International Psychogeriatrics: page 1 of 9 !

C International Psychogeriatric Association 2013

doi:10.1017/S1041610213000082

1 Healthy behavior and memory self-reports in young,

2 middle-aged, and older adults
.........................................................................................................................................................................................................................................................................................................................................................................

3 Gary W. Small,1 Prabha Siddarth,1 Linda M. Ercoli,1 Stephen T. Chen,1 David A. Merrill1
4 and Fernando Torres-Gil2
1
Department of Psychiatry and Biobehavioral Sciences and Semel Institute for Neuroscience and Human Behavior, UCLA Longevity Center, David Geffen
School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
5 2
Department of Public Policy, UCLA School of Public Affairs, University of California, Los Angeles, Los Angeles, California, USA

6 ABSTRACT

7 Background: Previous research has shown that healthy behaviors, such as regular physical exercise, a nutritious
8 diet, and not smoking, are associated with a lower risk for Alzheimer’s disease and dementia. However, less
9 is known about the potential link between healthy behaviors and mild memory symptoms that may precede
10 dementia in different age groups.
11 Methods: A daily telephone survey (Gallup-Healthways Well-Being Index) of US residents yielded a random
12 sample of 18,552 respondents ranging in age from 18 to 99 years, including 4,423 younger (age 18–39
13 years), 6,356 middle-aged (40–59 years), and 7,773 older (60–99 years) adults. The questionnaire included
14 demographic information and the Healthy Behavior Index (questions on smoking, eating habits, and frequency
15 of exercise). General linear models and logistic regressions were used in the analysis.
16 Results: Older adults were more likely to report healthy behaviors than were middle-aged and younger adults.
17 Reports of memory problems increased with age (14% of younger, 22% of middle-aged, and 26% of older
18 adults) and were inversely related to the Healthy Behavior Index. Reports of healthy eating were associated
19 with better memory self-reports regardless of age, while not smoking was associated with better memory
20 reports in the younger and middle-aged and reported regular exercise with better memory in the middle-aged
21 and older groups.
22 Conclusions: These findings indicate a relationship between reports of healthy behaviors and better self-
23 perceived memory abilities throughout adult life, suggesting that lifestyle behavior habits may protect brain
24 health and possibly delay the onset of memory symptoms as people age.

25 Key words: healthy aging, memory, nutrition, physical activity, healthy behavior, telephone survey, lifestyle habits

26 Introduction begin gradually and are preceded by years of 38

steadily increasing cognitive declines – initially mild 39
27 Age is the greatest single risk factor for developing age-related memory complaints, followed by mild 40
28 dementia, and an estimated 34 million people cognitive impairment, a condition that increases the 41
29 suffer from this condition, which impairs an risk for developing dementia (Petersen, 2004). 42
30 individual’s ability to live independently (Barnes The most common cause of dementia is 43
31 and Yaffe, 2011). About 10% of individuals age Alzheimer’s disease (AD), defined by abnormal 44
32 65 years or older have dementia, but by age 85 protein fibers – amyloid plaques and tau tangles 45
33 years and older more than 45% suffer from the – that accumulate in brain areas controlling 46
34 condition (Alzheimer’s Association, 2012). The memory, language, judgment, thinking, and 47
35 annual caregiving and healthcare costs are estimated behavior (Knopman et al., 2001). Although 48
36 to exceed $400 billion in the USA (Alzheimer’s definitive AD is diagnosed at brain autopsy by high 49
37 Association, 2012). Dementia symptoms usually concentrations of plaques and tangles, positron 50
emission tomography (PET) scans using molecular 51
Correspondence should be addressed to: Gary W. Small, Semel Institute, Suite probes that bind to these protein deposits can 52
38-251, 760 Westwood Plaza, Los Angeles, CA 90024. Phone: +1 310-825- indicate patterns consistent with AD years before 53
0291; Fax: +1 310-825-3910. Email: gsmall@ucla.edu. Received 21 Oct 2012;
revision requested 17 Dec 2012; revised version received 7 Jan 2013; accepted people develop dementia symptoms (Small et al., 54
13 Jan 2013. 2012). 55
 2 G. W. Small et al.

