Clustering of Unhealthy Behaviors in the Aerobics Center
James R. Hebert
Steven N. Blair
Published online: 18 October 2011
The Author(s) 2011. This article is published with open access at Springerlink.com
Background Clustering of unhealthy behaviors has been
reported in previous studies; however the link with all-
cause mortality and differences between those with and
without chronic disease requires further investigation.
Objectives To observe the clustering effects of unhealthy
diet, fitness, smoking, and excessive alcohol consumption
in adults with and without chronic disease and to assess all-
cause mortality risk according to the clustering of unhealthy
Methods Participants were 13,621 adults (aged 20–84)
from the Aerobics Center Longitudinal Study. Four health
behaviors were observed (diet, fitness, smoking, and
drinking). Baseline characteristics of the study population
and bivariate relations between pairs of the health behaviors
were evaluated separately for those with and without
chronic disease using cross-tabulation and a chi-square test.
The odds of partaking in unhealthy behaviors were also
calculated. Latent class analysis (LCA) was used to assess
clustering. Cox regression was used to assess the relation-
ship between the behaviors and mortality.
Results The four health behaviors were related to each
other. LCA results suggested that two classes existed.
Participants in class 1 had a higher probability of partaking
in each of the four unhealthy behaviors than participants in
class 2. No differences in health behavior clustering were
found between participants with and without chronic
disease. Mortality risk increased relative to the number of
unhealthy behaviors participants engaged in.
Conclusion Unhealthy behaviors cluster together irrespec-
tive of chronic disease status. Such findings suggest that
multi-behavioral intervention strategies can be similar in
those with and without chronic disease.
Keywords Health behaviors
There is much uncertainty and debate about the proportion
of mortality in the United States and other developed
countries attributable to tobacco smoking, poor diet,
physical inactivity, and excessive alcohol consumption;
however, there is agreement that these four unhealthy
behaviors account for the vast majority of preventable
causes of death (Adler and Rehkopf 2008; Lopez et al.
2006; Mathers and Loncar 2006; World Health Organiza-
tion 2009). There also is evidence that these four unhealthy
behaviors often occur simultaneously within an individual
(Chiolero et al. 2006; Fine et al. 2004; Kvaavik et al. 2010;
Laaksonen et al. 2001; Poortinga 2007; Schuit et al. 2002).
For example, a recent study reported that over 70% of
adults with one of these four unhealthy behaviors engaged
in at least one of the remaining three (Poortinga 2007).
Despite this evidence, the majority of public health and
I. Janssen (*)
School of Kinesiology and Health Studies, Queen’s University,
28 Division Street Kingston,
Ontario, Canada K7L 3 N6
S. N. Blair
Department of Exercise Science, University of South Carolina,
J. R. Hebert
S. N. Blair
Epidemiology and Biostatistics, Arnold School of Public Health,
University of South Carolina,
Prev Sci (2012) 13:183–195