Preventive Medicine 51 (2010) 268274

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Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y p m e d

Multiple healthy behaviors and optimal self-rated health: Findings from the 2007 Behavioral Risk Factor Surveillance System Survey
James Tsai , Earl S. Ford, Chaoyang Li, Guixiang Zhao, William S. Pearson, Lina S. Balluz
Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention, Atlanta, GA 30341, USA

a r t i c l e

i n f o

a b s t r a c t
Objective. The aim of this study was to examine the association between the number of healthy behaviors (i.e., not currently smoking, not currently drinking excessively, physically active, and consuming fruits and vegetables ve or more times per day) and optimal self-rated health (SRH) among U.S. adults or adults with cardiovascular diseases (CVDs) or diabetes. Methods. We estimated the age-standardized prevalence of optimal SRH among a total of 430,912 adults who participated in the 2007 Behavioral Risk Factor Surveillance System (BRFSS). Prevalence ratios were produced with multivariate Cox regression models using number of healthy behaviors as a predictor; status of optimal SRH was used as an outcome variable while controlling for sociodemographic and health risk factors. Results. The age-standardized prevalence of reporting optimal SRH was 83.5%, 55.6%, and 56.3% among adults overall, and adults with CVDs or diabetes, respectively. Also in the aforementioned order, adults who reported having four healthy behaviors had 33%, 85%, and 87% increased likelihoods of reporting optimal SRH, when compared to their counterparts who reported none of these behaviors. Conclusion. The ndings of this study indicate that number of healthy behaviors is associated with optimal SRH among adults, especially adults with CVDs or diabetes. These ndings reinforce the support for identifying and implementing clinical and population-based intervention strategies that effectively promote multiple healthier lifestyle behaviors among adults. Published by Elsevier Inc.

Available online 18 July 2010 Keywords: Multiple health behaviors Cigarette smoking Excessive drinking Physical activity Fruits and vegetables Self-rated health Cardiovascular diseases Diabetes

Introduction Unhealthy behaviors are the modiable risk factors for the development of leading chronic diseases, including cardiovascular diseases (CVDs) and type 2 diabetes (Fine et al., 2004; Noar et al., 2008; Prochaska et al., 2008b). In particular, cigarette smoking, excessive drinking, physical inactivity, and inadequate daily consumption of fruits and vegetables are four modiable unhealthy lifestyle behaviors that contribute to the development of many chronic diseases or conditions, such as heart attack, angina or coronary heart disease, stroke, and type 2 diabetes in the adult population (Fine et al., 2004; Greenlund et al., 2004; Khaw et al., 2008; Orozco et al., 2008; WHO, 2007). Individuals who have more than one unhealthy behavior are often at heightened risk for severe health consequences, including developing chronic conditions, co-morbid Disclaimer: The ndings and conclusions in this report are those of the authors and do not necessarily represent the ofcial position of the Centers for Disease Control and Prevention. Corresponding author. Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention (CDC), 4770 Buford Highway, Mail Stop K66, Atlanta, GA 30341, USA. Fax: +1 770 488 8150. E-mail address: jxt9@cdc.gov (J. Tsai). 0091-7435/$ see front matter. Published by Elsevier Inc. doi:10.1016/j.ypmed.2010.07.010

ities, complications, disabilities, and premature death (Ford et al., 2009; Khaw et al., 2008). Nevertheless, many unhealthy behaviors are interrelated and amenable to interventions. In addition, the success in changing one unhealthy behavior may increase individuals' self-efcacy and motivation to modify other unhealthy behaviors (Eriksson et al., 2006a; Prochaska et al., 2008b; Schwarzer, 2008). Accumulating evidence shows that multiple health behavior change (MHBC) is an effective prevention strategy for individuals at risk for or already diagnosed with CVDs or diabetes (Eriksson et al., 2006b; Gaede et al., 2003; Goldstein et al., 2004; Jones et al., 2003; Jrgensen et al., 2003; Praet and van Loon, 2009). Interventions that address multiple health behaviors simultaneously or sequentially could not only confer increased efcacy, decreased likelihoods of co-morbidity, and improved quality of life, but could also prevent initiation of high-risk behaviors, reduce health care burden and socioeconomic costs among adult population (Edington, 2001; Eriksson et al., 2006a; Johnson et al., 2008; Ketola et al., 2000; Mills et al., 2007; Norris et al., 2001; Orozco et al., 2008; Prochaska et al., 2006, 2008b; Smith et al., 2005). Self-rated health (SRH) is a validated, overall health indicator that is highly predictive of future morbidity and mortality, functional decline, and health care utilization among adults including those with CVDs and diabetes (DeSalvo et al., 2006; Idler and Benyamini, 1997; Idler et al., 2000; Jylha, 2009). Several previous studies evaluated the