56 Available medications can temporarily benefit telephone interviews in all 50 US states and 110
57 cognitive and behavioral symptoms of AD, but no use dual-frame sampling, which includes listed 111
58 cure yet exists. Because genetics account for only landline interviewing and wireless phone sampling 112
59 part of the risk for AD and related dementias, to reach those in “wireless-only” and “wireless- 113
60 investigators have searched for nongenetic factors mostly” households, as well as unlisted, landline- 114
61 that contribute to risk and earlier symptom onset. only households. A random selection method (by 115
62 Clinical trials and epidemiological studies have asking for the person 18 years or older with the 116
63 linked smoking (Cataldo et al, 2010) and midlife most recent or last birthday) chooses respondents 117
64 overweight and obesity (Fitzpatrick et al., 2009) to within the household. The survey includes Spanish 118
65 increasing dementia risk in late life, while adherence language interviews for respondents who speak 119
66 to the Mediterranean diet (Sofi et al., 2010), eating only Spanish and a three-call design to reach 120
67 fruits and vegetables (Hughes et al., 2010), and respondents not contacted on the initial attempt. 121
68 regular physical exercise (Hamer and Chida, 2009) Nightly quotas ensure that the unweighted samples 122
69 are associated with lower risk. are proportionate by region and gender. The data 123
70 Lifestyle behaviors also may impact the extent of are weighted daily based on the 2011 Current 124
71 cognitive symptoms that people without dementia Population Survey Annual Social and Economic 125
72 experience. These milder cognitive impairments Supplement to match targets by age, sex, region, 126
73 are common and may represent a stage of education, ethnicity, and race. Sampling weights 127
74 decline that precedes mild cognitive impairment, correct for unequal selection probability and 128
75 which increases an individual’s risk for dementia compensate for disproportionalities in selection 129
76 (Reisberg and Guathier, 2008). Moreover, in probabilities and nonresponse. With the inclusion 130
77 most normal individuals objective evidence of of the cell phone-only households and Spanish 131
78 age-related cognitive decline can be measured language interviews, over 90% of the US adult 132
79 by age 45 years (Singh-Manoux et al., 2011). population is represented. Response rates refer to 133
80 Previous studies support the role of physical the response fraction or the number of respondents 134
81 exercise, nutrition, and not smoking in protecting providing a given response divided by the total 135
82 brain health and memory ability (Joseph et al., number that responded to the particular question. 136
83 2009; Etgen et al., 2010; Heffernan et al., 2010). The response rates for the survey, using standard 137
84 A better understanding and recognition of mild definitions from the American Association for 138
85 memory symptoms has the potential to impact Public Opinion Research (2008) were as follows: 139
86 medical practice. A recent four-year longitudinal contact rate (number of households reached divided 140
87 study showed that subjective memory complaints by the number of working, nonbusiness telephone 141
88 in an older general practice population predicted numbers dialed), 51%; refusal rate (number 142
89 subsequent hospital-based dementia diagnosis, of respondents that refused to be interviewed 143
90 suggesting that general practitioners might identify divided by the number of all potentially eligible 144
91 vulnerable older patients by asking about memory cases), 23%; cooperation rate (the number of 145
92 complaints (Waldorff et al., 2012). eligible respondents who gave initial consent to 146
93 Despite the prior research linking healthy be interviewed, divided by the total number 147
94 behaviors to a lower probability of developing of households reached), 29%; and completion 148
95 AD and related dementias, studies of associations rate (the proportion of initially cooperating and 149
96 between healthy behavior and memory in people eligible households where someone completed the 150
97 from different age groups are limited. To address interview), 93%. Gallup uses professionally trained 151
98 this knowledge gap, we assessed memory symptoms interviewers, who have the leeway to terminate calls 152
99 in Gallup Poll telephone surveys of a random if the respondent seems unable to understand or 153
100 sample of adults aged 18–99 years to determine respond to the questions. Because this analysis did 154
101 relationships between healthy behaviors and self- not pose risk to respondents and was an analysis 155
102 reported memory abilities. of data collected by the Gallup Organization, it 156
received a waiver from the UCLA Human Subjects 157
Protection Committee. 158
103 Methods
104 Survey procedures Questionnaire items 159
105 Gallup Poll Daily tracking interviews of 18,552 The questionnaire included items providing 160
106 US adults, aged 18 years and older, for the demographic information and measuring lifestyle 161
107 period between December 19, 2011, and January habits with established relationships to health 162
108 31, 2012, provided the data set for this analysis. outcomes. The Healthy Behavior Index (HBI) is 163
109 The Gallup daily survey methods rely on live one of six subcomponents of the Gallup-Healthways 164
 Healthy behavior and memory 3

