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Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Chaim Sheba Medical Center, Tel Hashomer, Israel
3To whom correspondence and reprint requests should be addressed. E-mail: floral{at}gertner.health.gov.il.
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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25 g of dietary fiber daily [HR = 0.57 (95% CI: 0.41–0.72)], and 42% lower for those consuming <300 mg/d of cholesterol [HR = 0.58 (95% CI: 0.34–0.96)]. Accumulating an average of 0.5 h/d of moderate physical activity reduced mortality by 47% [HR = 0.53 (95% CI: 0.29–0.97)]. Smoking, increased systolic BP, older age and male sex increased mortality risk. We conclude that in our study, although ethnic origin and lifestyle habits are interrelated, each affects mortality independently.
KEY WORDS: • ethnicity • nutrition • lifestyle habits • mortality
Reported associations between dietary habits and mortality risk are contradictory, although populations characterized by specific dietary habits were found to differ in their morbidity and mortality risk. An example is the Mediterranean 16 countries diet study, in which countries were characterized by their similarities in food patterns and by their relatively lower mortality rate (1 ), a finding that led to portraying the health benefits of a "Mediterranean diet" (1 –6 ). Identification of ethnic-related dietary patterns and their contribution to health was shown to have a great effect on guidelines for general healthy diets in public health education programs.
Ethnicity is a complex construct of biology, culture, language, religion and distinct health beliefs and behaviors, encompassing a range of biological and environmental exposures (7 ). In the absence of more detailed historical information, demographers in Israel prefer to describe ethnicity by geographical area of birth.
Migrant populations provide an opportunity to study differences in morbidity and mortality patterns in populations that are exposed to various environments (8 ). After immigration, lifestyle characteristics are usually maintained for a few decades, even while absorbing local patterns.
The influence of lifestyle patterns on longevity on the one hand, and mortality on the other, has been evaluated in numerous ecological and analytical studies. Avoiding cigarette smoking, (9 –11 ) maintaining a normal body mass index (BMI), (12 ,13 ) and adding physical activity into the daily activities, (11 –19 ) are well-studied lifestyle habits, strongly associated with decreased rates of mortality.
The Israeli population is characterized by its marked ethnic diversity; Middle East, Yemen/Aden, North Africa and Europe/America comprise the four representative ethnic groups that constitute the Israeli Jewish population (20 –22 ). In Israel, traditional ethnic food, acquired in their country of origin, has remained in the diet of ethnic migrant subgroups for generations and may play a role in the differences in morbidity and mortality patterns observed among the Israeli subpopulations. The aim of the present study was to evaluate the association between dietary and other lifestyle patterns, and 18-y all-cause mortality in a sample of the four main ethnic groups of the Israeli population.
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SUBJECTS AND METHODS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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A sample of 8400 subjects was obtained in 1968 from the Israeli Central Population Registry, stratified according to sex, year of birth and ethnic origin. The sample was approached twice between 1969 and 1972, and 1977 and 1983. A subgroup of 632 subjects residing in the central area of Israel, free of diabetes or other major chronic disease, was drawn from this cohort. Members of the sample were interviewed personally in 1982 to assess dietary intake and physical activity habits. This sample was 41–70 y old at the time of interview. A detailed description of the total cohort methodology has been described (20 –22 ). Nine subjects, who reported extreme values of dietary intake, were considered to be of low credibility and were therefore excluded from the analysis, which was finally based on 623 subjects.
Ethnic origin.
Ethnic origin was determined according to the subjects’ country of origin; among Israeli born (n = 119), origin was determined according to the father’s country of birth. Countries of origin were categorized into four geographical groups: Yemen+Aden, Europe+America, North Africa and the Middle East.
Assessment of dietary intake.
A detailed, quantified dietary food-frequency questionnaire including >240 food items was developed in our department, and has been used repeatedly in dietary studies. Its methodology was also evaluated and described in detail (22 ).
It was planned to include known traditional ethnic foods and to allow the recording of additional reported foods in open-ended spaces, by asking if there are additional foods consumed by interviewee that were not mentioned. For reported foods that did not appear in the local food composition tables, we deliberately collected these recipes; for some, we were present during their preparation at family homes and documented their ingredients. Food components/100 g were calculated and added to the nutritional data program. "Ethnic" foods were identified in the program by a specific two-digit code. This questionnaire was home administered to participants by well-trained interviewers.