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relationship between number of unhealthy behaviors and suboptimal SRH (i.e., fair or poor) (Li et al., 2008; Pisinger et al., 2009; Tsai et al., 2010b). To the best of our knowledge, no studies have evaluated an association between the number of healthy behaviors (i.e., cumulative and clustering patterns) and optimal SRH (i.e., excellent, very good, or good) pertaining to the general population of U.S. adultsespecially those with CVDs or diabetes conditions. Population-based epidemiologic studies can provide important observational evidence to inform healthier lifestyle choices that foster optimal health and well-being among individuals and at-risk populations. Therefore, the aim of this study was to examine the association between the number of healthy behaviors (i.e., not currently smoking, not currently drinking excessively, physically active, and consuming fruits and vegetables ve or more times per day) and optimal SRH among adults overall, as well as adults with CVDs or diabetes in the United States by using the data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey.
Methods Participants The BRFSS is the largest ongoing, state-based, random-digit-dialed telephone survey that collects information on health-related risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury (CDC, 2009a). With a survey median cooperation rate of 72.1% in 2007, a total of 430,912 individuals aged 18 years and older from all 50 states, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands participated in the survey (CDC, 2009a). Status of CVD or diabetes was

determined by an afrmative answer to the questions of CVDs and diabetes history (Table 1). Measures Healthy behaviors We evaluated four healthy behaviors in this study: (1) not currently smoking, dened as having smoked less than 100 cigarettes during their lifetime, or who were currently not smoking every day or some days at the time of interview (CDC, 2007); (2) not currently drinking excessively, dened as using alcohol currently without heavy drinking (i.e., an average of N2 drinks/day for men or N1 drink/day for women) or binge drinking (i.e., N5 drinks on one occasion for men or N 4 drinks on one occasion for women) during the previous 30 days (Tsai et al., 2010b); (3) physically active dened as reporting at least 150 min per week of moderate activity, or at least 75 min per week of vigorous activity, or a combination of moderate and vigorous activity totaling at least 150 min per week (DHHS, 2008); and (4) fruits and vegetables consumption, dened as having ve or more times (servings) of fruits and vegetables daily (DHHS, 2000) (Table 1). Optimal self-rated health As part of a set of questions covering health-related quality of life, the BRFSS survey asked participants to rate their overall health. We dichotomized these responses into the categories of optimal (i.e., excellent, very good, or good) and suboptimal (i.e., fair or poor) for this analysis (Table 1). Covariates In addition to the sociodemographic variables such as age, sex, race/ ethnicity, education, marital status, and employment, information about

Table 1 Survey questions for multiple healthy behaviors, self-rated health, and health risk factors for the year 2007, BRFSS, United States. Measure Healthy behavior Cigarette smoking Survey questions

(1) Have you smoked at least 100 cigarettes in your entire life? (2) Do you now smoke cigarettes every day, some days, or not at all? Alcohol use (1) During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? (2) During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage? (3) One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? (4) Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks for men or 4 or more drinks for women on an occasion? Physical activity Moderate activity (1) When you are not working, in a usual week, do you do moderate activities for at least 10 min at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate? (2) How many days per week do you do these moderate activities for at least 10 min at a time? (3) On days when you do moderate activities for at least 10 min at a time, how much total time per day do you spend doing these activities? Vigorous activity (1) When you are not working, in a usual week, do you do vigorous activities for at least 10 min at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate? (2) How many days per week do you do these vigorous activities for at least 10 min at a time? (3) On days when you do vigorous activities for at least 10 min at a time, how much total time per day do you spend doing these activities? Fruits and vegetables Fruits consumption (1) How often do you drink fruit juices such as orange, grapefruit, or tomato? (2) Not counting juice, how often do you eat fruit? Vegetables (1) How often do you eat green salad? (2) How often do you eat potatoes, not including French fries, fried potatoes, or potato chips? (3) How often do you eat carrots? (4) Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? Self-rated health Would you say that in general your health is excellent, very good, good, fair, or poor? Health risk factor Cardiovascular Have you ever been told by a doctor, nurse, or other health professional that you have had: diseases (1) a heart attack, also called a myocardial infarction; or, (2) angina or coronary heart disease; or, (3) a stroke? Diabetes Have you ever been told by a doctor that you have diabetes? Arthritis Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or bromyalgia? Health care access Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare? Body mass index Self-reported weight (kilograms) divided by the square of height (meters): (BMI) (1) neither overweight nor obese (b 25 kg/m2) (2) overweight (25b 30 kg/m2) (3) obese ( 30 kg/m2).

