Cardiovascular health metrics, muscle mass and function among Italian community-dwellers: the Lookup 7+ project

Cardiovascular health metrics, muscle mass and function among Italian community-dwellers: the... Abstract Background Primordial prevention is essential for promoting cardiovascular health and longevity through the so-called seven cardiovascular health metrics (CHMs) (i.e. smoking, body mass index, diet, physical activity, blood pressure, blood glucose and total cholesterol). Measures of muscle mass and function are recognized as powerful predictors of health-related events and survival. Therefore, the present study was undertaken to assess the prevalence and distribution of the seven CHMs and measures of muscle mass and function in an unselected cohort of community-dwellers. Methods The Longevity check-up 7+ (Lookup 7+) project is an ongoing cross-sectional survey conducted in unconventional settings (e.g. exhibitions, malls and health promotion campaigns) across Italy. CHMs are assessed through a brief questionnaire and by measurement of standing height, body weight, blood glucose, blood cholesterol and blood pressure. Muscle mass is estimated from calf circumference, whereas muscle strength and function are measured via handgrip strength and chair-stand testing, respectively. Results Analyses were conducted in 6323 community-living adults (mean age: 54 ± 15 years, 57% women) recruited between 1 June 2015 and 30 June 2017. Participants presented on average 4.3 ± 1.3 ideal CHMs, which decreased with age. Only 19.5% of participants met >5 ideal metrics, while 8.3% met <3. All seven ideal metrics were met by 4.7% of enrollees. Muscle mass, strength and function declined progressively with age, starting at 45–50 years. Conclusion Our population showed suboptimal CHMs scores, with very low prevalence of all ideal metrics. The number of ideal metrics decreased progressively with age and so did muscle mass and function. Introduction Cardiovascular disease (CVD) is the main cause of morbidity and mortality in developed countries, in spite of widespread implementation of preventive strategies and the development of effective therapeutic options.1,2 While primary and secondary prevention measures target individuals who have suffered a cardiovascular event or present with one or more risk factors, primordial prevention aims at promoting cardiovascular health at the population level.3,4 This may be accomplished through the assessment of various cardiovascular health factors and behaviors, including smoking, body mass index (BMI), healthy diet, engagement in physical activity, blood pressure, blood glucose and total blood cholesterol.5 A recent systematic review found that meeting an increasing number of ideal cardiovascular health metrics (CHMs) was associated with lower prevalence and incidence of both CVD-related and non-CVD outcomes such as cancer, depression and cognitive impairment.6 The authors also reported that the prevalence and distribution of CHMs was relatively homogeneous between US and non-US populations, with low proportions of people meeting six or more ideal metrics.6 Besides traditional risk factors, skeletal muscle mass and function are increasingly recognized as powerful predictors of incident CVD and other relevant health-related outcomes.7–10 It is therefore plausible that the combination of the seven CHMs with ‘unconventional’ risk factors pertaining to muscle mass and function may provide a more comprehensive outlook of an individual's cardiovascular health and new targets for prevention. The present study was therefore undertaken to collect information on the prevalence and distribution of CHMs and measurements of muscle mass and function in an unselected cohort of Italian adults living in the community. The time needed to complete the assessment and participant acceptance were also determined. Methods The Longevity check-up 7+ (Lookup 7+) project is an ongoing initiative developed by the Department of Geriatric Medicine of the Catholic University of the Sacred Heart (Rome, Italy). The initiative was designed to raise awareness in the general population on major lifestyle behaviors and cardiovascular risk factors. Since the program did not aim at testing any pre-specified hypothesis, no sample size calculation was conducted. A team of medical doctors, researchers, and nutritionists assess people visiting public places (e.g. malls and exhibition centers) and those adhering to prevention campaigns launched by our department. These locations are chosen because allowing for enrolling relatively unselected participants, outside of conventional healthcare or research settings. Candidates are considered to be eligible for enrolment if they are at least 18 years of age and provide written informed consent. Pregnancy, inability to perform functional tests and unwillingness to give written informed consent are considered exclusionary. The study protocol was approved by the Catholic University Ethics Committee (protocol #: A.1220/CE/2011). The manuscript was prepared in compliance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) reporting guidelines for observational studies. Study sample The present study was conducted in participants enrolled between 1 June 2015 and 30 June 2017. Recruitment took place in the following settings: Milan EXPO 2015 (Milan, June–October 2015), Mese del Cuore (Rome, October–September 2016), La Romanina—Check your Longevity (Rome, December 2017), Mese del Cuore (Milan, March–April 2017), Ministry of Health—Women’s Day (Rome, April 2017), CamBio Vita (Catania, May 2017), COOP shopping centers (Bologna, Modena, Genoa, Rimini and Grosseto, May–June 2017). Depending on the setting, the initiative was advertized in newspapers, magazines and TV broadcasting. Visitors were also invited to participate by direct contact. Data collection People who accepted to be screened underwent individual assessments consisting of a brief questionnaire, the measurement of objective CHMs, and the evaluation of anthropometric parameters [BMI, calf circumference (CC)], and functional performance (handgrip strength and lower extremity muscle power). Each Lookup 7+ evaluation was structured according to the same schedule: informed consent acquisition, lifestyle interview, measurement of blood pressure, body weight and standing height, CC, handgrip strength test, chair-stand test. Participant satisfaction with the Lookup 7+ evaluation was assessed through a 4-level rating scale (‘Very satisfied’, ‘Satisfied’, ‘Neither satisfied nor dissatisfied’, ‘Dissatisfied’). Assessment of cardiovascular health metrics The seven CHMs were assessed through closed questions and direct measurements.11,12 Smoking status was defined as follows: current smoker (has smoked 100+ cigarettes in lifetime and currently smokes cigarettes), never smoked (has never smoked or has smoked <100 cigarettes in lifetime) and former smoker (has smoked at least 100 cigarettes in lifetime but had quit at least 28 days before the interview). For the purpose of the analyses, smoking status was categorized as current or never/former smoker. Sedentariness was considered as the lack of involvement in any kind of physical activity for a minimum of two times a week.13 To be assigned to the physically active group the following activities were considered: light walking for at least 30 min per session, cycling, swimming, running or practicing resistance training for at least 15 min per session.13 An analogue medical scale was used to measure body weight, while body height was measured through a standard stadiometer. BMI was then calculated as the weight (kg) divided by the square of height (m). BMI was categorized as <18.5 (underweight), 18.5–24.9 (normal), 25.0–29.9 (overweight) and ≥30.0 (obesity). Healthy diet was considered as the consumption of at least three portions of fruit and/or vegetables per day. As previously reported,14 daily intake of fruit and vegetables was calculated based on reference tables for the Italian population released by the Italian Society of Nutrition (SINU). Accordingly, three or more portions of fruit and/or vegetables correspond to >400 g, which is the minimum amount recommended by the World Health Organization. The use of three or more portions to identify a healthy diet is in line with Italian dietary habits for fruit