Based on international (23 ) and local (24 ) sources as well as calculation of food components out of home-prepared recipes, a comprehensive computerized program was developed specifically for dietary data analysis. The program includes macro- and micronutrient content/100 g and portion sizes; it also accounts for length of season for relevant foods. Dietary fiber food content values were based on published food composition tables (23 ).
Reported food consumption (monthly and weekly) was converted into mean daily amounts. First the program converted all frequencies into a weekly frequency, all portion sizes into mean weekly amounts of energy and macro- and micronutrient intake, and then to mean daily consumption.
Physical activity.
Information on physical activity was obtained for 510 (82%) consecutive subjects because the physical activity questionnaire was introduced after the beginning of the study. The questionnaire was designed to address sedentary middle-aged individuals (20 –22 ). Information included frequency (daily, weekly or monthly) and amount of time spent (hours or minutes per day) in resting, light as well as moderate physical activity, at work, during housekeeping and at leisure. Physical activity was categorized according to the Centers for Disease Control and Prevention (25 ) recommendation on increasing energy expenditure by accumulating a daily 30 min or more of moderate physical activity.
Other parameters studied: relative weight, blood pressure and smoking habits.
Study nurses measured weight and height at home using standard calibrated transportable scales and a uniform technique for measuring height. BMI [weight (kg)/height (m2)] was calculated and three categories were defined: normal/low: BMI <25, overweight 25–29.9 or obese 30 kg/m2. Blood pressure measurements were also performed at the participants’ homes on two consecutive days. The mean value of the measurements from both days was used in this analysis. Cigarette smoking was categorized as past, current or never smoked.
Mortality ascertainment.
Date and cause of death were obtained by linkage of the study file with the Israeli Central Population Registry file according to a personal identification number. The mortality follow-up period was from the year of interview beginning in 1982 until June 2000.
Statistical analysis.
Food components were analyzed as continuous and as categorical variables. Categories were defined according to the following guidelines (26
): <35% of mean daily energy from total fat; <300 mg of mean daily cholesterol intake; 25 g of mean daily dietary fiber intake; a ratio of unsaturated to saturated fatty acids 2; and monounsaturated to saturated and polyunsaturated to saturated fat ratios 1. Preliminary analyses done separately for men and women showed similar consumption gradients among ethnic groups for both sexes. Therefore, combined analyses were performed.
Differences among ethnic origins with respect to categorical variables were analyzed by X2 tests for contingency tables, and by the general linear model for continuous variables.
Cox proportional hazards models were used to calculate both the crude and the adjusted hazard ratios (HR). The multivariate model included age (5-y increments), sex (men compared with women), ethnic origin (Yemenite as a reference group to European/American, Middle Eastern and North African), BMI categories (<25, as the reference category to 25–29.9 and 30 kg/m2), cigarette smoking (never smoked as a reference to current and past), physical activity (accumulating 30 min vs. <30 min/d), and systolic BP (increments of 5 mm Hg), as well as dietary characteristics. Regression coefficients were estimated, and the relative independent effect of each risk factor on the survival function was expressed as a HR and 95% confidence interval (CI) (27
). The significance of the effect of ethnicity was further estimated using the difference between the -2 log likelihood ratio of 2 models, i.e., one that included all covariates and a second, which included all variables, excluding origin. This difference has a 
2 distribution with 3 df. Differences among ethnic groups were considered significant at P < 0.05. All analyses were performed using the SAS (SAS Institute, Cary, NC, version 8.2) statistical software. Values in the text are means ± SD unless stated otherwise.
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RESULTS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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The study included 112 (18.0%) Yemenites, 153 (24.6%) Middle Easterners, 100 (16.0%) North Africans and 258 (41.4%) Europeans/Americans. Distributions of demographic and anthropometric characteristics of the study sample for each ethnic group are presented in Table 1 . The age of the sample at baseline was 55.2 ± 8.0 y. The BMI of the overall sample was 26.2 ± 3.9 kg/m2, and it differed among study groups (P < 0.01), with North Africans having the highest index, followed by Middle Easterners, Europeans/Americans and Yemenites with the lowest. Major differences were also noted in self-reported weekly hours of physical activity (P < 0.01), with Yemenites performing 22 min of moderate to high physical activity daily compared with 12 min for Europeans/Americans. The lowest smoking rates were reported by Yemenites and the highest by Middle Easterners. Systolic BP was highest in North Africans followed by Europeans/Americans, and was significantly lower in both Yemenites and Middle Easterners.