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health risk factors, such as mass index (BMI), arthritis, and health care access was also collected and analyzed (Table 1). Statistical analysis We estimated the age-standardized prevalence of optimal SRH among the entire sample of adults, as well as adults with CVDs or diabetes and subgroups stratied by age, sex, race/ethnicity, education, employment, marital status, cigarette smoking, drinking, leisure time physical activity, consumption of fruits and vegetables, history of arthritis, health care access, and BMI. All subsequent analyses were limited to adult men and nonpregnant women aged 18 years and older. We constructed an ordinal variable to indicate the total number of healthy behaviors ranging from values 0 to 4. To examine the association between the number of healthy behaviors and optimal SRH, prevalence ratios (PRs) and 95% condence intervals were generated with multivariate Cox regression analyses for complex samples with constant time using number of healthy behaviors as a predictor and status of optimal SRH as an outcome variable (Barros and Hirakata, 2003; Nijem et al., 2005). We present one unadjusted and two adjusted models controlling for sociodemographic characteristics such as age, sex, race/ethnicity, education, employment, and marital status, as well as additional covariates such as health care access, BMI, history of CVDs, diabetes, and arthritis. We performed orthogonal polynomial contrasts to test linear and quadratic trends to indicate the increase or decrease of PRs across the number of healthy behaviors. Additionally, we estimated the percentage distribution of the 16 clustering combinations for 4 healthy behaviors and PRs for reporting optimal SRH among adults overall, as well as adults with CVDs or diabetes. We performed the data management and analysis using SPSS 17 Complex Samples for Survey Analysis (SPSS Inc., Chicago, IL, 2008) and STATA 11 (StataCorp LP, College Station, TX, 2009) to account for multiple stages of sampling, stratication, and clustering (Korn and Graubard, 1999).

