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Impact
of Mediterranean Lifestyle on quality of
life - A sample of East Mediterranean community
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Guzel Discigil
Assistant
Professor, Adnan Menderes University
Department of Family Medicine
Erdem
Ozkisacik
Assistant Professor, Adnan Menderes
University,
Department of Cardiovascular Surgery
Guzel Discigil
MD
Assistant Professor
Department of Family Medicine
Adnan Menderes University Medical
Faculty
1962 sokak No:30/1
Aydin, 09100
TURKEY
Phone: +90 256 213 9373
Fax: +90 256 214 6495
E-mail: guzeld@yahoo.com
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ABSTRACT
Aim: The aim of the present
study was to evaluate relationships
between health behaviors, some medical
conditions and health related quality
of life in an east Mediterranean community
sample.
Method: Study population consisted
of 327 adult Datca-Knidos county residents.
Participants filled out a questionnaire
regarding health behaviors, medical
history and an extensive health related
quality of life (HRQOL) measurement
short form questionnaire (SF-36v2).
Results: The majority of participants
were born in Datca (Turkey). Mean
age was 50.3±12.0. Mediterranean
diet, at least moderate physical activity
and regular swimming were associated
with better outcomes on most scales
of health related quality of life
(HRQOL). Mental and physical dimensions
of SF-36v2 were adversely affected
by coronary heart disease (CHD), hypertension
(HT), diabetes mellitus type 2 (DM)
and age over 40.
Conclusion: Mediterranean
diet, physical activity and regular
swimming are associated with better
outcomes on HRQOL in an east Mediterranean
community sample. Overall quality
of life declines in the presence of
chronic diseases and advanced age.
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Keywords: Health
related quality of life, Mediterranean diet,
east Mediterranean community.
Quality of life is a
multidimensional construct including individuals'
overall satisfaction with life assessing
functional status in physical, emotional
and social dimensions (1).
Chronic diseases alter well-being and health
related quality of life (HRQOL) (2,3,4)
The relationship between health measurements
and chronic conditions are well studied
in a variety of age groups including the
elderly and HRQOL found declining with chronic
disease presence such as coronary heart
disease, hypertension, diabetes (2,3,5,6,7,8,9).
Several hospital-based studies have previously
addressed impact of medical or surgical
treatment of chronic conditions on HRQOL
(3,4,7,8,9).
However relatively fewer studies have evaluated
HRQOL and its relationship with dietary
habits and physical activity which are currently
not very well addressed
(2,5) .
In the present study, we aimed to verify
the relationship between quality of life
and health behaviors such as dietary habits,
physical activity and frequently seen chronic
diseases.
The
current study is based on a sample from
the registered residents in the county of
Datca, ancient name known as Knidos. Datca
is a semi-urban, partly agricultural west
Anatolian county located on the east Mediterranean
coast, with an adult population of around
3000. The study was announced to adults
living in Datca by mail, hand-outs and loudspeaker
announcement system via local municipal
organizations. Volunteers were interviewed
face to face by trained physicians. Approval
consent was taken from each participant.
108 men and 219 women completed a questionnaire
and Turkish version of SF-36v2 form.
SF-36v2
Form:
Short form 36 version 2 (SF-36v2) is a widely
used as an extensive health related quality
of life measurement. The major domains of
SF-36v2 form are physical functioning (PF),
social functioning (SF), role-emotional
(RE), role-physical (RP), bodily pain (BP),
vitality (VT), mental health (MH) and general
health perception (GH). The calculated score
of each scale was transformed to have a
mean of 50 and standard deviation of 10
in general population, with higher scores
indicating a better state of health(10).
A Turkish version of SF-36v2 was used with
permission of the Medical Outcome Trust
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Questionnaire:
Elements of the questionnaire consisted
of demographics, chronic disease history,
physical activity and dietary habits.
Age,
gender and smoking habits were integrated
in the demographics section of the questionnaire.
Four
categories were included in the physical
activity part of the questionnaire.
- Sedentary, mostly
sitting during the day.
- Mild activity such
as walking at least 20 minutes at a time
and 3 days a week.
- Moderate activity
such as biking or running at least 20
minutes at a time and 3 days a week.
- Vigorous activity
such as weight lifting or hoeing in the
garden at least 20 minutes at a time and
3 days a week.
