The Cognition and Behavior of Lifestyle-Related Diseases Prevention in Middle-Aged Women and Their Association with Physical Assessment

The subjects were women aged 40 to 74 years who had received specific health checkups at Hyogo Prefecture Prevention Medicine Association. A total of 1,748 questionnaires were handed out; 585 were collected (a collection ratio of 33.5%), among which 522 were analyzed (a ratio of valid responses of 29.9%). These included responses from 63 women whose ages were unknown. Oophorectomy and hormone therapy were excluded from the study.


Introduction
Recently, the average life expectancy of Japanese women has reached 87 years, while the unhealthy period, defined as being in a dependent living situation, has risen to over 12 years [1,2]. It is well known that, in Japan, lifestyle-related diseases such as diabetes or hypertension have been increasing due to rapid changes in lifestyle, which might be contributable to the disturbance of QOL and the high prevalence of three major illnesses (malignant neoplasms, heart disease and cerebrovascular disease) in middle-aged women [3,4]. Healthcare during and after menopause may be an important priority for healthy life in middle-aged women. Recent studies have indicated the effects of education programs on dietary habits and exercise on the prevention of lifestyle-related diseases [5][6][7][8][9]. As for knowledge and recognition of lifestyle-related disease prevention, these were enhanced through medical checkups and health education. Specific health checkups for the prevention of lifestyle-related diseases began in 2008 in Japan [10]. It is possible that there are great differences in lifestyle and metabolic and endocrine status, as well as cognitive behavior among women in each life stage.
However, there are no reports demonstrating whether cognitive behavior on the prevention of lifestyle-related diseases affects physical determinants or measurements in each life stage among middle aged women.
Thus, we conducted the present study to examine the cognition and behavior of lifestyle-related disease prevention, and physical determinants (height, weight, BMI, waist circumference, blood pressure, lipids, blood glucose) in middle-aged women, and compared the results for each life stage.
The subjects were asked about their stress levels on a scale of 1 to 10, with 1-3 being "weak," 4-6 being "moderate," and 7 or more being "strong," The subjects' ability to cope with stress was asked about with a "Yes" or "No" answer. The SMI is a simple scale with demonstrated validity for measuring general menopausal symptoms in consideration of the peculiarities of Japanese people. The scale consists of the following 10 items: items (1-4) mainly assess physical symptoms (hot flushes, perspiration, cold feeling and palpitations); items (5-8) chiefly evaluate mental symptoms (insomnia, irritation, depression and headaches); and items (9) and (10) assess general symptoms, including shoulder/joint pain and fatigue. The answer to each question was described using a 4-point scale as "absent, " "mild, " "moderate" or "severe. " Scores of 0 to 14 were then assigned to each answer. The SMI score was calculated as the sum of these scores, ranging from 0 to 100. In the present study, on the basis of the SMI score and the severity of climacteric disturbance, women with scores of 0-25 points were classified as "low," and those with scores of 51-100 points were classified as "high," and analysis was conducted.

Physical and laboratory examination
We asked each of the respondents to transfer the results of their specific health checkups (height, weight, BMI, abdominal circumference, blood pressure, lipids (TG, LDL-C and HDL-C), blood sugar).