(Table 4 and Fig. 1). Although adults with CVDs or diabetes appeared to have a higher prevalence of clustering of certain healthy behaviors (e.g. not currently smoking and consuming fruits and vegetables 5 times/day) than those of the general adult population, they have a lower prevalence of all four healthy behaviors (Table 4 and Fig. 1). Discussion Whereas several previous studies demonstrated a graded relationship between the number of unhealthy behaviors and suboptimal SRH, our study extends previous research by assessing the association between optimal SRH and multiple healthy behaviors specic to the general population of U.S. adults, as well adults with CVDs or diabetes. Furthermore, several population representative estimates, including the prevalence of optimal SRH, as well as the clustering patterns of healthy behaviors among U.S. adults with CVDs or diabetes were not available previously. The ndings of our study have several important clinical and public health implications. First, improving health among adults with CVDs or diabetes remains a challenging public health goal because of the low prevalence of optimal SRH. Diabetes could be more likely to engage in certain healthy behaviors (e.g. not currently smoking and consuming fruits and vegetables 5 times/day) upon the diagnosis. Second, the nding that more than 1 in 4 adults in the general population reported only 01 healthy lifestyle behavior provides support for population-based efforts. There are effective population-based multiple health risk behavior interventions that are designed to maximize the coverage of a general population (CDC, 2009b; Johnson et al., 2008; Noar et al., 2007). Such broad-based approach can be complemented by targeted interventions in order to enhance both reach and effectiveness for at-risk population and subgroups (Abrams et al., 1996; Ketola et al., 2000). Third, adults with CVDs or diabetes generally reported fewer numbers of, or had lower prevalence of, healthy behaviors than those of the general population. An evaluation of the BRFSS data indicated that up to 86.9% adults reported visiting a doctor for routine checkup within the past year. Thus, effectively addressing MHBC is increasingly important in health care settings, as the health-related quality of life for adults with CVDs or diabetes is often greatly impaired. The U.S. Preventive Services Task Force has concluded that effective interventions are available to clinicians to address many of these lifestyle unhealthy behaviors (Kirk et al., 2007; Orleans, 2004). Although screening for high-risk behaviors can take place in many health care and community settings, the routine checkup is considered an ideal occasion (Coups et al., 2004; Tsai et al., 2010a). Finally, the difference in reporting optimal SRH across subgroups with regard to sociodemographic factors (e.g., education) demonstrates the need for evidence-based research to identify interdisciplinary intervention strategies that integrate science, practice, and policy to address health disparities among the population (Braveman et al., 2010; Dankwa-Mullan et al., 2010a,b; Rufn, 2010). The BRFSS data have been found to provide valid and reliable estimates as compared to the national household surveys (Nelson et al., 2001; Nelson et al., 2003), nevertheless, our study has several limitations. For example, cross-sectional surveys such as BRFSS are not designed to determine a causal relationship. In addition, the survey data used for this study was based on self-reports, and research has shown that self-reported data, particularly pertaining to socially desirable behaviors, are subject to biased recall (Yun et al., 2006). For example, self-reported physical activity is a subjective method of assessment; it may yield higher estimates of activity than the objective measurements obtained with an accelerometer (Troiano et al., 2008; Valanou et al., 2006). Moreover, BRFSS is a landline survey, thus people with no telephone service or with cell phone service only are excluded, possibly resulting in sampling bias. We conducted a sensitivity analysis using a modied denition of not currently drinking excessively (i.e., not currently using alcohol or

Results The age-standardized prevalence of reporting optimal SRH was 83.5%, 55.6%, and 56.3%, among adults overall, and adults with CVDs or diabetes, respectively (Table 2). Regardless of status of CVDs or diabetes, a greater prevalence of optimal SRH was found among participants who had a college education, were employed, were nonexcessive drinkers, were physically active, or had no history of arthritis, when compared to their respective counterparts (p b 0.001 for 2 test). Additionally, the prevalence of optimal SRH was higher among adults overall who were aged 1844 years, were male, were non-Hispanic white, were married, were currently not smoking, consumed fruits and vegetables at least ve times per day, had health care access, or were neither overweight nor obese, as compared to their respective counterparts (p b 0.001 for 2 test). Similar distribution of prevalence was found among adults with CVDs concerning age but not BMI, as well as among adults with diabetes regarding smoking (p b 0.001 for 2 test). Regardless of status of CVDs or diabetes, participants who reported having four healthy behaviors had the highest prevalence of optimal SRH, and the prevalence of optimal SRH increased progressively with the number of healthy behaviors (Table 3). Upon controlling for covariates such as age, sex, race/ethnicity, education, employment, marital status, smoking, drinking, BMI, health care access, history of CVDs, diabetes, and arthritis in Cox regression models, adults overall, adults with CVDs, and adults with diabetes who reported having four healthy behaviors were 1.33, 1.85, and 1.87 times more likely to indicate optimal SRH, respectively, as compared to their counterparts who reported none of these healthy behaviors (Table 3). Regardless of status of CVDs or diabetes, the associations (PRs) were increased with a greater number of healthy behaviors (p b 0.001 for both linear and quadratic trends). Table 4 shows that the prevalence of having all four healthy behaviors was 6.5% among adults overall, 3.5% among adults with CVDs, and 3.8% among adults with diabetes. Nevertheless, the distribution of clustering combinations of these healthy behaviors was similar among adults regardless of status of CVDs or diabetes