Table 1. Gallup poll questions on healthy behavior correlations with external metrics of health risk 206
and memory factors underscore the construct validity of the 207
index. 208
HEALTHY BEHAVIOR INDEX (HBI) QUESTIONS
.........................................................................................................................................................

1. Do you smoke? (yes or no) Statistical analyses 209

2. Did you eat healthy all day yesterday? (yes or no) Analyses were performed using SAS 9.2, which 210
3. In the last seven days, on how many days did you have allows estimation of parameters and hypothesis 211
five or more servings of fruits and vegetables? (0 to 7) testing weighted by sample weights to ensure correct 212
4. In the last seven days, on how many days did you computation of standard errors. Respondents were 213
exercise for 30 or more minutes? (0 to 7) divided into three age groups: younger (18–39 214
MEMORY QUESTION years), middle-aged (40–59 years), and older (60 215
1. Do you have any problems with your memory? (yes or years and older) adults. 216
no) Mean HBI scores were calculated for subjects 217
Note: Possible responses are indicated in parentheses. in the three age groups, and effect sizes for 218
group differences (Cohen’s d) were calculated for 219
each pairwise comparison. The individual HBI 220
165 Well-Being Index, and includes four items: components and the proportion of participants 221
166 smoking, eating healthy, weekly consumption of with memory problems were also examined for 222
167 fruits and vegetables, and weekly exercise frequency each age group. We then calculated the mean 223
168 (Table 1). Yes or no responses to the “Do HBI for participants with and without memory 224
169 you smoke?” and “Did you eat healthy all day problems and the effect size for the mean difference 225
170 yesterday?” questions were recoded to reflect the both for the full sample and within each age 226
171 positive response only (i.e. “1” if nonsmoker/ate group. Educational and income levels were used as 227
172 healthy; “0” if smoker/did not eat healthy). If the covariates in the model. 228
173 participant’s response indicated ≥4 times/week for The relationship between memory symptoms 229
174 eating fruits and vegetables (question 3) or 3–7 and HBI was also studied using logistic regression, 230
175 times/week for exercise (question 4), then that item with memory group as the dependent variable 231
176 was given a positive value of 1 for that respondent; and HBI as the independent variable. In addition, 232
177 if not, that item was scored as 0. The HBI was then we examined the contribution of individual HBI 233
178 calculated as the mean of these 4 items multiplied components to memory symptoms by estimating a 234
179 by 100, and rounded to 1 decimal place. The mean logistic regression model with the individual items 235
180 score for HBI requires all 4 items to be present in as independent variables. Since obesity can be con- 236
181 order for the mean to be calculated. The cut-offs sidered a surrogate marker of healthy behavior, we 237
182 used in the scoring for the HBI were empirically included obesity (as a yes or no variable and defined 238
183 derived based on how the scale (days) differentiated as a body mass index (BMI) > 30) as an additional 239
184 on several well-being outcomes (life evaluation, predictor in the logistic regression and computed 240
185 emotional health, and physical health). In addition, the two models within each age group to determine 241
186 memory symptoms were assessed using a single how the age groups differed in their association 242
187 question about the presence of memory problems between memory symptoms and healthy behaviors. 243
188 with yes or no as possible responses (Table 1). Because of the large sample size, results can be 244
189 This question was adapted from a meta-memory statistically significant even when actual effect sizes 245
190 questionnaire item, and responses to this question are small. In this analysis, we thus emphasized effect 246
191 are associated with objective memory performance sizes and odds ratios over p-values. Effect size is a 247
192 scores (Schofield et al., 1997). simple way of quantifying the differences between 248
193 The Gallup HBI (Gallup-Healthways Well- groups by emphasizing the size of the difference 249
194 Being Index, further information is available at without confounding this difference with sample 250
195 http://www.well-beingindex.com) has been com- size. 251
196 pared with external sources of health and well-
197 being data to study construct validity. The HBI
198 displays strong associations with external indicators, Results 252
199 such as the percentage of adults who: participate in
200 moderate or vigorous physical activities (r = 0.66, Subjects 253
201 p < 0.001), are obese (r = –0.85, p < 0.0001), have Older age was associated with a higher proportion 254
202 diabetes (r = –0.59, p < 0.001), have ever been of women, Caucasian respondents, and individuals 255
203 told by a doctor that they have diabetes (r = – with postgraduate education, while obesity rates 256
204 0.59, p < 0.001), smoke (r = –0.74, p < 0.001), and were higher in middle-aged and older adults 257
205 consume tobacco (r = –0.68, p < 0.001). These compared with younger adults (Table 2). As noted, 258
 4 G. W. Small et al.