and vegetables which are typically eaten during the main meals rather than as snacks.15 Reference amounts are available at http://www.sinu.it/html/cnt/larn.asp. Cholesterol was measured from capillary blood samples using disposable strips based on a reflectometric system with a portable device (MultiCare-In, Biomedical Systems International srl, Florence Italy).16 Total blood cholesterol was categorized as <200 mg/dl (if untreated), 200–239 mg/dl (or treated to goal) and ≥240 mg/dl. Lipid-lowering drug use was also recorded. Blood glucose was measured from capillary blood samples using disposable strips based on an amperometric system with a MultiCare-In portable device.16 Participants who declared being diabetic and those who presented with a random blood glucose level >200 mg/dl were considered to be suffering from diabetes. Blood pressure was measured with an electronic sphygmomanometer according to recommendations from international guidelines.17 Blood pressure values were categorized as <120/80 mmHg (if untreated), 120/80–139/89 mmHg (or treated to goal) and ≥140/90 mmHg. Antihypertensive drug use was also recorded. The following findings were considered as ideal CHMs: never/former smoker, regular engagement in physical activity, BMI 18.5–24.9, healthy diet, untreated total blood cholesterol <200 mg/dl, absence of diabetes, untreated blood pressure <120/80 mmHg. One point was assigned to each ideal metric, while a score of 0 was attributed to non-ideal categories. The CHMs score was finally calculated as the sum of individual items.12 Estimation of muscle mass and measurement of physical performance Muscle mass was estimated by measuring CC using a standard flexible tape, as described elsewhere.18 Muscle strength was assessed by using a North Coast handheld hydraulic dynamometer (North Coast Medical, Morgan Hill, CA), as previously described.19 Participants performed one familiarization trial and one measurement trial with each hand, and the result from the stronger side was used for the analyses. Lower extremity muscle power was determined by the chair-stand test.15 The test, a component of the Short Physical Performance Battery (SPPB),20 involves standing up from a chair with the arms folded across the chest five times in a row as quickly as possible. The time taken to complete the task was recorded. Statistical analysis Characteristics of study participants are described according to the different surveys. Data were analyzed to obtain descriptive statistics. Normal distribution of continuous variables was ascertained through the Kolmogorov–Smirnov test. Data for continuous variables are expressed as mean ± standard deviation (SD), whereas categorical variables are presented as absolute numbers and percentages. The primary focus of the analytic plan was to explore the distribution of CHMs and muscle mass and function measurements across ages and genders. To this aim, the study sample was divided in the following age groups: <25, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79 and 80+ years. Differences in proportions and means of covariates across genders and age groups were assessed using the Fisher’s Exact test and one-way analysis of variance (ANOVA) statistics, respectively. All analyses were performed using the SPSS software (version 11.0, SPSS Inc., Chicago, IL), with statistical significance set at P < 0.05. Results During the enrolment time-frame considered for the present study, 6323 participants were recruited. The main characteristics of the study population according to the individual surveys are shown in table 1. The mean age of enrollees was 54.2 years (SD 15.2, range 18–98 years) and 3595 (57%) were women. Age and gender distribution was homogeneous across surveys, with the exception of lower age of participants enrolled during Milan EXPO and CamBio Vita Catania, and an expected higher representation of women at the Ministry of Healthy—Women’s Day. Table 1 General characteristics of the study sample according to the different surveys Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Note: Data are given as number (percent) for gender, smoking habit, physical activity and healthy diet; for all other variables, means and standard deviation are reported. Table 1 General characteristics of the study sample according to the different surveys Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Note: Data are given as number (percent) for gender, smoking habit, physical activity and healthy diet; for all other variables, means and standard deviation are reported. Current smoking was recorded in 1043 (16%) participants. Engagement in regular physical activity and consumption of healthy diet were pursued by 3772 (59%) and 4556 (72%) participants, respectively. The mean BMI was 25.4 kg/m2 (SD 4.3). Ideal body weight, as defined as BMI 18.5–24.9 kg/m2, was recorded in 3190 (51%) participants. Non-treated blood pressure <120/80 mmHg was found in 2530 (42%) enrollees. The mean total blood cholesterol was 211 mg/dl (SD 35), with 2021 (34%) participants presenting ideal blood cholesterol with no pharmacological treatment. Finally, mean blood glucose was 103 mg/dl (SD 23), with 5675 (92%) participants being free of diabetes. Overall, Lookup 7+ participants presented on average 4.3 (SD 1.3) ideal CHMs. 1233 (19.5%) participants met >5 ideal CHMs, while 525 (8.3%) showed <3 ideal health metrics. Only 297 (4.7%) enrollees met all seven ideal CHMs. Means and SDs for individual CHMs and cumulative scores according to age groups are shown in figure 2. Active smoking was more frequent among younger individuals, peaking in males aged 25–29. Past the age of 45, the prevalence of smoking decreased progressively reaching 6% in 80+ year-old men (figure 1A). Regular participation in physical activity was higher in young and old age groups, with a significant deflection between 35 and 55 years of age. In all age groups, men were more physically active than women (figure 1B). Conversely, adherence to healthy diet was more frequent in women. The prevalence of healthy diet was found to be around 60% in young and adult participants. The frequency of healthy diet increased starting at 55 years and reached about 80% in the oldest age group (figure 1C). Figure 1 View largeDownload slide Prevalence of current smoking (A), engagement in regular physical activity (B), and adherence to healthy diet (C) in men and women across age groups. Data are shown as percentages (n = 6323) Figure 1 View largeDownload slide Prevalence of current smoking (A), engagement in regular physical activity (B), and adherence to healthy diet (C) in men and women across age groups. Data are shown as percentages (n = 6323) Figure 2 View largeDownload slide Mean body mass index (A), systolic blood pressure (B), diastolic blood pressure (C), total blood cholesterol (D), blood glucose (E), and cardiovascular health metrics score (F) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) Figure 2 View largeDownload slide Mean body mass index (A), systolic blood pressure (B), diastolic blood pressure (C), total blood cholesterol (D), blood glucose (E), and cardiovascular health metrics score (F) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) The BMI increased steadily up to 65–69 years in both genders and declined thereafter (figure 2A), with values >25 kg/m2 observed in men of 35–39 years and in women at the age of 60–65. Underweight (i.e. BMI <18.5 kg/m2) was detected in 167 participants (2.7%). As expected, systolic and diastolic blood pressure levels increased progressively with age starting at around 45–49 years (figure 2B and 2C). Blood cholesterol levels were significantly higher in middle-aged participants compared with younger and older age groups, without significant gender differences (figure 2D). Blood glucose increased progressively with age starting at 50–54 years (figure 2E). Conversely, CHMs scores decreased with advancing age in relation to a greater number of risk factors among older participants (in particular, blood pressure and blood glucose) (figure 2F). Women showed better scores than men in all age groups. Muscle mass and muscle strength declined significantly past the age of 45 in both genders (figure 3A and 3B). Similarly, lower extremity muscle power remained stable between 18 and 40–44 years and declined thereafter in both genders (figure 3C). Figure 3 View largeDownload slide Mean calf circumference (A), handgrip strength (B), and time to complete the chair-stand test (C) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) Figure 3 View largeDownload slide Mean calf circumference (A), handgrip strength (B), and time to complete the chair-stand test (C) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) Finally, the vast majority of participants (4917; 82%) declared to be very satisfied with the initiative, 688 (14%) were satisfied, 148 (3%) declared to be neither satisfied nor dissatisfied, and only 49 (1%) were not satisfied. Each Lookup 7+ evaluation required on average 12.8 (SD 1.6) min to be completed, with no significant differences across genders, age groups or settings. Discussion In the present study, the prevalence and age-related differences of established CHMs were explored in a large and relatively unselected sample of Italian community-dwellers. Patterns of muscle mass and physical performance decline with age were also determined to obtain a more comprehensive characterization of the participant health status. These investigations were made possible through the implementation of a simple and quick screening tool. Participants of the Lookup 7+ project met an average of four ideal CHMs, a slightly higher number than previously reported in other European and US surveys.11,12,21 Only two out of 10 participants met >5 ideal health metrics, while almost one out of 10 met <3 ideal metrics. High blood pressure, elevated blood cholesterol and sedentariness were the most prevalent non-ideal CHMs. In contrast, diabetes and active smoking were the least frequent risk factors. The present data also indicate that muscle mass, strength and function decline across age groups, starting at approximately 50 years. Noticeably, advancing age is accompanied by substantial changes in body composition and, as a consequence, in glucose and lipid metabolism.15 Declining muscle mass and increases in adiposity are also independently associated with the development of hypertension.22,23 Alterations of glucose and lipid metabolism, deterioration of body composition and high blood pressure describe the so-called metabolic syndrome, the prevalence of which is well known to be higher in older adults.24–26 Smoking cessation in late adulthood and old age is a well-described phenomenon and so is the increased propensity to follow a healthier diet compared with younger people.27,28 This latter finding is in line with a report by the Progressi delle Aziende Sanitarie per la Salute in Italia (PASSI) survey, in which the prevalence of healthy diet was indeed higher in late adulthood and in women.29 In contrast, the consumption of fruit and vegetable reported by the Lookup 7+ population seems to be higher than that reported by the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey.30 Though, the different way healthy diet was defined in the three surveys impedes a thorough comparison among the studies. Quite unexpectedly, older Lookup 7+ participants declared to engage in regular physical activity more often than middle-aged enrollees. Remarkably, almost 30% of the youngest Lookup 7+ enrollees declared not to be engaged in any kind of physical activity, a moderately higher percentage than reported by Teleman et al.31 among Italian university students. Overall, the present data support the fact that the age between 35 and 55 years is critical for cardiovascular risk. Indeed, in this age group, a generalized worsening of CHMs was observed. It is also noteworthy that during this period of life, muscle mass, strength and physical performance begin to decline. Middle age is therefore a crucial time for implementing specific screening and prevention campaigns to foster active longevity.3,13 This would allow for preventing irreversible cardiovascular damage to accrue and delaying the decline in physical function. In this context, a screening tool such as the one implemented in the Lookup 7+ project may serve as an easy-to-apply instrument to raise awareness on cardiovascular prevention in the general population and promote public health, especially outside of conventional healthcare settings. Albeit dealing with a highly relevant issue, the present study presents some limitations that deserve being discussed and taken into account in the interpretation of results. First, although a priori selection criteria were not set, candidate participants had to be able to reach shopping centers or exhibition places. This requisite may have selected a relatively healthy and functionally competent population. Since the initiative was mostly advertised in newspapers, magazines and TV broadcasting, the response rate could not be calculated, which may limit the representativeness of findings. Although anthropometric measures are frequently adopted for estimating lean body mass, they do not represent the gold standard for the quantification of muscle mass.32 However, the measurement of CC provides an easy-to-apply, inexpensive, non-invasive and reproducible means for muscle mass estimation, particularly suitable for community-based studies.13–15,18,19 The study setting may have influenced the assessment of some CHMs. Indeed, random cholesterol and glucose determinations could overestimate both parameters. Furthermore, cholesterol and glucose levels were determined in capillary blood samples. Although this procedure was previously validated,11 the error of portable devices is higher than with standard equipment. Despite the fact that blood pressure was measured following international guidelines, it is possible that the setting may have influenced the measurement outcome. Since evaluations were performed throughout the day, the possibility cannot be discarded that some participants may have been walking for longer time than others, which could have an impact on their performance levels. To limit this potential bias, participants were allowed to rest until they felt comfortable with the strength testing. Finally, results were obtained from cross-sectional surveys and differences in birth cohort might have influenced some parameters. For instance, the higher prevalence of healthy diet observed among older participants could be related to an intrinsic attitude of this birth cohort and not be associated to an actual age-related change. Despite these limitations, the Lookup 7+ project offered the unique opportunity to investigate the prevalence of CHMs and age- and gender-specific trends of muscle mass and function in a large sample of Italian community-living people. Our project showed that a quick, yet rather comprehensive screening program provides useful health information at the population level, besides being very well accepted by participants. The Lookup 7+ project may therefore represent a prototypical approach to raise awareness on unhealthy behaviors and cardiovascular risk factors in the general population. Acknowledgements The authors thank the entire Lookup 7+ team (Giulia Battaglia, Vincenzo Brandi, Marianna Broccatelli, Camilla Cattaneo, Agnese Collamati, Giuseppe Colloca, Emanuela D'Angelo, Mariaelena D'Elia, Domenico Fusco, Ambra Maestroni, Alessandra Nesossi, Monica Ramaschi, Alex Sisto and Alice Tappella) for their great enthusiasm in performing participant assessments. Funding The Lookup 7+ project was supported by Italia Longeva; Marche Region; Ferrarini, Tedaldi, Fileni, and Elanco; Danone Italia; and Merck Sharp & Dohme Italia. The study was also partly supported by intramural research grants from the Catholic University of the Sacred Heart (D3.2 2013 and D3.2 2015) and by the non-profit research foundation ‘Centro Studi Achille e Linda Lorenzon’. Conflicts of interest: R.C., F.L., E.M. and M.T. are partners of the SPRINTT Consortium, which is partly funded by the European Federation of Pharmaceutical Industries and Associations (EFPIA). All other authors declare no conflict of interest. Key points The implementation of the cardiovascular health metrics paradigm may be used to raise awareness in the general population on major lifestyle behaviors and risk factors for cardiovascular disease. Skeletal muscle mass and function have emerged as novel predictors of incident cardiovascular disease and other health-related outcomes. Overall, participants in the Lookup 7+ project met <5 ideal cardiovascular health metrics. Only a small proportion of enrollees met all seven ideal metrics. The number of ideal cardiovascular health metrics was higher in women and declined with advancing age. High blood pressure, elevated blood cholesterol and lack of physical activity were the most prevalent non-ideal cardiovascular health metrics. Diabetes and active smoking were the least frequent risk factors. Muscle mass, strength and function declined progressively with age in both genders, starting at 45–50 years. References 1 Laaksonen M , Talala K , Martelin T , et al. Health behaviours as explanations for educational level differences in cardiovascular and all-cause mortality: a follow-up of 60 000 men and women over 23 years . Eur J Public Health 2008 ; 18 : 38 – 43 . Google Scholar CrossRef Search ADS PubMed 2 Roger VL , Go AS , Lloyd-Jones DM , et al. Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association . Circulation 2012 ; 125 : 188 – 97 . Google Scholar CrossRef Search ADS PubMed 3 Ose D , Rochon J , Campbell SM , et al. Health-related quality of life and risk factor control: the importance of educational level in prevention of cardiovascular diseases . Eur J Public Health 2014 ; 24 : 679 – 84 . Google Scholar CrossRef Search ADS PubMed 4 GBD 2015 Eastern Mediterranean Region Cardiovascular Disease Collaborators AH , Mokdad AH . Burden of cardiovascular diseases in the Eastern Mediterranean Region, 1990–2015: findings from the Global Burden of Disease 2015 study . Int J Public Health 2017 . doi: 10.1007/s00038-017-1012-3. [Epub ahead of print]. 5 Lloyd-Jones DM , Hong Y , Labarthe D , et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond . Circulation 2010 ; 121 : 586 – 613 . Google Scholar CrossRef Search ADS PubMed 6 Younus A , Aneni EC , Spatz ES , et al. A systematic review of the prevalence and outcomes of ideal cardiovascular health in US and non-US populations . Mayo Clin Proc 2016 ; 91 : 649 – 70 . Google Scholar CrossRef Search ADS PubMed 7 Rantanen T , Masaki K , He Q , et al. Midlife muscle strength and human longevity up to age 100 years: a 44-year prospective study among a decedent cohort . Age (Dordr) 2012 ; 34 : 563 – 70 . Google Scholar CrossRef Search ADS PubMed 8 Timpka S , Petersson IF , Zhou C , Englund M . Muscle strength in adolescent men and risk of cardiovascular disease events and mortality in middle age: a prospective cohort study . BMC Med 2014 ; 12 : 62 . Google Scholar CrossRef Search ADS PubMed 9 Srikanthan P , Horwich TB , Tseng CH . Relation of muscle mass and fat mass to cardiovascular disease mortality . Am J Cardiol 2016 ; 117 : 1355 – 60 . Google Scholar CrossRef Search ADS PubMed 10 Andersen K , Rasmussen F , Held C , Neovius M , Tynelius P , Sundström J . Exercise capacity and muscle strength and risk of vascular disease and arrhythmia in 1.1 million young Swedish men: cohort study . BMJ 2015 ; 351 : h4543 . Google Scholar CrossRef Search ADS PubMed 11 Vetrano DL , Martone AM , Mastropaolo S , et al. Prevalence of the seven cardiovascular health metrics in a Mediterranean country: results from a cross-sectional study . Eur J Public Health 2013 ; 23 : 858 – 62 . Google Scholar CrossRef Search ADS PubMed 12 Yang Q , Cogswell ME , Flanders WD , et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults . JAMA 2012 ; 307 : 1273 – 83 . Google Scholar CrossRef Search ADS PubMed 13 Landi F , Calvani R , Picca A , et al. Impact of habitual physical activity and type of exercise on physical performance across ages in community-living people . PLoS One 2018 ; 13 : e0191820 . Google Scholar CrossRef Search ADS PubMed 14 Marzetti E , Hwang A-C , Tosato M , et al. Age-related changes of skeletal muscle mass and strength among Italian and Taiwanese older people: results from the Milan EXPO 2015 survey and the I-Lan Longitudinal Aging Study . Exp Gerontol 2018 ; 102 : 76 – 80 . Google Scholar CrossRef Search ADS PubMed 15 Landi F , Calvani R , Tosato M , et al. Age-related variations of muscle mass, strength, and physical performance in community-dwellers: results from the Milan EXPO survey . J Am Med Dir Assoc 2017 ; 18 : 88.e17 – e24 . Google Scholar CrossRef Search ADS 16 Rapi S , Bazzini C , Tozzetti C , et al. Point-of-care testing of cholesterol and triglycerides for epidemiologic studies: evaluation of the multicare-in system . Transl Res 2009 ; 153 : 71 – 6 . Google Scholar CrossRef Search ADS PubMed 17 Mancia G , De Backer G , Dominiczak A , et al. 2007 Guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) . Eur Heart J 2007 ; 28 : 1462 – 536 . Google Scholar PubMed 18 Landi F , Onder G , Russo A , et al. Calf circumference, frailty and physical performance among older adults living in the community . Clin Nutr 2014 ; 33 : 539 – 44 . Google Scholar CrossRef Search ADS PubMed 19 Landi F , Calvani R , Tosato M , et al. Impact of physical function impairment and multimorbidity on mortality among community-living older persons with sarcopaenia: results from the ilSIRENTE prospective cohort study . BMJ Open 2016 ; 6 : e008281 . Google Scholar CrossRef Search ADS PubMed 20 Guralnik JM , Simonsick EM , Ferrucci L , et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission . J Gerontol 1994 ; 49 : M85 – 94 . Google Scholar CrossRef Search ADS PubMed 21 Hulsegge G , van der Schouw YT , Daviglus ML , et al. Determinants of attaining and maintaining a low cardiovascular risk profile—the Doetinchem Cohort Study . Eur J Public Health 2016 ; 26 : 135 – 40 . Google Scholar CrossRef Search ADS PubMed 22 Stafford M , Soljak M , Pledge V , Mindell J . Socio-economic differences in the health-related quality of life impact of cardiovascular conditions . Eur J Public Health 2012 ; 22 : 301 – 5 . Google Scholar CrossRef Search ADS PubMed 23 de Oliveira C , Marmot MG , Demakakos P , et al. Mortality risk attributable to smoking, hypertension and diabetes among English and Brazilian older adults (The ELSA and Bambui cohort ageing studies) . Eur J Public Health 2016 ; 26 : 831 – 5 . Google Scholar CrossRef Search ADS PubMed 24 Lee W-J , Peng L-N , Chiou S-T , Chen L-K . Relative handgrip strength is a simple indicator of cardiometabolic risk among middle-aged and older people: a nationwide population-based study in Taiwan . PLoS One 2016 ; 11 : e0160876 . Google Scholar CrossRef Search ADS PubMed 25 Kósa Z , Moravcsik-Kornyicki Á , Diószegi J , et al. Prevalence of metabolic syndrome among Roma: a comparative health examination survey in Hungary . Eur J Public Health 2015 ; 25 : 299 – 304 . Google Scholar CrossRef Search ADS PubMed 26 Jansen-Chaparro S , Mancera J , Cuende JI , et al. Metabolic syndrome and vascular risk estimation in a Mediterranean non-diabetic population without cardiovascular disease . Eur J Intern Med 2012 ; 23 : 558 – 63 . Google Scholar CrossRef Search ADS PubMed 27 van Loon AJM , Tijhuis M , Surtees PG , Ormel J . Determinants of smoking status: cross-sectional data on smoking initiation and cessation . Eur J Public Health 2005 ; 15 : 256 – 61 . Google Scholar CrossRef Search ADS PubMed 28 Toft UN , Kristoffersen LH , Aadahl M , et al. Diet and exercise intervention in a general population—mediators of participation and adherence: the Inter99 study . Eur J Public Health 2007 ; 17 : 455 – 63 . Google Scholar CrossRef Search ADS PubMed 29 Guberti E . Feeding health: problems, opportunities, goals . Ann Ig 2014 ; 26 : 121 – 30 . Google Scholar PubMed 30 Giampaoli S , Krogh V , Grioni S , et al. Eating behaviours of Italian adults: results of the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey . Epidemiol Prev 2015 ; 39 : 373 – 9 . Google Scholar PubMed 31 Teleman AA , De Waure C , Soffiani V , et al. Physical activity and health promotion in Italian university students . Ann Ist Super Sanità 2015 ; 51 : 106 – 10 . Google Scholar PubMed 32 Tosato M , Marzetti E , Cesari M , et al. Measurement of muscle mass in sarcopenia: from imaging to biochemical markers . Aging Clin Exp Res 2017 ; 29 : 19 – 27 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Cardiovascular health metrics, muscle mass and function among Italian community-dwellers: the Lookup 7+ project

Loading next page...
 
/lp/ou_press/cardiovascular-health-metrics-muscle-mass-and-function-among-italian-twbOf5IqnW
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
eISSN
1464-360X
D.O.I.