Statistics
SPSS23.0J software was used for statistical analysis. The subjects were divided to four age brackets 40s, 50s, 60s and 70s and compared in terms of their cognition and behavior of lifestyle-related disease prevention, and the physical determinants of the four groups. In the analyses, independence was tested using the chi-square test, while differences in the mean between the four groups were determined using the t-test.
In all cases, P values of > 0.05 were considered statistically significant.
The percentages of subjects who had late-night snake more than 3 times per week were 22.4% (n=13), 32.8% (n=20), 15.2% (n=37) and 14.5% (n=23) in 40's, 50's, 60's and 70's, respectively. Table 3 (Supplementary File) shows the cognition and behavior of lifestyle-related diseases prevention of the subjects. The percentages of subjects who had knowledge on metabolic syndrome (Metabolic syndrome) were 72.4% (n=42), 68.8% (n=42), 71.4% (n=174) and 75.5% (n=120) in 40's, 50's, 60's and 70's, respectively. The percentages of subjects who had knowledge menopausal features were 48.3% (n=28), 65.6% (n=40), 78.7% (n=192) and 72.3% (n=115) for those in their 40s, 50s, 60s and 70s, respectively. The percentages of subjects who paid attention to lifestyle-related disease prevention were 50.8% (n=31), 58.2% (n=142) and 59.1% (n=94) for those in their 50s, 60s and 70s, respectively. The percentages of subjects who engaged in behavior of lifestyle-related disease prevention were 37.9% (n=22), 36.0% (n=22), 49.5% (n=121) and 58.5% (n=93) for those in their 40s, 50s, 60s and 70s, respectively. Table 4 (Supplementary File) shows the physical assessments of the subjects. The mean heights of the subjects were 159.6 ± 3.8 cm, 157.9 ± 5.3 cm, 154.7 ± 5.3 cm and 152.1 ± 4.8 cm in for those their 40s, 50s, 60s, and 70s, respectively. The mean weights of the subjects were 52.9 ± 6.5 kg, 50.7±7.7 kg, 50.6±7.6 kg, and 49.6±6.6 kg for those in their 40s, 50s, 60s and 70s respectively, with the highest mean weight recorded for those in their 40s, at 52.9±6.5 kg, and the highest BMI for those in their 70s, at 21.4 ± 2.6. The mean abdominal circumference was 74.4 cm for those in their 40s, and 79.2 cm for those in their 70s. Systolic blood pressure was 109.5 mmHg for those in their 40's, and 128.8 mmHg for those in their 70s. The percentages of subjects who experienced weight gain of 10 kg or more after the age of 20 was 19.7% (n=24) for those in their 60s. The percentages of subjects who had experienced recent weight gain were 58.6% (n=34) for those in their 40s, compared to 27.9% (n=17), 27.0% (n=66), and 20.8% (n=33) for those in their 50s, 60s and 70s, respectively. Table 5 (Supplementary File) shows the factors related to cognition and behavior of lifestyle-related disease prevention. There was a correlation in cognition of lifestyle-related disease prevention between those who knew about metabolic syndrome and those who didn't know about metabolic syndrome in their 60s and 70s. There was a correlation in cognition of lifestyle-related disease prevention between those who had knowledge of menopausal features and those who didn't have knowledge of menopausal features in their 50s and 60s. There was a correlation in behavior of lifestyle-related disease prevention between those who could cope with stress, those who knew about metabolic syndrome, those who knew about menopausal features and couldn't cope with stress, those who didn't know about metabolic syndrome, and those who didn't know about menopausal features, in their 70s. Table 6 (Supplementary File) shows the cognition and behavior of lifestyle-related disease prevention and their association with physical assessment. The weight of subjects who had knowledge of metabolic syndrome tended to be lower than that of subjects who didn't have knowledge of metabolic syndrome. The HDL-C of subjects who had knowledge of menopausal features tended to be higher than that of subjects who didn't have knowledge of menopausal features. The LDL-C of subjects who could pay attention to lifestyle-related disease prevention tended to be lower than that of subjects who couldn't pay attention to lifestyle-related disease prevention. The weight of subjects who engaged in behavior of preventing lifestyle-related diseases tended to be lower than that of subjects who didn't engage in behavior of preventing lifestyle-related diseases.