For each category, time
spent for the addressed physical activity
was asked. Swimming 30 minutes at a time
3 days a week was considered as regular
swimming. Swimming period of months in a
year were asked separately in the physical
activity part of the questionnaire.
Presence of coronary
heart disease (CHD), hypertension (HT),
type 2 Diabetes Mellitus (DM), and family
history of these chronic diseases were questioned
in the chronic disease part of the questionnaire.
Dietary habits were questioned
in 5 categories and in a scale of 5. The
five categories questioned were red meat,
fish, fruit, olive oil and vegetables (raw
and cooked) consumption. Scale One signifiedconsuming
every day; scale Two, =3 times/week; scale
Three, 1-3 times/week; scale Four: <once/week;
scale Five, <once/month or never eaten.
All participants reported
olive oil preference in their daily cooking.
Participants consuming vegetable and fruit
everyday, fish, equal or more than once
a week and red meat less than once a week
and preferring olive oil rather than butter,
were considered as using a Mediterranean
diet.
Height and weight of
each participant was measured using a standard
procedure. BMI was calculated as weight
in kilograms divided by the square of the
height in meters [weight (kg) / height (m)
² and participants were grouped as
normal, overweight and obese according to
their BMI values
(11).
Blood pressure was measured
after 20 minute of resting.
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Statistical Analysis:
Data were analyzed using the Statistical
Package for the Social Sciences program
(SPSS 10.0). Values are expressed as mean
± S.D. Pearson² - test was used
to analyze differences between demographic
factors and chronic diseases. Correlation
between quality of life dimensions, demographic,
medical and health behavior indices were
analyzed by Spearman's rank correlation
coefficient. In order to study association
between eight major domains of SF-36 questionnaire
and certain categorical variables such as
age, gender, health behaviors and chronic
diseases, multiple linear regression analysis
was carried out.
Demographics:
The majority of the participants were born
in Datca. Mean age of the total group was
50.3 ±12.0. Mean BMI was 27.5 ±
4.6. Participants who were active swimmers
were swimming in an average of 2.3 months
in a year. One in five participants had
co-morbidity of the chronic disease that
was included in the questionnaire. Demographic
features are shown in Table
1.
Physical function,
role physical, role emotional, mental health,
vitality and general health perception domains
of SF-36 were negatively affected by advanced
age. Men rated higher scores on social function,
mental health and vitality. Non- smokers
rated high on physical function and role
physical scale of the SF-36. (Table
2 and Table 3).
Number of chronic diseases (r=0.348 p<0.001),
BMI (r=0.260 p<0.001), systolic blood
pressure (r=0.527 p<0.001) and diastolic
blood pressure (r=0.393 p<0.001) were
seen to be increasing with age. Smoking
years were positively associated with number
of chronic diseases (r=0.131 p=0.02).
Chronic Conditions:
Both mental and physical dimensions of SF-36v2
were affected by CHD, HT and DM. Scores
in the physical function dimension of SF-36v2
were lower for those with CHD and HT whereas
both RP and RE were affected in DM. On the
contrary, mental health was not affected
by any of the chronic diseases (Table
2).
Co-morbidity was
more common in sedentary (OR:1,955 p=0.01),
non-swimmer (OR:4,340 p<0.001), overweight
and obese (OR: 9,450 p<0.001) participants.
Overweight was associated with HT (OR: 9.404
p<0.001), CHD (OR: 2.706 p=0.001) and
DM (OR: 7.714 p<0.001).
Physical Activity:
Sedentary or mildly active participants
had significantly lower scores in PF, SF,
VT, BP and GH scales of the HRQOL (Table
2 and Table 3).
BMI (r= - 0.188
p=0.001) inversely, physical function (r
= 0.274 p<0.001), social function (r=0.192
p<0.001) and bodily pain (r= 0.143 p=0.01)
directly correlated with increased physical
activity.
Swimming was seen
to have a positive effect on both mental
and physical components of HRQOL. Regular
swimmers had higher scores in PF, RE, and
GH scales of the SF-36v2.
Dietary Habits:
Scores in many dimensions of the SF-36v2
were higher for those having Mediterranean
style of diet. Non-obese participants rated
higher scores on SF, RP, and VT scales of
the SF-36v2(Table 2 and
Table 3).