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Table 2 Age-standardized prevalence of optimal SRH by socio-demographic characteristics and healthy behaviors among adults or adults with CVDs or diabetes in 2007, BRFSS, United States. Demographic characteristics and risk factors Optimal self-rated healtha All adults (n = 428,888) nc Unadjusted Age-standardized Age (years) 1824 2534 3544 4564 65 Sex Male Female Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other Education Less than high school High school graduates College education Employment Employed Unemployed Not in workforce Marital Status Marriedf Unmarriedg Not currently smoking Yes No Not currently drinking excessively Yes No Physically active Yes No Fruits and vegetables 5 times per day Yes No History of arthritis Yes No Have health care access Yes No Body mass index (kg/m2) Neither overweight nor obese (b 25) Overweight (25b 30) Obese ( 30)
a b c d e f g

Adults with CVDsb (n = 45,841)

d

Adults with diabetes (n = 47,712) 95% CI 49.951.8 53.457.9 72.390.3 50.667.2 47.757.0 45.648.6 50.853.1 54.460.6 49.555.8 58.062.4 52.161.1 36.246.6 48.961.2 29.139.2 50.957.2 63.668.7 67.473.2 46.860.0 37.345.3 54.961.9 46.652.5 57.062.1 44.151.5 60.870.0 49.754.8 64.069.6 41.448.5 56.364.0 52.057.2 42.849.0 60.966.3 43.352.1 56.560.9 55.262.4 57.965.2 45.253.5 % 52.5 56.3 p = 0.043 63.8 65.1 55.2 51.3 51.4 p = 0.129 58.3 54.2 p = 0.002 62.3 54.1 40.5 58.6 p b 0.001 36.6 54.5 63.1 p b 0.001 67.0 49.4 45.0 p = 0.082 57.7 51.1 p b 0.001 58.6 46.9 p b 0.001 67.9 52.7 p b 0.001 63.8 45.7 p = 0.030 60.0 54.7 p b 0.001 42.7 63.1 p = 0.001 60.0 44.3 p = 0.029 57.1 63.5 52.9 95% CI 51.553.4 53.958.7 48.479.2 59.370.8 51.658.7 50.052.7 50.052.7 54.562.2 51.357.3 59.864.7 49.758.5 35.545.7 51.665.7 30.942.2 51.357.7 59.267.1 63.570.4 42.156.6 41.848.2 54.161.3 47.954.3 55.661.4 43.050.7 64.471.4 49.855.6 60.866.9 42.249.2 55.764.2 51.857.6 37.247.8 60.765.5 57.662.3 39.948.6 51.962.2 59.867.3 50.055.9

% 83.3 83.5 p b 0.001e 90.3 89.5 87.9 80.6 71.5 p b 0.001 83.9 83.2 p b 0.001 87.1 77.8 69.1 82.3 p b 0.001 60.7 80.3 89.2 p b 0.001 89.6 74.9 73.3 p b 0.001 84.9 78.4 p b 0.001 85.3 76.2 p b 0.001 89.7 80.0 p b 0.001 88.7 75.6 p b 0.001 86.0 82.8 p b 0.001 72.3 87.8 p b 0.001 85.3 73.3 p b 0.001 87.4 86.0 76.0

95% CI

% 50.8 55.6 p b 0.001 81.3 58.9 52.3 47.1 52.0 p = 0.015 57.5 52.7 p = 0.174 60.1 56.6 41.3 55.1 p b 0.001 34.1 54.1 66.2 p b 0.001 70.3 53.4 41.3 p = 0.104 58.4 49.5 p = 0.005 59.5 47.8 p b 0.001 65.4 52.3 p b 0.001 66.8 45.0 p 0.016 60.1 54.6 p b 0.001 45.9 63.6 p = 0.034 47.8 58.7 p b 0.001 58.8 61.5 49.2

425,285 425,285

83.083.5 83.383.8 89.391.3 88.890.2 87.388.4 80.280.9 71.072.0 83.484.3 82.983.5 86.987.3 77.078.7 67.970.3 82.384.5 59.461.9 79.980.8 88.989.5 89.290.0 73.376.5 72.773.8 84.485.4 78.078.9 85.085.6 75.676.9 89.290.2 79.780.4 88.489.0 75.076.1 85.486.5 82.583.1 71.373.3 87.588.1 85.085.5 72.374.3 87.087.8 85.586.4 75.376.7

425,285

421,566

424,210

423,887

424,012

423,584

410,997

395,163

415,537

416,545

424,240

406,928

Self-rated health reported as excellent, very good, or good. Cardiovascular diseases include heart attack, angina, coronary heart disease, or stoke. Maximum subgroup sample size. Condence interval. p-Value for Pearson chi-square test. Included unmarried couples. Reported as divorced, widowed, separated, or never married.

