Combined Healthy Behaviors and Healthcare Services Use in Older Adults


      Data on the combined impact of healthy behaviors on healthcare use in older adults are limited.


      Study with community-dwelling individuals aged ≥60 years from the Spanish Seniors-ENRICA cohort, recruited in 2008–2010, followed through 2012–2013, and analyzed in 2016 (N=2,021). At baseline, the following healthy behaviors were self-reported: three traditional (never smoking, being physically active, having a healthy diet) and three emerging (sleeping 7–8 hours/day, sitting <8 hours/day, not living alone). Outcomes were self-reported polypharmacy (five or more drugs per day), primary care physician visits (one or more per month), medical specialist visits (more than one per year), and hospitalization (one or more in the last year). The associations between baseline healthy behaviors and healthcare services used in 2012–2013 were summarized with ORs and 95% CIs from multiple logistic regression, adjusting for demographics, lifestyles, comorbidities, and baseline health services used.


      Most single healthy behaviors were associated with lower use of most health services. Compared with participants with zero or one healthy behavior, those with five or six healthy behaviors showed lower risk of polypharmacy (OR=0.46, 95% CI=0.24, 0.85, p-trend=0.001), visits to the primary care physician (OR=0.50, 95% CI=0.26, 0.96, p-trend=0.013), and hospitalization (OR=0.50, 95% CI=0.24, 1.01, p-trend=0.016). No association was found with visits to the medical specialist.


      The combination of five to six healthy behaviors in older adults is associated with half the risk of polypharmacy and using several healthcare services. In an era of constrained resources in most countries, this information may help inform health policy to control healthcare spending in the future.
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        • Nie J.X.
        • Wang L.
        • Tracy C.S.
        • Moineddin R.
        • Upshur R.E.
        Health care service utilization among the elderly: findings from the Study to Understand the Chronic Condition Experience of the Elderly and the Disabled (SUCCEED project).
        J Eval Clin Pract. 2008; 14: 1044-1049
        • Cano Pérez M.D.
        • Castell Alcalá M.V.
        • Queipo Matas R.
        • Martín Martín S.
        • Mateo Pascual C.
        • Otero Puime Á.
        Use of primary care services, care specialized and drug use by population 65 years and more in the community of Madrid, Spain.
        Rev Esp Salud Publica. 2016; 90: e1-e11
        • Bjerrum L.
        • Søgaard J.
        • Hallas J.
        • Kragstrup J.
        Polypharmacy in general practice: differences between practitioners.
        Br J Gen Pract J R Coll Gen Pract. 1999; 49: 195-198
        • Charlesworth C.J.
        • Smit E.
        • Lee D.S.H.
        • Alramadhan F.
        • Odden M.C.
        Polypharmacy among adults aged 65 years and older in the United States: 1988-2010.
        J Gerontol A Biol Sci Med Sci. 2015; 70: 989-995
        • Andersen R.
        • Newman J.F.
        Societal and individual determinants of medical care utilization in the United States.
        Milbank Mem Fund Q Health Soc. 1973; 51: 95-124
        • Østbye T.
        • Taylor D.H.
        • Jung S.-H.
        A longitudinal study of the effects of tobacco smoking and other modifiable risk factors on ill health in middle-aged and old Americans.
        Prev Med. 2002; 34: 334-345
        • de Groot L.C.P.M.G.
        • Verheijden M.W.
        • de Henauw S.
        • Schroll M.
        • van Staveren W.A.
        • SENECA Investigators
        Lifestyle, nutritional status, health, and mortality in elderly people across Europe: a review of the longitudinal results of the SENECA study.
        J Gerontol A Biol Sci Med Sci. 2004; 59: 1277-1284
        • Martínez-Gómez D.
        • Guallar-Castillón P.
        • León-Muñoz L.M.
        • López-García E.
        • Rodríguez-Artalejo F.
        Combined impact of traditional and non-traditional health behaviors on mortality: a national prospective cohort study in Spanish older adults.
        BMC Med. 2013; 11: 47
        • Kvaavik E.
        • Batty G.D.
        • Ursin G.
        • Huxley R.
        • Gale C.R.
        Influence of individual and combined health behaviors on total and cause-specific mortality in men and women: the United Kingdom health and lifestyle survey.
        Arch Intern Med. 2010; 170: 711-718
        • Knoops K.T.B.