It is remarkable
that higher consumption of raw vegetables
(r=0.230 p<0.001) and fruit (r=0.126
p=0.02), increased physical activity (r=0.179
p=0.001) and swimming period in a year (r=0.219
p=0.001) were positively correlated with
overall quality of life. On the contrary,
BMI (r=-0.147 p=0.01), systolic blood pressure
((r=-0.173 p=0.005) and diastolic blood
pressure (-0.179 p=0.003) were negatively
correlated with overall quality of life.
Furthermore, higher BMI was associated with
increased red meat consumption (r=0.130
p=0.02).
Mediterranean diet,
at least moderate physical activity and
regular swimming more than 3 months in a
year have better impact on general health
perception. However, general health perception
declines in the presence of CHD, and over
40 years of age.
In the present study,
HRQOL have been analyzed in a sample of
semi-urban east Mediterranean community
with a multivariate approach to identify
associations with health behavior along
with some chronic diseases.
Several studies have
shown that older age results in worse HRQOL,
reflecting physical health but not in scales
reflecting mental health. (12,13).
However, in our study population, age affected
both physical and mental parameters.
There is a strong correlation
with obesity and anxiety, depression, personal
dissatisfaction and disturbed eating attitude
(14). Additionally,
poor perceived health status and increased
chronic disease risk factors are reported
more prevalently in obese people
(15). In our study mental and physical
component of HRQOL was better in non-obese
participants.
It must be pointed out
that, HT, DM and myocardial infarction adversely
affect HRQOL (2).
It is remarkable that chronic diseases affect
quality of life not only by physical means
but emotionally as well. It has been reported
that anxiety, depression and negative beliefs
about DM were related to lower physical
and mental functioning in diabetics (3).
Participants in our study, with CHD, HT
and DM rated lower scores in some of the
physical and mental components of SF-36v2.
Moreover, low HRQOL can
be a risk factor for cardiovascular events
or complications which might result in increased
mortality rate (2,16).
Several studies report lower scores on most
dimensions in HRQOL with general health
perception being the most influenced domain
(2,5). On
a lighter note, GH is assumed to reflect
both physical and mental health. Related
to this is that a low general health perception
indicates a belief that health is likely
to get worse whereas psychosocial factors
such as labeling effect might affect HRQOL
among hypertensives
(2). However, there is conflicting
data about HT in relation to lower scores
both in PCS and MCS (2,17).
Our study results show that both physical
function and role emotional, were affected
in hypertensive participants.
Many studies address
relationship between increased levels of
exercise and improved health status. Sedentary
people reported lowest scores on physical
health (18). Besides daily physical activity,
we have questioned swimming separately and
evaluated if it has a unique affect on HRQOL.
We have found that regular swimming, more
than 3 months in a year, is associated with
better outcomes on both physical and mental
components and general health perception
of HRQOL.
Dietary habits are linked
to socioeconomic conditions and lifestyle,
possibly reflecting cultural development
of past habits and may be influenced by
diseases (19).
High intake of fat, sugar and milk products
and low intake of vegetables and fruits
are considered to be related to cardiovascular
disease (16).
Furthermore, fish consumption had been linked
to a decrease of coronary heart disease
in women (20,21).
As it was pointed out previously, higher
intake of fruits, vegetables, fish and preference
of olive oil and lower intake of red meat
and fat are characteristics of Mediterranean
diet. Mediterranean life style programs
produced significant improvement on behavioral
risk factors of coronary heart disease such
as eating patterns and physical activity
and improvement in quality of life was also
significant (20).
As a result, in our study, better scores
on HRQOL were obtained by participants with
Mediterranean dietary habits, which include
regular fish consumption.
Limitations of our study
are the relatively small number of participants
for general population studies and lack
of detailed energy intake information. Nevertheless,
we designed our study on a voluntary basis
and Datca-Knidos is a well preserved typical
east Mediterranean county. In addition,
information bias is a possibility in self-reported
studies. We believe inclusion of biological
outcomes assessment and detailed dietary
information should be a focus of further
research.
Consequently, the present
study focuses on related factors on quality
of life in a group of people living in east
Mediterranean. Mediterranean diet, at least
moderate physical activity and regular swimming
are associated with better outcomes on HRQOL.