using alcohol currently without heavy drinking or binge drinking during the previous 30 days) and found similar but attenuated associations (not shown). Given that there are many possible sources of inaccuracy in measuring patterns, quantity, frequency, timing, and duration of alcohol consumption, and that harmful use of alcohol has been linked to a variety of adverse social and health consequences among some susceptible subgroups of the general population (e.g., adolescents, women of childbearing age, younger and older adults), the potential cardiovascular benets due to moderate drinking ought to be viewed with caution, whereas excessive drinking should be avoided (Corrao et al., 2004; NIAAA, 2003; WHO, 2007).

Although SRH is generated by individuals through a subjective, contextual, and non-arbitrary process, research shows that there are important biological, physiological, psychological, and behavioral determinants (Jylha, 2009; Jylha et al., 2006; Molarius and Janson, 2002; Tsai et al., 2010b,c). Individuals with poor SRH have a twofold higher mortality risk compared with those with excellent SRH (DeSalvo et al., 2006). Furthermore, the lower rating has been linked to heart diseases and stroke, lower extremity amputation, blindness, and kidney failure (CDC, 2006). Health and behavior are an interplay of biological, behavioral, and social inuences over the cumulative experiences of one's life-course (Halfon and Hochstein, 2002; IOM,

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Table 3 Estimated prevalence and prevalence ratios for reporting optimal SRH by number of healthy behaviors among adults or adults with CVDs or diabetes in 2007, BRFSS, United States. Number of healthy behaviors Optimal self-rated health Prevalencea Unadjusted (%) All adultse (nf = 384,107) 4 3 2 1 0 Adults with CVDsg (n = 41,115) 4 3 2 1 0 Adults with diabetesh (n = 42,851) 4 3 2 1 0
a b c d e f g h

Un-adjusted 95% CI
d

Adjusted model 1b 95% CI 1.441.51 1.381.45 1.291.36 1.121.18 Reference 2.342.96 2.052.55 1.632.03 1.211.51 Reference 2.232.82 1.882.35 1.601.99 1.211.52 Reference Prevalence ratio 1.35 1.31 1.25 1.13 1.00 1.96 1.83 1.58 1.25 1.00 1.95 1.71 1.56 1.28 1.00 95% CI 1.321.38 1.281.34 1.221.28 1.111.16 Reference 1.742.20 1.642.04 1.411.76 1.121.40 Reference 1.742.20 1.541.90 1.411.73 1.161.42 Reference

Adjusted model 2c Prevalence ratio 1.33 1.30 1.26 1.16 1.00 1.85 1.77 1.58 1.25 1.00 1.87 1.67 1.58 1.32 1.00 95% CI 1.301.36 1.271.33 1.231.29 1.131.19 Reference 1.642.01 1.571.99 1.411.78 1.101.40 Reference 1.642.13 1.481.89 1.411.78 1.171.48 Reference

Prevalence ratio 1.48 1.42 1.32 1.15 1.00 2.63 2.28 1.82 1.35 1.00 2.51 2.10 1.78 1.36 1.00

94.9 90.9 84.9 73.9 64.2 77.5 67.3 53.6 39.8 29.4 78.4 65.7 55.6 42.4 31.3

94.395.4 90.491.3 84.485.3 73.374.5 62.765.8 73.681.0 65.069.5 51.955.3 38.141.5 26.432.7 74.082.2 63.468.0 54.057.3 40.844.0 28.134.6

Self-rated health reported as excellent, very good, or good. Adjusted for age, sex, race/ethnicity, education, employment, and marital status. Adjusted for age, sex, race/ethnicity, education, employment, marital status, health care access, BMI, history of CVDs, diabetes, and arthritis. Condence interval. Limited to adult men and nonpregnant women aged 18 years and older. Maximum subgroup sample size. Model 2 adjusted for age, sex, race/ethnicity, education, employment, marital status, health care access, BMI, history of diabetes and arthritis (CVDs = Cardiovascular diseases). Model 2 adjusted for age, sex, race/ethnicity, education, employment, marital status, health care access, BMI, history of CVDs and arthritis.