        • de Groot L.C.P.G.M.
        • Kromhout D.
        • et al.
        Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project.
        JAMA. 2004; 292: 1433-1439
        • de Rezende L.F.M.
        • Rey-López J.P.
        • Matsudo V.K.R.
        • do Carmo
        • Luiz O.
        Sedentary behavior and health outcomes among older adults: a systematic review.
        BMC Public Health. 2014; 14: 333
        • Chen L.-J.
        • Lai Y.-J.
        • Sun W.-J.
        • Fox K.R.
        • Chu D.
        • Ku P.-W.
        Associations of exercise, sedentary time and insomnia with metabolic syndrome in Taiwanese older adults: a 1-year follow-up study.
        Endocr Res. 2015; 40: 220-226
        • Vals K.
        • Kiivet R.-A.
        • Leinsalu M.
        Alcohol consumption, smoking and overweight as a burden for health care services utilization: a cross-sectional study in Estonia.
        BMC Public Health. 2013; 13: 772
        • Davis M.A.
        • Bynum J.P.W.
        • Sirovich B.E.
        Association between apple consumption and physician visits.
        JAMA Intern Med. 2015; 175: 777-783
        • Natarajan S.
        • Nietert P.J.
        Hypertension, diabetes, hypercholesterolemia, and their combinations increased health care utilization and decreased health status.
        J Clin Epidemiol. 2004; 57: 954-961
        • Graciani A.
        • León-Muñoz L.M.
        • Guallar-Castillón P.
        • Rodríguez-Artalejo F.
        • Banegas J.R.
        Cardiovascular health in a southern Mediterranean European country: a nationwide population-based study.
        Circ Cardiovasc Qual Outcomes. 2013; 6: 90-98
        • Prochaska J.O.
        Multiple Health Behavior Research represents the future of preventive medicine.
        Prev Med. 2008; 46: 281-285
        • Rodríguez-Artalejo F.
        • Graciani A.
        • Guallar-Castillón P.
        • et al.
        [Rationale and methods of the study on nutrition and cardiovascular risk in Spain (ENRICA)].
        Rev Esp Cardiol. 2011; 64: 876-882
        • Wareham N.J.
        • Jakes R.W.
        • Rennie K.L.
        • et al.
        Validity and repeatability of a simple index derived from the short physical activity questionnaire used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.
        Public Health Nutr. 2003; 6: 407-413
        • The InterAct Consortium
        Validity of a short questionnaire to assess physical activity in 10 European countries.
        Eur J Epidemiol. 2012; 27: 15-25
        • Guallar-Castillón P.
        • Sagardui-Villamor J.
        • Balboa-Castillo T.
        • et al.
        Validity and reproducibility of a Spanish dietary history.
        PloS One. 2014; 9: e86074
        • Schröder H.
        • Fitó M.
        • Estruch R.
        • et al.
        A short screener is valid for assessing Mediterranean Diet adherence among older Spanish men and women.
        J Nutr. 2011; 141: 1140-1145
        • Pate R.R.
        • O’Neill J.R.
        • Lobelo F.
        The evolving definition of “sedentary.”.
        Exerc Sport Sci Rev. 2008; 36: 173-178
        • Kharicha K.
        • Iliffe S.
        • Harari D.
        • Swift C.
        • Gillmann G.
        • Stuck A.E.
        Health risk appraisal in older people 1: Are older people living alone an “at-risk” group?.
        Br J Gen Pr. 2007; 57: 271-276
        • Mesas A.E.
        • López-García E.
        • León-Muñoz L.M.
        • Guallar-Castillón P.
        • Rodríguez-Artalejo F.
        Sleep duration and mortality according to health status in older adults.
        J Am Geriatr Soc. 2010; 58: 1870-1877
        • Gnjidic D.
        • Hilmer S.N.
        • Blyth F.M.
        • et al.
        Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes.
        J Clin Epidemiol. 2012; 65: 989-995
        • Palacios-Ceña D.
        • Hernández-Barrera V.
        • Jiménez-García R.
        • Valle-Martín B.
        • Fernández-de-las-Peñas C.
        • Carrasco-Garrido P.
        Has the prevalence of health care services use increased over the last decade (2001-2009) in elderly people? A Spanish population-based survey.
        Maturitas. 2013; 76: 326-333
        • Guallar-Castillón P.