Table 2. Characteristics of subjects according to age group

YOUNGER ADULT MIDDLE-AGED OLDER ADULTS
CHARACTERISTIC (n = 4,423) (n = 6,356) (n = 7,773)
............................................................................................................................................................................................................................................................................

Age, mean (SD), y 27.8 (8.0) 49.3 (5.8) 70.1 (6.3)

Education (%)
Less than high school 11.8 9.6 14.6
High school 25.3 29.4 34.3
Some college 34.1 27.5 23.2
College graduate 18.2 19.4 12.7
Postgraduate 10.6 14.1 15.2
Women (%) 47.7 49.3 54.6
Race (%)
White 62.4 75.6 84.0
African American 13.2 10.0 6.8
Asian 3.8 1.4 0.7
Other 20.6 13.0 8.5
Ethnicity (%)
Hispanic 20.0 11.0 6.1
BMI, mean (SD) 26.6 (7.4) 28.3 (6.2) 27.7 (4.5)
Obese (%) 21.9 31.5 28.0
Notes: Weighted numbers and percentages are presented. Younger adults: age 18–39 years; middle-aged: 40–59 years;
older adults: 60–99 years. Obese defined as BMI > 30.

and 57.9 (34.4) for younger subjects (ES = 0.38 267

for older vs. middle-aged; ES = 0.42 for older vs. 268
younger; ES = 0.09 for middle-aged vs. younger). 269
Controlling for educational and income levels, the 270
effect size was 0.39 for older versus middle-aged, 271
0.42 for older versus younger, and 0.07 for middle- 272
aged versus younger adults. 273
Several HBI subcomponents differed signific- 274
antly according to age (Figure 1). Only 12.4% 275
of older adults smoked, while 24.8% of young 276
adults and 23.7% of middle-aged adults smoked. 277
A higher proportion of older adults reported eating 278
healthy yesterday (80.4%) and eating five or more 279
Figure 1. (Colour online) The histograms indicate the percentage
daily servings of fruits and vegetables during the 280
of respondents engaging in each of the behaviors comprising
previous week (64.0%) compared with middle- 281
the subcomponents of the Healthy Behavior Index and reporting aged adults (65.8% and 53.9%, respectively) and 282
memory problems, according to age group. younger adults (56.2% and 49.1%). Comparable 283
Note: Healthy behavior subcomponents and memory problems proportions of adults participated in regular exercise 284
according to age group. in the different age groups (younger: 50.9%; 285
∗
Ate five or more servings of fruits and vegetables at least 4 middle-aged: 46.6%; older: 46.7%). 286
times/week.
∗∗
Exercised for 30 or more minutes at least 3 times/week.
Healthy behavior, memory, and age 287
Only 14.4% of younger adults reported memory 288
259 the data were weighted to match targets from the problems compared with 22.0% of middle-aged 289
260 U.S. Census Bureau by age, sex, region, education, and 26.4% of older adults (Figure 1). Respondents 290
261 ethnicity, and race. with memory problems had significantly lower 291
mean (SD) HBI scores of 60.9 (26.5) compared 292
262 Healthy behavior and age to 66.2 (26.4) for those without problems. The 293
263 Reports of healthy behaviors were more common effect sizes for this relationship were comparable 294
264 in older than in middle-aged and younger adults. among the three age groups (younger: ES = 0.26; 295
265 The mean (SD) HBI for older subjects was 69.8 middle-aged: ES = 0.30; and older: ES = 0.25) and 296
266 (19.8) compared to 60.7 (28.0) for middle-aged controlling for educational and income levels of the 297
 Healthy behavior and memory 5