10.1093/eurpub/cky034
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Primordial prevention is essential for promoting cardiovascular health and longevity through the so-called seven cardiovascular health metrics (CHMs) (i.e. smoking, body mass index, diet, physical activity, blood pressure, blood glucose and total cholesterol). Measures of muscle mass and function are recognized as powerful predictors of health-related events and survival. Therefore, the present study was undertaken to assess the prevalence and distribution of the seven CHMs and measures of muscle mass and function in an unselected cohort of community-dwellers. Methods The Longevity check-up 7+ (Lookup 7+) project is an ongoing cross-sectional survey conducted in unconventional settings (e.g. exhibitions, malls and health promotion campaigns) across Italy. CHMs are assessed through a brief questionnaire and by measurement of standing height, body weight, blood glucose, blood cholesterol and blood pressure. Muscle mass is estimated from calf circumference, whereas muscle strength and function are measured via handgrip strength and chair-stand testing, respectively. Results Analyses were conducted in 6323 community-living adults (mean age: 54 ± 15 years, 57% women) recruited between 1 June 2015 and 30 June 2017. Participants presented on average 4.3 ± 1.3 ideal CHMs, which decreased with age. Only 19.5% of participants met >5 ideal metrics, while 8.3% met <3. All seven ideal metrics were met by 4.7% of enrollees. Muscle mass, strength and function declined progressively with age, starting at 45–50 years. Conclusion Our population showed suboptimal CHMs scores, with very low prevalence of all ideal metrics. The number of ideal metrics decreased progressively with age and so did muscle mass and function. Introduction Cardiovascular disease (CVD) is the main cause of morbidity and mortality in developed countries, in spite of widespread implementation of preventive strategies and the development of effective therapeutic options.1,2 While primary and secondary prevention measures target individuals who have suffered a cardiovascular event or present with one or more risk factors, primordial prevention aims at promoting cardiovascular health at the population level.3,4 This may be accomplished through the assessment of various cardiovascular health factors and behaviors, including smoking, body mass index (BMI), healthy diet, engagement in physical activity, blood pressure, blood glucose and total blood cholesterol.5 A recent systematic review found that meeting an increasing number of ideal cardiovascular health metrics (CHMs) was associated with lower prevalence and incidence of both CVD-related and non-CVD outcomes such as cancer, depression and cognitive impairment.6 The authors also reported that the prevalence and distribution of CHMs was relatively homogeneous between US and non-US populations, with low proportions of people meeting six or more ideal metrics.6 Besides traditional risk factors, skeletal muscle mass and function are increasingly recognized as powerful predictors of incident CVD and other relevant health-related outcomes.7–10 It is therefore plausible that the combination of the seven CHMs with ‘unconventional’ risk factors pertaining to muscle mass and function may provide a more comprehensive outlook of an individual's cardiovascular health and new targets for prevention. The present study was therefore undertaken to collect information on the prevalence and distribution of CHMs and measurements of muscle mass and function in an unselected cohort of Italian adults living in the community. The time needed to complete the assessment and participant acceptance were also determined. Methods The Longevity check-up 7+ (Lookup 7+) project is an ongoing initiative developed by the Department of Geriatric Medicine of the Catholic University of the Sacred Heart (Rome, Italy). The initiative was designed to raise awareness in the general population on major lifestyle behaviors and cardiovascular risk factors. Since the program did not aim at testing any pre-specified hypothesis, no sample size calculation was conducted. A team of medical doctors, researchers, and nutritionists assess people visiting public places (e.g. malls and exhibition centers) and those adhering to prevention campaigns launched by our department. These locations are chosen because allowing for enrolling relatively unselected participants, outside of conventional healthcare or research settings. Candidates are considered to be eligible for enrolment if they are at least 18 years of age and provide written informed consent. Pregnancy, inability to perform functional tests and unwillingness to give written informed consent are considered exclusionary. The study protocol was approved by the Catholic University Ethics Committee (protocol #: A.1220/CE/2011). The manuscript was prepared in compliance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) reporting guidelines for observational studies. Study sample The present study was conducted in participants enrolled between 1 June 2015 and 30 June 2017. Recruitment took place in the following settings: Milan EXPO 2015 (Milan, June–October 2015), Mese del Cuore (Rome, October–September 2016), La Romanina—Check your Longevity (Rome, December 2017), Mese del Cuore (Milan, March–April 2017), Ministry of Health—Women’s Day (Rome, April 2017), CamBio Vita (Catania, May 2017), COOP shopping centers (Bologna, Modena, Genoa, Rimini and Grosseto, May–June 2017). Depending on the setting, the initiative was advertized in newspapers, magazines and TV broadcasting. Visitors were also invited to participate by direct contact. Data collection People who accepted to be screened underwent individual assessments consisting of a brief questionnaire, the measurement of objective CHMs, and the evaluation of anthropometric parameters [BMI, calf circumference (CC)], and functional performance (handgrip strength and lower extremity muscle power). Each Lookup 7+ evaluation was structured according to the same schedule: informed consent acquisition, lifestyle interview, measurement of blood pressure, body weight and standing height, CC, handgrip strength test, chair-stand test. Participant satisfaction with the Lookup 7+ evaluation was assessed through a 4-level rating scale (‘Very satisfied’, ‘Satisfied’, ‘Neither satisfied nor dissatisfied’, ‘Dissatisfied’). Assessment of cardiovascular health metrics The seven CHMs were assessed through closed questions and direct measurements.11,12 Smoking status was defined as follows: current smoker (has smoked 100+ cigarettes in lifetime and currently smokes cigarettes), never smoked (has never smoked or has smoked <100 cigarettes in lifetime) and former smoker (has smoked at least 100 cigarettes in lifetime but had quit at least 28 days before the interview). For the purpose of the analyses, smoking status was categorized as current or never/former smoker. Sedentariness was considered as the lack of involvement in any kind of physical activity for a minimum of two times a week.13 To be assigned to the physically active group the following activities were considered: light walking for at least 30 min per session, cycling, swimming, running or practicing resistance training for at least 15 min per session.13 An analogue medical scale was used to measure body weight, while body height was measured through a standard stadiometer. BMI was then calculated as the weight (kg) divided by the square of height (m). BMI was categorized as <18.5 (underweight), 18.5–24.9 (normal), 25.0–29.9 (overweight) and ≥30.0 (obesity). Healthy diet was considered as the consumption of at least three portions of fruit and/or vegetables per day. As previously reported,14 daily intake of fruit and vegetables was calculated based on reference tables for the Italian population released by the Italian Society of Nutrition (SINU). Accordingly, three or more portions of fruit and/or vegetables correspond to >400 g, which is the minimum amount recommended by the World Health Organization. The use of three or more portions to identify a healthy diet is in line with Italian dietary habits for fruit and vegetables which are typically eaten during the main meals rather than as snacks.15 Reference amounts are available at http://www.sinu.it/html/cnt/larn.asp. Cholesterol was measured from capillary blood samples using disposable strips based on a reflectometric system with a portable device (MultiCare-In, Biomedical Systems International srl, Florence Italy).16 Total blood cholesterol was categorized as <200 mg/dl (if untreated), 200–239 mg/dl (or treated to goal) and ≥240 mg/dl. Lipid-lowering