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Table
1. Demographic features of 327
participants
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Women
(n=219)
n
(%)
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Men
(n=108)
n
(%)
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Total
(n=327)
n
(%)
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Age:
< 40 years old
40-54 years old
55-64 years old
≥ 65 years old
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39 (12.1%)
128
(39.4%)
30
(9.2%)
21(6.4%)
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18
(5.5%)
42
(12.8%)
27
(8.3%)
21
(6.4%)
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57
(17.4%)
170
(52.3%)
58
(17,5%)
42
(12.8%)
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Born in
Datca
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156
(71.2%)
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57
(52.8%)
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213
(65.1%)
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Smoker
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99
(45.2%)
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93
(86.1%)
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192
(58.7%)
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Coronary
Artery Disease
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69
(31.5%)
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36
(33.3%)
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105
(32.1%)
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Hypertension
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78
(35.6%)
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30
(27.8%)
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108
(33.0%)
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DM Type
2
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36
(16.4%)
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21
(19.4%)
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57
(17.4%)
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Dietary
Habits
Red meat (< once/week)
Fish ( ≥3 times/week)
Fruit (everyday)
Vegetable (everyday)
Raw
Cooked
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28
(12.8%)
171
(78.1%)
111 (50.7%)
90
(41.1%)
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63
(58.3%)
15
(13.9%)
57
(52.8%)
57
(52.8%)
18
(16.7%)
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180
(55.0%)
43
(13.1%)
228
(69.7%)
168
(51.4%)
108
(33.0%)
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Physical
Activity
I Sedentary
II Mild
III Moderate
IV Vigorous
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27 (12.3%)
54
(24.6%)
108
(49.3%)
30
(13.7%)
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15
(13.9%)
21
(19.4%)
42
(38.9%)
30
(27.8%)
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42
(12.8%)
75
(22.9%)
150
(45.8%)
60
(18.3%)
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Regular
swimmers
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138
(63.0%)
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72
(66.7%)
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210
(64.2%)
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Obesity
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75
(34.2%)
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21(19.4%)
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96
(29.4%)
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back
to text
Table
2. Results of linear regression
analysis of SF-36v2 scores, Physical
Function (PF), Social Function (SF),
Role physical (RP), Role Emotional
(RE) |
Variables
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PF
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SF
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RP
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RE
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Age
≥41 years
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-4,896*
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1,608
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-3,653
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-6,764**
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Male
gender
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3,312
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5,032**
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-3,133
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2,109
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Non-smoker
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5,848**
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-0,563
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6,905***
|
2,314
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Coronary
Artery Disease
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-10,848***
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-4,261*
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-2,210
|
0,522
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Hypertension
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-4,899*
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-2,518
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0,180
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-6,468**
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DM
Type 2
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-1,641
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-0,713
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-3,540*
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-6,598**
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Mediterranean
Diet
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10,031**
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4,764
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2,428
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9,444**
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Sedentary
or mildly active
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-4,189*
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-7,032***
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-0,706
|
0,103
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Swimming > 3 months/year
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5,082**
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0,768
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2,183
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6,277**
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Non-obese
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2,289
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4,770*
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5,087**
|
1,430
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Adjusted
RČ
|
0,309
|
0,097
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0,076
|
0,088
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Significance
|
<0.001
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<0.001
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<0.001
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<0.001
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* p<0.05
**p<0.01 ***p<0.001
back
to text
Table
3. Results of linear regression
analysis of SF-36v2 scores Mental
Health (MH), Vitality (VT), Bodily
Pain (BP), and General Health (GH) |
Variables
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MH
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VT
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BP
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GH
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Age ≥41 years
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-10,146***
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-7,776***
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-3,263
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-7,288***
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Male
gender
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3,692**
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3,121**
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-0,685
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-1,740
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Non-smoker
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-1,393
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-0,684
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3,652
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-0,687
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Coronary
Artery Disease
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-1,851
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0,508
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-10,182***
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-4,977**
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Hypertension
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-0,770
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-1,239
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2,343
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-0,680
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DM
Type 2
|
-2,298
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-3,221*
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2,137
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-3,561
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Mediterranean
Diet
|
10,286***
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9,119***
|
6,050
|
7,124**
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Sedentary
or mildly active
|
-0,780
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-2,686*
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-4,167*
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-6,846***
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Swimming > 3 months/year
|
0,520
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0,826
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3,450
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4,106**
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Non-obese
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-0,239
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2,715*
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-0,108
|
1,574
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Adjusted
RČ
|
0,219
|
0,172
|
0,110
|
0,230
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Significance
|
<0.001
|
<0.001
|
<0.001
|
<0.001
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*p<0.05
**p<0.01 ***p<0.001
back
to text
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