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Yemenites had greater daily intakes of energy and macronutrients than the other ethnic groups, although their dietary composition was closer to the recommended guidelines of a "healthy diet" (Tables 2
and 3
). Almost 60% of the Yemenites complied with the recommended unsaturated to saturated fatty acids ratio of 2; 87% consumed foods with a ratio of monounsaturated to saturated fatty acids >1, and 71% consumed the recommended mean daily allowance of 25 g of dietary fiber. A more detailed analysis of food intake differences between the two extreme groups, Yemenites and European/American born in our sample, is presented in Table 4 . Yemenites’ energy consumption from their ethnic foods was greater than that of Middle Easterners and North Africans (not shown), and significantly greater compared with Europeans/Americans.
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Over the 18-y follow-up period, 151 (24%) deaths occurred [34 from cancer, 38 from cardiovascular disease (CVD), 10 from a cerebrovascular accident, 25 from other causes and 44 from unavailable causes]. The highest mortality rate was among Europeans/Americans (29.1%), and the lowest among Yemenites (16.1%; P < 0.01).
The unadjusted mortality HR and 95% CI associated with risk factors differed slightly from the adjusted values (Table 5 ). The unadjusted differences among ethnic groups were significant with North Africans, Middle Easterners and Europeans/Americans having higher rates than Yemenites (P = 0.04). Adjustment for dietary and other lifestyle habits somewhat reduced the difference between European/Americans and Yemenites; as a result, the global test between ethnic groups was not significant (P = 0.21). However, the individual pairwise comparison between European/Americans and Yemenites remained quite large [HR = 1.77 (95% CI: 1.01–3.09)] and the other two ethnic groups had HR that were not less than before adjustment. Unadjusted HR were generally similar to those that were adjusted, although the effects associated with gender and age were reduced after the addition of dietary and lifestyle factors. The association with current smoking strengthened after such adjustment, as did the associations with cholesterol consumption.
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30 min moderate to high level of physical activity per day had a 47% lower risk of mortality [HR = 0.53 (95% CI: 0.29–0.97)] compared with those having lower physical activity. BMI was not associated with mortality in our population when analyzed as a continuous variable nor when the effect of the U-shaped distribution of weight on mortality (12 ) was tested using categories of BMI.
A daily intake of 25 g of dietary fiber and consumption of <300 mg/d of cholesterol, adjusted for energy intake, independently decreased the hazard for mortality (43 and 42%, respectively). Individual foods, such as red meat, vegetables and fruits, were also evaluated but were not found to affect the risk of mortality in our study sample.
The adjusted survival curves by ethnic group indicated better survival among Yemenites followed by North Africans and Middle Easterners, with the lowest survival among Europeans/Americans (Fig. 1 ).
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DISCUSSION |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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Being of European/American origin, male sex, smoking or having increased systolic BP significantly increased the risk of mortality. On the other hand, being of Yemenite origin, accumulating at least 30 min/d of moderate-to-high levels of physical activity, or consuming the recommended amount of dietary fiber (25g/d) and cholesterol (<300 mg/d), significantly decreased this risk. Our findings of an association between ethnicity and lifestyle emphasize the importance of studying exposures of interest in relation to ethnic groups.
The unadjusted differences in mortality among ethnic groups were significant, with the North Africans, Middle Easterners and Europeans/Americans having higher rates than Yemenites (P = 0.04). Adjustment for dietary and other lifestyle habits somewhat reduced the difference between Europeans/Americans and Yemenites. However, the individual pairwise comparison between Europeans/Americans and Yemenites remained quite large [HR = 1.77 (1.01–3.09)], possibly due to other lifestyle or genetic characteristics that were not measured.
Similar findings have been reported in other countries. In Italy, the use of adherence to overall recommended levels of macronutrient intake to characterize populations’ dietary habits and mortality risk was associated with lower total mortality (6 ). A mortality follow-up on a cohort from Copenhagen used a predefined "prudent diet" as a reference, which reflected daily intake of whole-meal bread, fruits and vegetables (28 ). Consumption of this prudent diet was inversely related to adjusted all-cause mortality. A dietary pattern characterized by the consumption of recommended foods was also associated with decreased risk of mortality in women in California (29 ).