drug use was also recorded. Blood glucose was measured from capillary blood samples using disposable strips based on an amperometric system with a MultiCare-In portable device.16 Participants who declared being diabetic and those who presented with a random blood glucose level >200 mg/dl were considered to be suffering from diabetes. Blood pressure was measured with an electronic sphygmomanometer according to recommendations from international guidelines.17 Blood pressure values were categorized as <120/80 mmHg (if untreated), 120/80–139/89 mmHg (or treated to goal) and ≥140/90 mmHg. Antihypertensive drug use was also recorded. The following findings were considered as ideal CHMs: never/former smoker, regular engagement in physical activity, BMI 18.5–24.9, healthy diet, untreated total blood cholesterol <200 mg/dl, absence of diabetes, untreated blood pressure <120/80 mmHg. One point was assigned to each ideal metric, while a score of 0 was attributed to non-ideal categories. The CHMs score was finally calculated as the sum of individual items.12 Estimation of muscle mass and measurement of physical performance Muscle mass was estimated by measuring CC using a standard flexible tape, as described elsewhere.18 Muscle strength was assessed by using a North Coast handheld hydraulic dynamometer (North Coast Medical, Morgan Hill, CA), as previously described.19 Participants performed one familiarization trial and one measurement trial with each hand, and the result from the stronger side was used for the analyses. Lower extremity muscle power was determined by the chair-stand test.15 The test, a component of the Short Physical Performance Battery (SPPB),20 involves standing up from a chair with the arms folded across the chest five times in a row as quickly as possible. The time taken to complete the task was recorded. Statistical analysis Characteristics of study participants are described according to the different surveys. Data were analyzed to obtain descriptive statistics. Normal distribution of continuous variables was ascertained through the Kolmogorov–Smirnov test. Data for continuous variables are expressed as mean ± standard deviation (SD), whereas categorical variables are presented as absolute numbers and percentages. The primary focus of the analytic plan was to explore the distribution of CHMs and muscle mass and function measurements across ages and genders. To this aim, the study sample was divided in the following age groups: <25, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79 and 80+ years. Differences in proportions and means of covariates across genders and age groups were assessed using the Fisher’s Exact test and one-way analysis of variance (ANOVA) statistics, respectively. All analyses were performed using the SPSS software (version 11.0, SPSS Inc., Chicago, IL), with statistical significance set at P < 0.05. Results During the enrolment time-frame considered for the present study, 6323 participants were recruited. The main characteristics of the study population according to the individual surveys are shown in table 1. The mean age of enrollees was 54.2 years (SD 15.2, range 18–98 years) and 3595 (57%) were women. Age and gender distribution was homogeneous across surveys, with the exception of lower age of participants enrolled during Milan EXPO and CamBio Vita Catania, and an expected higher representation of women at the Ministry of Healthy—Women’s Day. Table 1 General characteristics of the study sample according to the different surveys Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Note: Data are given as number (percent) for gender, smoking habit, physical activity and healthy diet; for all other variables, means and standard deviation are reported. Table 1 General characteristics of the study sample according to the different surveys Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Characteristics Total sample EXPO Milan 2015 Mese del Cuore— Rome La Romanina— Check your Longevity Mese del Cuore—Milan Ministry of Health— Women's Day CamBio Vita— Catania COOP shopping centers (n = 6323) (n = 3201) (n = 1206) (n = 266) (n = 949) (n = 98) (n = 216) (n = 387) Age (years) 54.2 ± 15.2 51.9 ± 15.5 58.8 ± 14.0 52.6 ± 14.4 55.4 ± 15.0 51.4 ± 15.6 50.6 ± 13.8 59.8 ± 12.9 Gender (female) 3595 (57) 1693 (53) 671 (55) 145 (54) 655 (69) 73 (74) 110 (51) 248 (64) Smoking (current) 1043 (16) 535 (17) 216 (18) 40 (15) 130 (14) 18 (18) 62 (28) 42 (11) Physical activity (yes) 3772 (59) 2098 (65) 686 (57) 123 (46) 537 (57) 50 (50) 105 (49) 173 (45) Healthy diet (yes) 4556 (72) 2598 (81) 790 (65) 174 (65) 623 (65) 58 (58) 73 (38) 240 (72) BMI (kg/m2) 25.4 ± 4.3 25.2 ± 4.2 26.4 ± 4.6 26.1 ± 4.1 24.9 ± 4.3 24.9 ± 4.5 26.0 ± 4.1 25.1 ± 3.9 SBP (mmHg) 126 ± 17 129 ± 17 125 ± 15 121 ± 16 121 ± 15 115 ± 16 115 ± 15 126 ± 19 DBP (mmHg) 76 ± 10 79 ± 9 75 ± 10 73 ± 9 72 ± 9 71 ± 9 70 ± 10 75 ± 10 Total blood cholesterol (mg/dl) 211 ± 35 209 ± 38 205 ± 35 208 ± 28 219 ± 28 210 ± 28 216 ± 22 225 ± 32 Blood glucose (mg/dl) 103 ± 23 106 ± 26 103 ± 19 104 ± 20 96 ± 19 100 ± 25 105 ± 23 99 ± 19 Cardiovascular health metrics score 4.3 ± 1.3 4.5 ± 1.2 4.1 ± 1.3 4.1 ± 1.3 4.2 ± 1.2 4.3 ± 1.3 3.7 ± 1.4 4.0 ± 1.2 Calf circumference (cm) 35.4 ± 3.4 36.0 ± 3.1 34.7 ± 3.5 34.9 ± 4.0 34.8 ± 3.3 36.7 ± 4.4 35.8 ± 3.0 34.6 ± 3.6 Chair-stand test (s) 7.7 ± 2.2 7.5 ± 2.0 8.1 ± 2.4 7.7 ± 1.8 7.7 ± 1.8 7.5 ± 4.0 7.6 ± 2.1 8.1 ± 2.8 Handgrip strength (kg) 31.6 ± 11.8 33.5 ± 11.8 28.9 ± 11.7 32.1 ± 12.3 29.7 ± 11.4 28.6 ± 10.7 31.9 ± 11.7 30.6 ± 11.8 Note: Data are given as number (percent) for gender, smoking habit, physical activity and healthy diet; for all other variables, means and standard deviation are reported. Current smoking was recorded in 1043 (16%) participants. Engagement in regular physical activity and consumption of healthy diet were pursued by 3772 (59%) and 4556 (72%) participants, respectively. The mean BMI was 25.4 kg/m2 (SD 4.3). Ideal body weight, as defined as BMI 18.5–24.9 kg/m2, was recorded in 3190 (51%) participants. Non-treated blood pressure <120/80 mmHg was found in 2530 (42%) enrollees. The mean total blood cholesterol was 211 mg/dl (SD 35), with 2021 (34%) participants presenting ideal blood cholesterol with no pharmacological treatment. Finally, mean blood glucose was 103 mg/dl (SD 23), with 5675 (92%) participants being free of diabetes. Overall, Lookup 7+ participants presented on average 4.3 (SD 1.3) ideal CHMs. 1233 (19.5%) participants met >5 ideal CHMs, while 525 (8.3%) showed <3 ideal health metrics. Only 297 (4.7%) enrollees met all seven ideal CHMs. Means and SDs for individual CHMs and cumulative scores according to age groups are shown in figure 2. Active smoking was more frequent among younger individuals, peaking in males aged 25–29. Past the age of 45, the prevalence of smoking decreased progressively reaching 6% in 80+ year-old men (figure 1A). Regular participation in physical activity was higher in young and old age groups, with a significant deflection between 35 and 55 years of age. In all age groups, men were more physically active than women (figure 1B). Conversely, adherence to healthy diet was more frequent in women. The prevalence of healthy diet was found to be around 60% in young and adult participants. The frequency of healthy diet increased starting at 55 years and reached about 80% in the oldest age group (figure 1C). Figure 1 View largeDownload slide Prevalence of current smoking (A), engagement in regular physical activity (B), and adherence to healthy diet (C) in men and women across age groups. Data are shown as percentages (n = 6323) Figure 1 View largeDownload slide Prevalence of current smoking (A), engagement in regular physical activity (B), and adherence to healthy diet (C) in men and women across age groups. Data are shown as percentages (n = 6323) Figure 2 View largeDownload slide Mean body mass index (A), systolic blood pressure (B), diastolic blood pressure (C), total blood cholesterol (D), blood glucose (E), and cardiovascular health metrics score (F) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) Figure 2 View largeDownload slide Mean body mass index (A), systolic blood pressure (B), diastolic blood pressure (C), total blood cholesterol (D), blood glucose (E), and cardiovascular health metrics score (F) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) The BMI increased steadily up to 65–69 years in both genders and declined thereafter (figure 2A), with values >25 kg/m2 observed in men of 35–39 years and in women at the age of 60–65. Underweight (i.e. BMI <18.5 kg/m2) was detected in 167 participants (2.7%). As expected, systolic and diastolic blood pressure levels increased