Discussion
Among middle-aged women, there were generation-specific characteristics or differences in lifestyles such as work, housewife status, sleep and exercise. It was indicated for the first time that, the higher the age bracket, the higher the levels of knowledge, cognition and practice of lifestyle-related disease prevention, and that the cognition and behavior of lifestyle-related disease prevention showed an association with physical assessments that showed some differences between the age brackets.
We demonstrated that there were some differences in lifestyle among the age brackets of the middle-aged women. Women in all the age brackets slept for at least six hours, but those in the higher age brackets were more satisfied with their sleep. On the other hand, the percentages of subjects who suffered from strong or moderate stress were more than 60% for those in their 40s and 50s, which might indicate that the younger age brackets were more prone to stress. The report by the Ministry of Health, Labour and Welfare demonstrated that the percentage of subjects whose duration of sleep was less than six hours a day had increased significantly since 2007 [13]. Subjects in their 40s to 50s cited "housewife" status (i.e., housework) and "work" as reasons for their shortened sleeping time, which might result in unsatisfactory sleep. Furthermore, it is reported that Japanese women in their 40s and 50s are burdened by work, housework and child care, and have difficulty securing the time to practice lifestylerelated disease prevention [14]. Therefore, it is essential that health professionals provide health advice in accordance with individual circumstances, which will lead to the actual practice of lifestylerelated disease prevention behaviors among the younger age brackets.
Although middle-age women of all age brackets knew the term "metabolic syndrome" well, higher percentages among the higher age brackets "knew" that metabolic syndrome (lifestyle-related disease) was likely to occur during the post-menopause period. The number of people who engaged in behaviors toward lifestyle-related disease prevention also increased the higher the age bracket. The endocrine and metabolic changes at the time of menopause and the manifestation of lifestyle-related diseases such as dyslipidemia, diabetes mellitus and osteoporosis after the age of 60 may be contributable to higher recognition of lifestyle-related disease prevention among the higher age brackets [15,16].
Next, with regard to preventive behavior related to lifestylerelated diseases, more than 90% of the subjects knew that exercise, regular eating habits and a well-balanced diet were important for the prevention of lifestyle-related disease. Regarding eating behavior, "daily" consumption of breakfast increased the higher the age bracket. The report by the Ministry of Health, Labour and Welfare demonstrated that the rate of eating a balanced diet containing staple foods, main vegetables, and side dishes decreased among the lower age brackets, and the rate of having breakfast decreased among the higher age brackets [13,17]. The rate of doing exercise more than two or three times a week increased among the higher age brackets. This suggests that, although the lower age brackets may recognize the importance of preventive behavior regarding lifestyle-related diseases, they find it difficult to put it into practice [17]. Interestingly, regarding the relationship between knowledge and preventive behavior, the knowledge of lifestyle disease prevention was significantly associated with preventive behavior for lifestyle related diseases for those in their 70s. It was suggested that those in their 70s might engage in preventive behavior through the accumulation of knowledge of lifestyle-related disease and their awareness thereof, whereas among those in their 50s and 60s, preventive behavior was constrained with work and nursing care [14].
Regarding the physical and laboratory examinations related to lifestyle-related diseases, the mean values of physique, blood pressure, triglyceride, HDL-C, and blood glucose were within the normal range for all the age brackets. Comparing the data among the age brackets, BMI increased with age, and both systolic and diastolic blood pressure among those in their 40s and 50s increased, while blood glucose and triglyceride levels among those in their 50s and 60s increased and HDL-C among those in their 60s and 70s decreased. In addition, the mean abdominal circumference was 77.3 cm, lying within the normal range. The mean abdominal circumference increased by about 5 cm among those in their 70s (79.2 cm) from the mean of 74.4 cm among those in their 40s.
A previous study indicated that an abdominal circumference more than 80 cm in women increased the risk of overlooking lifestyle-related diseases and myocardial infarction; therefore, such a circumference among those in their 70s was a high risk level [18]. It is important for health professionals to be aware of age-dependent changes in physical determinations related to lifestyle-related diseases and prevent accelerated progression toward them.
Regarding the associations between knowledge and behavior, and physical assessment for lifestyle-related diseases, the weights of subjects who had knowledge of and engaged in preventive behavior regarding lifestyle-related diseases tended to be lower among the younger age brackets, while HDL-C in subjects who had knowledge of lifestyle-related disease prevention tended to be higher and LDL-C in such patients tended to be lower among those in their 70s. It was indicated that health education programs on lifestyle-related disease prevention should be provided among lower age brackets and be structured and based on age-specific characteristics, such as focusing on interest in physique among young people.

Conclusions
There were age-specific characteristics or differences in lifestyles in terms of work, housewife status, sleep and exercise. The higher the age bracket, the higher the levels of knowledge, cognition and practice of lifestyle-related disease prevention, and the cognition and behavior of lifestyle-related disease prevention showed an association with physical assessments, which showed some differences among the age brackets. It was suggested that knowledge of lifestyle-related disease prevention should be provided from a younger age and also based on age-specific characteristics.