The first National Health and Nutrition Examination Survey follow-up study established a diversity foods intake score (dairy, meats, grains, fruits and vegetables), and found that diets that omitted several of these food groups, i.e., unbalanced diets, were associated with increased risk of mortality (30 ).
Although dietary fiber, as such, has not been evaluated in relation to mortality risk, a number of studies using different "healthy diet" references include the recommendation to consume more foods rich in dietary fiber to promote longer survival (31 ). For example, in a cohort of African-Americans in California (32 ) including Seventh Day Adventists, the risk of mortality decreased considerably with increased consumption of nuts and green salad, foods high in dietary fiber. Changes of up to 20% in life expectancy were observed immediately after World War II in countries such as Austria and Czechoslovakia, and these were explained by differences in patterns of food consumption. In Austria, the consumption of milk, oils, fruits, vegetables and nuts was considerably higher, although meats were consumed in similar amounts in both countries (33 ). Once again, vegetables, fruits and nuts increased the dietary fiber content.
During the last two decades, there has been a decline in mortality from CVD in the Western world. Countries with Westernized medical care systems similar to those in Australia, the United States and the UK showed differences in mortality patterns at the beginning of this decline (34 ); these were attributed to differences in the polyunsaturated to saturated fat ratio consumed in the diets. In our study, subpopulations characterized by a similar fat intake pattern were also shown to be at lower mortality risk.
The successful Finnish experience in which intervention programs were established to change national dietary habits, reducing saturated fat and increasing daily fiber consumption, has reduced national CVD mortality; a monitoring system showed that morbidity and mortality could be influenced by changes in dietary habits (35 ,36 ).
The Seven Country Study (37 ) showed that intake of saturated fatty acids was positively associated with all-cause mortality from CVD. Moreover, this pooled analysis study found that a 5% reduction in saturated fat energy intake, a 20 mg increase in vitamin C and a 10% decrease in smoking could decrease the 25-y all-cause mortality rate by 12% compared with the average all-cause mortality of 45%. Butter, lard and meat intake were selected as significant mortality markers. In the present study, we did not find animal fat or meat intake to be associated with increased mortality, although higher cholesterol intake, a component of animal fat, was identified as increasing mortality.
BMI is one of the most significant lifestyle-related factors associated with mortality (12 ). This association was not found in our study, although mean BMI was lower in Yemenites, who also had a lower mortality rate. The number of clinical and epidemiologic studies showing the benefits of regular physical activity for reducing various causes of morbidity at all ages continues to mount (10 ,11 ,15 –18 ,20 ,28 32 ,38 ). In the present study, we found that individuals who accumulated 30 min/d of moderate-to-high physical activity had decreased mortality risk.
A limitation of the present study is its relatively small sample size, which was drawn from a large cohort study; differences existed in the baseline characteristics among ethnic groups, for example, a relatively high number of younger Middle Easterners. To overcome this limitation, mortality hazard ratios were adjusted for age, and patterns of intake described were adjusted for energy intake. The strength of this study is that the evaluation of lifestyle patterns included dietary assessment using quantified dietary history with almost all ethnic foods consumed in Israel, as well as the assessment of physical activity, smoking habits, BMI and BP.
Finally, our findings of the association between ethnicity and mortality risk concur with those of others, who reported lower CVD and cancer risks among Yemenites in Israel (38 –40 ). There may be other biological and socioeconomic factors associated with ethnicity that influence mortality. Although our results support the concept that biological characteristics, ethnic origin and lifestyle habits are interrelated, Yemenites, whose dietary and physical activity habits are closer to the healthy dietary and physical activity guidelines, have the lowest mortality.
We conclude from our study that although ethnic origin and lifestyle habits are interrelated, each factor affects mortality rate independently.
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FOOTNOTES |
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2 Supported by the Israeli German fund, the Israel-US Binational Fund and the Sackler School of Medicine, Schreiber Fund.
4 Abbreviations used: BMI, body mass index; BP, blood pressure; CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio.
Manuscript received 4 September 2002. Initial review completed 24 September 2002. Revision accepted 31 December 2002.
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