progressively with age starting at around 45–49 years (figure 2B and 2C). Blood cholesterol levels were significantly higher in middle-aged participants compared with younger and older age groups, without significant gender differences (figure 2D). Blood glucose increased progressively with age starting at 50–54 years (figure 2E). Conversely, CHMs scores decreased with advancing age in relation to a greater number of risk factors among older participants (in particular, blood pressure and blood glucose) (figure 2F). Women showed better scores than men in all age groups. Muscle mass and muscle strength declined significantly past the age of 45 in both genders (figure 3A and 3B). Similarly, lower extremity muscle power remained stable between 18 and 40–44 years and declined thereafter in both genders (figure 3C). Figure 3 View largeDownload slide Mean calf circumference (A), handgrip strength (B), and time to complete the chair-stand test (C) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) Figure 3 View largeDownload slide Mean calf circumference (A), handgrip strength (B), and time to complete the chair-stand test (C) in men and women across age groups. Data are shown as means ± standard deviations (n = 6323) Finally, the vast majority of participants (4917; 82%) declared to be very satisfied with the initiative, 688 (14%) were satisfied, 148 (3%) declared to be neither satisfied nor dissatisfied, and only 49 (1%) were not satisfied. Each Lookup 7+ evaluation required on average 12.8 (SD 1.6) min to be completed, with no significant differences across genders, age groups or settings. Discussion In the present study, the prevalence and age-related differences of established CHMs were explored in a large and relatively unselected sample of Italian community-dwellers. Patterns of muscle mass and physical performance decline with age were also determined to obtain a more comprehensive characterization of the participant health status. These investigations were made possible through the implementation of a simple and quick screening tool. Participants of the Lookup 7+ project met an average of four ideal CHMs, a slightly higher number than previously reported in other European and US surveys.11,12,21 Only two out of 10 participants met >5 ideal health metrics, while almost one out of 10 met <3 ideal metrics. High blood pressure, elevated blood cholesterol and sedentariness were the most prevalent non-ideal CHMs. In contrast, diabetes and active smoking were the least frequent risk factors. The present data also indicate that muscle mass, strength and function decline across age groups, starting at approximately 50 years. Noticeably, advancing age is accompanied by substantial changes in body composition and, as a consequence, in glucose and lipid metabolism.15 Declining muscle mass and increases in adiposity are also independently associated with the development of hypertension.22,23 Alterations of glucose and lipid metabolism, deterioration of body composition and high blood pressure describe the so-called metabolic syndrome, the prevalence of which is well known to be higher in older adults.24–26 Smoking cessation in late adulthood and old age is a well-described phenomenon and so is the increased propensity to follow a healthier diet compared with younger people.27,28 This latter finding is in line with a report by the Progressi delle Aziende Sanitarie per la Salute in Italia (PASSI) survey, in which the prevalence of healthy diet was indeed higher in late adulthood and in women.29 In contrast, the consumption of fruit and vegetable reported by the Lookup 7+ population seems to be higher than that reported by the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey.30 Though, the different way healthy diet was defined in the three surveys impedes a thorough comparison among the studies. Quite unexpectedly, older Lookup 7+ participants declared to engage in regular physical activity more often than middle-aged enrollees. Remarkably, almost 30% of the youngest Lookup 7+ enrollees declared not to be engaged in any kind of physical activity, a moderately higher percentage than reported by Teleman et al.31 among Italian university students. Overall, the present data support the fact that the age between 35 and 55 years is critical for cardiovascular risk. Indeed, in this age group, a generalized worsening of CHMs was observed. It is also noteworthy that during this period of life, muscle mass, strength and physical performance begin to decline. Middle age is therefore a crucial time for implementing specific screening and prevention campaigns to foster active longevity.3,13 This would allow for preventing irreversible cardiovascular damage to accrue and delaying the decline in physical function. In this context, a screening tool such as the one implemented in the Lookup 7+ project may serve as an easy-to-apply instrument to raise awareness on cardiovascular prevention in the general population and promote public health, especially outside of conventional healthcare settings. Albeit dealing with a highly relevant issue, the present study presents some limitations that deserve being discussed and taken into account in the interpretation of results. First, although a priori selection criteria were not set, candidate participants had to be able to reach shopping centers or exhibition places. This requisite may have selected a relatively healthy and functionally competent population. Since the initiative was mostly advertised in newspapers, magazines and TV broadcasting, the response rate could not be calculated, which may limit the representativeness of findings. Although anthropometric measures are frequently adopted for estimating lean body mass, they do not represent the gold standard for the quantification of muscle mass.32 However, the measurement of CC provides an easy-to-apply, inexpensive, non-invasive and reproducible means for muscle mass estimation, particularly suitable for community-based studies.13–15,18,19 The study setting may have influenced the assessment of some CHMs. Indeed, random cholesterol and glucose determinations could overestimate both parameters. Furthermore, cholesterol and glucose levels were determined in capillary blood samples. Although this procedure was previously validated,11 the error of portable devices is higher than with standard equipment. Despite the fact that blood pressure was measured following international guidelines, it is possible that the setting may have influenced the measurement outcome. Since evaluations were performed throughout the day, the possibility cannot be discarded that some participants may have been walking for longer time than others, which could have an impact on their performance levels. To limit this potential bias, participants were allowed to rest until they felt comfortable with the strength testing. Finally, results were obtained from cross-sectional surveys and differences in birth cohort might have influenced some parameters. For instance, the higher prevalence of healthy diet observed among older participants could be related to an intrinsic attitude of this birth cohort and not be associated to an actual age-related change. Despite these limitations, the Lookup 7+ project offered the unique opportunity to investigate the prevalence of CHMs and age- and gender-specific trends of muscle mass and function in a large sample of Italian community-living people. Our project showed that a quick, yet rather comprehensive screening program provides useful health information at the population level, besides being very well accepted by participants. The Lookup 7+ project may therefore represent a prototypical approach to raise awareness on unhealthy behaviors and cardiovascular risk factors in the general population. Acknowledgements The authors thank the entire Lookup 7+ team (Giulia Battaglia, Vincenzo Brandi, Marianna Broccatelli, Camilla Cattaneo, Agnese Collamati, Giuseppe Colloca, Emanuela D'Angelo, Mariaelena D'Elia, Domenico Fusco, Ambra Maestroni, Alessandra Nesossi, Monica Ramaschi, Alex Sisto and Alice Tappella) for their great enthusiasm in performing participant assessments. Funding The Lookup 7+ project was supported by Italia Longeva; Marche Region; Ferrarini, Tedaldi, Fileni, and Elanco; Danone Italia; and Merck Sharp & Dohme Italia. The study was also partly supported by intramural research grants from the Catholic University of the Sacred Heart (D3.2 2013 and D3.2 2015) and by the non-profit research foundation ‘Centro Studi Achille e Linda Lorenzon’. Conflicts of interest: R.C., F.L., E.M. and M.T. are partners of the SPRINTT Consortium, which is partly funded by the European Federation of