        • Rodríguez-Artalejo F.
        • Díez Gañán L.D.
        • Banegas Banegas J.R.
        • Lafuente Urdinguio P.L.
        • Herruzo Cabrera R.H.
        Consumption of alcoholic beverages and subjective health in Spain.
        J Epidemiol Community Health. 2001; 55: 648-652
        • Bähler C.
        • Huber C.A.
        • Brüngger B.
        • Reich O.
        Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study.
        BMC Health Serv Res. 2015; 15: 23
        • Elrashidi M.Y.
        • Jacobson D.J.
        • St Sauver J.
        • et al.
        Body mass index trajectories and healthcare utilization in young and middle-aged adults.
        Medicine (Baltimore). 2016; 95: e2467
        • Banegas J.R.
        • Rodríguez-Artalejo F.
        • Ruilope L.M.
        • et al.
        Hypertension magnitude and management in the elderly population of Spain.
        J Hypertens. 2002; 20: 2157-2164
        • Kobalava Z.D.
        • Kotovskaya Y.V.
        [Isolated systolic hypertension in different ages].
        Kardiologiia. 2015; 55: 84-90
        • Katz M.H.
        Multivariable Analysis: A Practical Guide for Clinicians.
        Cambridge University Press, Cambridge2006
        • Kleinbaum D.G.
        • Kupper L.L.
        • Morgenstern H.
        Epidemiologic Research: Principles and Quantitative Methods.
        Van Nostrand Reinhold, New York1982
        • Maxwell C.J.
        • Hirdes J.P.
        The prevalence of smoking and implications for quality of life among the community-based elderly.
        Am J Prev Med. 1993; 9: 338-345
        • Dankel S.J.
        • Loenneke J.P.
        • Loprinzi P.D.
        Combined associations of muscle-strengthening activities and accelerometer-assessed physical activity on multimorbidity: findings from NHANES.
        Am J Health Promot. 2017; 31: 274-277
        • Dhalwani N.N.
        • O’Donovan G.
        • Zaccardi F.
        • et al.
        Long terms trends of multimorbidity and association with physical activity in older English population.
        Int J Behav Nutr Phys Act. 2016; 13: 8
        • Dhalwani N.N.
        • Zaccardi F.
        • O’Donovan G.
        • et al.
        Association between lifestyle factors and the incidence of multimorbidity in an older English population.
        J Gerontol A Biol Sci Med Sci. 2017; 72: 528-534
        • Autenrieth C.S.
        • Kirchberger I.
        • Heier M.
        • et al.
        Physical activity is inversely associated with multimorbidity in elderly men: results from the KORA-Age Augsburg Study.
        Prev Med. 2013; 57: 17-19
        • Bosch-Lenders D.
        • Maessen D.W.H.A.
        • Stoffers H.E.J.H.J.
        • Knottnerus J.A.
        • Winkens B.
        • van den Akker M.
        Factors associated with appropriate knowledge of the indications for prescribed drugs among community-dwelling older patients with polypharmacy.
        Age Ageing. 2016; 45: 402-408
        • Chaput J.-P.
        • McNeil J.
        • Després J.-P.
        • Bouchard C.
        • Tremblay A.
        Seven to eight hours of sleep a night is associated with a lower prevalence of the metabolic syndrome and reduced overall cardiometabolic risk in adults.
        PloS One. 2013; 8: e72832
        • Mitka M.
        Mediterranean diet may reduce stroke risk in individuals with genetic predisposition to diabetes.
        JAMA. 2013; 310: 1013
        • Roberts R.O.
        • Bergstralh E.J.
        • Schmidt L.
        • Jacobsen S.J.
        Comparison of self-reported and medical record health care utilization measures.
        J Clin Epidemiol. 1996; 49: 989-995
        • Salazar J.A.
        • Poon I.
        • Nair M.
        Clinical consequences of polypharmacy in elderly: expect the unexpected, think the unthinkable.
        Expert Opin Drug Saf. 2007; 6: 695-704
        • Weissman J.S.
        • Rothschild J.M.
        • Bendavid E.
        • et al.
        Hospital workload and adverse events.
        Med Care. 2007; 45: 448-455
        • Kaye K.S.
        • Marchaim D.
        • Chen T.-Y.
        • et al.
        Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults.
        J Am Geriatr Soc. 2014; 62: 306-311