2001). Long-term MHBC is challenging and may require sustained efforts over extended periods of time (Blissmer et al., 2010; Goldstein et al., 1999). There are still knowledge gaps, however, in the research and practice of MHBC. For example, an increased level of physical activity may not boost the consumption of fruits and vegetables or decrease the intake of fat (Dutton et al., 2008). One study showed that moderate to vigorous physical activity was an effective strategy for sustained smoking abstinence, yet physical activity was not associated

with a decreased level of alcohol consumption in another study (Poortinga, 2007; Prochaska et al., 2008a). Conclusions The ndings of this study indicate that number of healthy behaviors is associated with optimal SRH among adults, especially adults with CVDs or diabetes. These ndings reinforce the support for

Table 4 Percentage distribution of clustering of healthy behaviors and prevalence ratios for report optimal SRH among adults or adults with CVDs or diabetes in 2007, BRFSS, United States. Number of healthy behaviors 4 3 3 3 3 2 2 2 2 2 2 1 1 1 1 0 Total
a b

Not currently smoking + + + + + + + +

f

Not currently drinking excessively + + + + + + + +

Physically Active

Consuming fruits and vegetables 5 Times/day + g + + + + + + +

All adultsa (n = 356,356) % 6.5 15.0 0.8 8.8 1.8 7.2 2.9 1.8 22.1 4.0 0.3 15.4 1.6 6.7 0.7 4.2 100.0 PRb 1.27 1.26 1.24 1.24 1.20 1.19 1.20 1.20 1.24 1.11 1.13 1.09 1.09 1.18 0.95 1.00 CIc 1.241.30 1.231.29 1.201.28 1.211.27 1.161.24 1.16 1.22 1.161.23 1.161.24 1.211.26 1.081.15 1.051.21 1.071.12 1.051.13 1.151.21 0.881.02 Reference

Adults with cardiovascular diseases (n = 38,919) % 3.5 8.4 0.5 9.1 1.7 7.3 1.4 1.3 19.9 7.7 0.2 27.1 1.3 4.2 1.0 5.3 100.0 PRd 1.86 1.84 1.65 1.71 1.69 1.57 1.76 1.55 1.70 1.23 1.26 1.22 1.25 1.48 1.22 1.00 CI 1.652.09 1.642.07 1.202.28 1.511.93 1.461.95 1.391.77 1.542.00 1.301.86 1.521.91 1.071.41 0.831.91 1.091.38 1.061.49 1.291.68 0.871.71 Reference

Adults with diabetes (n = 38,601) % 3.8 9.8 0.7 7.6 2.1 7.6 2.2 1.5 17.5 7.1 0.3 24.6 2.0 5.5 1.3 6.5 100.0 PRe 1.78 1.70 1.25 1.51 1.58 1.49 1.50 1.79 1.56 1.29 1.36 1.24 1.10 1.46 0.87 1.00 CI 1.582.01 1.521.91 0.911.72 1.341.70 1.371.82 1.321.68 1.281.77 1.462.19 1.411.75 1.141.45 0.981.90 1.111.39 0.911.32 1.281.66 0.651.15 Reference

+ + + + + + + +

Limited to adult men and nonpregnant women aged 18 years and older. Prevalence ratio for reporting optimal SRH adjusted for age, sex, race/ethnicity, education, employment, marital status, health care access, BMI, history of CVDs, diabetes, and arthritis. c Condence interval. d Prevalence ratio for reporting optimal SRH adjusted for age, sex, race/ethnicity, education, employment, marital status, health care access, BMI, history of diabetes and arthritis. e Prevalence ratio for reporting optimal SRH adjusted for age, sex, race/ethnicity, education, employment, marital status, health care access, BMI, history of CVDs and arthritis. f Yes. g No.

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Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, for making data available.

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Fig. 1. Estimated percentage (%) for number of healthy behaviors among adults by status of CVDs or diabetes in 2007, BRFSS, United States.

identifying and implementing clinical and population-based intervention strategies that effectively promote multiple lifestyle healthy behaviors among adults.
Conict of interest statement No potential conicts of interest relevant to this article were reported.

Acknowledgments The authors of this study sincerely thank BRFSS coordinators for all participating states and territories, the Division of Adult and

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