Pharmaceutical Industries and Associations (EFPIA). All other authors declare no conflict of interest. Key points The implementation of the cardiovascular health metrics paradigm may be used to raise awareness in the general population on major lifestyle behaviors and risk factors for cardiovascular disease. Skeletal muscle mass and function have emerged as novel predictors of incident cardiovascular disease and other health-related outcomes. Overall, participants in the Lookup 7+ project met <5 ideal cardiovascular health metrics. Only a small proportion of enrollees met all seven ideal metrics. The number of ideal cardiovascular health metrics was higher in women and declined with advancing age. High blood pressure, elevated blood cholesterol and lack of physical activity were the most prevalent non-ideal cardiovascular health metrics. Diabetes and active smoking were the least frequent risk factors. Muscle mass, strength and function declined progressively with age in both genders, starting at 45–50 years. References 1 Laaksonen M , Talala K , Martelin T , et al. Health behaviours as explanations for educational level differences in cardiovascular and all-cause mortality: a follow-up of 60 000 men and women over 23 years . Eur J Public Health 2008 ; 18 : 38 – 43 . Google Scholar CrossRef Search ADS PubMed 2 Roger VL , Go AS , Lloyd-Jones DM , et al. Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association . Circulation 2012 ; 125 : 188 – 97 . Google Scholar CrossRef Search ADS PubMed 3 Ose D , Rochon J , Campbell SM , et al. Health-related quality of life and risk factor control: the importance of educational level in prevention of cardiovascular diseases . Eur J Public Health 2014 ; 24 : 679 – 84 . Google Scholar CrossRef Search ADS PubMed 4 GBD 2015 Eastern Mediterranean Region Cardiovascular Disease Collaborators AH , Mokdad AH . Burden of cardiovascular diseases in the Eastern Mediterranean Region, 1990–2015: findings from the Global Burden of Disease 2015 study . Int J Public Health 2017 . doi: 10.1007/s00038-017-1012-3. [Epub ahead of print]. 5 Lloyd-Jones DM , Hong Y , Labarthe D , et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond . Circulation 2010 ; 121 : 586 – 613 . Google Scholar CrossRef Search ADS PubMed 6 Younus A , Aneni EC , Spatz ES , et al. A systematic review of the prevalence and outcomes of ideal cardiovascular health in US and non-US populations . Mayo Clin Proc 2016 ; 91 : 649 – 70 . Google Scholar CrossRef Search ADS PubMed 7 Rantanen T , Masaki K , He Q , et al. Midlife muscle strength and human longevity up to age 100 years: a 44-year prospective study among a decedent cohort . Age (Dordr) 2012 ; 34 : 563 – 70 . Google Scholar CrossRef Search ADS PubMed 8 Timpka S , Petersson IF , Zhou C , Englund M . Muscle strength in adolescent men and risk of cardiovascular disease events and mortality in middle age: a prospective cohort study . BMC Med 2014 ; 12 : 62 . Google Scholar CrossRef Search ADS PubMed 9 Srikanthan P , Horwich TB , Tseng CH . Relation of muscle mass and fat mass to cardiovascular disease mortality . Am J Cardiol 2016 ; 117 : 1355 – 60 . Google Scholar CrossRef Search ADS PubMed 10 Andersen K , Rasmussen F , Held C , Neovius M , Tynelius P , Sundström J . Exercise capacity and muscle strength and risk of vascular disease and arrhythmia in 1.1 million young Swedish men: cohort study . BMJ 2015 ; 351 : h4543 . Google Scholar CrossRef Search ADS PubMed 11 Vetrano DL , Martone AM , Mastropaolo S , et al. Prevalence of the seven cardiovascular health metrics in a Mediterranean country: results from a cross-sectional study . Eur J Public Health 2013 ; 23 : 858 – 62 . Google Scholar CrossRef Search ADS PubMed 12 Yang Q , Cogswell ME , Flanders WD , et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults . JAMA 2012 ; 307 : 1273 – 83 . Google Scholar CrossRef Search ADS PubMed 13 Landi F , Calvani R , Picca A , et al. Impact of habitual physical activity and type of exercise on physical performance across ages in community-living people . PLoS One 2018 ; 13 : e0191820 . Google Scholar CrossRef Search ADS PubMed 14 Marzetti E , Hwang A-C , Tosato M , et al. Age-related changes of skeletal muscle mass and strength among Italian and Taiwanese older people: results from the Milan EXPO 2015 survey and the I-Lan Longitudinal Aging Study . Exp Gerontol 2018 ; 102 : 76 – 80 . Google Scholar CrossRef Search ADS PubMed 15 Landi F , Calvani R , Tosato M , et al. Age-related variations of muscle mass, strength, and physical performance in community-dwellers: results from the Milan EXPO survey . J Am Med Dir Assoc 2017 ; 18 : 88.e17 – e24 . Google Scholar CrossRef Search ADS 16 Rapi S , Bazzini C , Tozzetti C , et al. Point-of-care testing of cholesterol and triglycerides for epidemiologic studies: evaluation of the multicare-in system . Transl Res 2009 ; 153 : 71 – 6 . Google Scholar CrossRef Search ADS PubMed 17 Mancia G , De Backer G , Dominiczak A , et al. 2007 Guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) . Eur Heart J 2007 ; 28 : 1462 – 536 . Google Scholar PubMed 18 Landi F , Onder G , Russo A , et al. Calf circumference, frailty and physical performance among older adults living in the community . Clin Nutr 2014 ; 33 : 539 – 44 . Google Scholar CrossRef Search ADS PubMed 19 Landi F , Calvani R , Tosato M , et al. Impact of physical function impairment and multimorbidity on mortality among community-living older persons with sarcopaenia: results from the ilSIRENTE prospective cohort study . BMJ Open 2016 ; 6 : e008281 . Google Scholar CrossRef Search ADS PubMed 20 Guralnik JM , Simonsick EM , Ferrucci L , et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission . J Gerontol 1994 ; 49 : M85 – 94 . Google Scholar CrossRef Search ADS PubMed 21 Hulsegge G , van der Schouw YT , Daviglus ML , et al. Determinants of attaining and maintaining a low cardiovascular risk profile—the Doetinchem Cohort Study . Eur J Public Health 2016 ; 26 : 135 – 40 . Google Scholar CrossRef Search ADS PubMed 22 Stafford M , Soljak M , Pledge V , Mindell J . Socio-economic differences in the health-related quality of life impact of cardiovascular conditions . Eur J Public Health 2012 ; 22 : 301 – 5 . Google Scholar CrossRef Search ADS PubMed 23 de Oliveira C , Marmot MG , Demakakos P , et al. Mortality risk attributable to smoking, hypertension and diabetes among English and Brazilian older adults (The ELSA and Bambui cohort ageing studies) . Eur J Public Health 2016 ; 26 : 831 – 5 . Google Scholar CrossRef Search ADS PubMed 24 Lee W-J , Peng L-N , Chiou S-T , Chen L-K . Relative handgrip strength is a simple indicator of cardiometabolic risk among middle-aged and older people: a nationwide population-based study in Taiwan . PLoS One 2016 ; 11 : e0160876 . Google Scholar CrossRef Search ADS PubMed 25 Kósa Z , Moravcsik-Kornyicki Á , Diószegi J , et al. Prevalence of metabolic syndrome among Roma: a comparative health examination survey in Hungary . Eur J Public Health 2015 ; 25 : 299 – 304 . Google Scholar CrossRef Search ADS PubMed 26 Jansen-Chaparro S , Mancera J , Cuende JI , et al. Metabolic syndrome and vascular risk estimation in a Mediterranean non-diabetic population without cardiovascular disease . Eur J Intern Med 2012 ; 23 : 558 – 63 . Google Scholar CrossRef Search ADS PubMed 27 van Loon AJM , Tijhuis M , Surtees PG , Ormel J . Determinants of smoking status: cross-sectional data on smoking initiation and cessation . Eur J Public Health 2005 ; 15 : 256 – 61 . Google Scholar CrossRef Search ADS PubMed 28 Toft UN , Kristoffersen LH , Aadahl M , et al. Diet and exercise intervention in a general population—mediators of participation and adherence: the Inter99 study . Eur J Public Health 2007 ; 17 : 455 – 63 . Google Scholar CrossRef Search ADS PubMed 29 Guberti E . Feeding health: problems, opportunities, goals . Ann Ig 2014 ; 26 : 121 – 30 . Google Scholar PubMed 30 Giampaoli S , Krogh V , Grioni S , et al. Eating behaviours of Italian adults: results of the Osservatorio Epidemiologico Cardiovascolare/Health Examination Survey . Epidemiol Prev 2015 ; 39 : 373 – 9 . Google Scholar PubMed 31 Teleman AA , De Waure C , Soffiani V , et al. Physical activity and health promotion in Italian university students . Ann Ist Super Sanità 2015 ; 51 : 106 – 10 . Google Scholar PubMed 32 Tosato M , Marzetti E , Cesari M , et al. Measurement of muscle mass in sarcopenia: from imaging to biochemical markers . Aging Clin Exp Res 2017 ; 29 : 19 – 27 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

The European Journal of Public HealthOxford University Press

Published: Mar 14, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off