
2026: 21 · 2025: 21 · 2024: 27 · 2023: 20 · 2022: 28 · 2021: 38 · 2020: 50 · 2019: 41 · 2018: 37 · 2017: 54 · 2016: 59 · 2015: 67 · 2014: 60 · 2013: 73 · 2012: 54
FWCI
45.36
Type
journal article
Language
en
Update notices
correction (2008-03-25)
Open access
Licence
cc-by
Locations
  • PLoS Medicine (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • UEA Digital Repository (University of East Anglia) (submittedVersion, cc-by)
Funders
  • British Heart Foundation
  • Stroke Association
  • Medical Research Council
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
  • Health Sciences › Health Professions › General Health Professions › Health and Lifestyle Studies
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
Keywords
health behavior, mortality, lifestyle, all-cause mortality, cardiovascular mortality, smoking, physical inactivity, alcohol consumption, vitamin C, fruit and vegetable intake, sex differences, EPIC-Norfolk
MeSH terms
Aged, Alcohol Drinking, Ascorbic Acid, Diet, England, Female, Fruit, Humans, Life Expectancy, Life Style, Male, Middle Aged, Morbidity, Mortality, Motor Activity, Physical Examination, Prospective Studies, Surveys and Questionnaires, Risk, Sex Factors, Smoking, Vegetables, Health Behavior

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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