298 survey respondents did not change the magnitude CI [1.00, 1.35]) increase in the odds of reporting 355
299 of these effect sizes. For a 25-unit decrease in HBI memory problems compared to a non-obese person 356
300 (equivalent to not participating in any one of the in the same age group. 357
301 four healthy behavior activities: not smoking, eating
302 healthy yesterday, eating five servings of fruits and
303 vegetables, or exercising three or more time a week),
Comment 358
304 the odds of reporting memory problems was 1.21
305 (95% confidence interval (CI) [1.17, 1.25]). For To our knowledge, this is the first large-scale study 359
306 respondents not participating in two of the four of a representative community sample demon- 360
307 healthy activities, the odds of reporting memory strating associations between reports of healthy 361
308 problems increased to 1.45 (95% CI [1.36, 1.55]). behaviors and fewer memory symptoms across 362
309 For those not participating in three of the four different age groups. Reports of healthy eating, 363
310 healthy activities, the odds of reporting memory regular physical exercise, and not smoking were all 364
311 problems increased to 1.75 (95% CI [1.59, 1.93]). associated with self-ratings of better memory. 365
312 For those not involved in any of the four healthy Other research suggests that individuals who 366
313 activities, the odds of reporting memory problems engage in one healthy behavior are likely to engage 367
314 was 2.11 (95% CI [1.85, 2.41]). in others. For example, cigarette smokers are 368
315 Reports of healthy eating were associated with less likely to consume fruits and vegetables than 369
316 better memory regardless of age. Controlling for nonsmokers, while those who attempt to quit 370
317 the other factors (smoking, regular exercise, obesity, smoking are more likely to succeed if they eat 371
318 educational, and income levels), a person who did higher quantities of fruits and vegetables (Haibach 372
319 not report healthy eating had an odds ratio of et al., 2013). In our study, respondents engaging 373
320 1.26 (95% CI [1.14, 1.39]) for reporting memory in just one healthy behavior (e.g., not smoking 374
321 problems compared to a person who reported eating or eating healthy yesterday) were 21% less likely 375
322 healthy. This effect was most pronounced in older to report memory symptoms than those who did 376
323 individuals: while younger adults who reported not. Moreover, the higher the number of healthy 377
324 healthy eating had a 1.48 (95% CI [1.26, 1.74]) behaviors reported, the less like were respondents 378
325 increase in odds compared to younger adults who to report memory problem. Those reporting two 379
326 did not report healthy eating and middle-aged healthy behaviors were 45% less likely to report 380
327 adults had a 1.28 (95% CI [1.10, 1.50]) increase in memory problems, while respondents reporting 381
328 odds, older adults who did not report healthy eating three or four healthy behaviors were 75% and 382
329 habits had a 1.86 (95% CI [1.49, 2.31]) increase in 111% less likely to report memory problems. These 383
330 the odds of reporting memory problems compared findings suggest a dose response effect in engaging 384
331 to those who reported healthy eating habits. in more than one healthy behavior in reducing 385
332 Smoking was associated with memory symptoms memory symptoms. 386
333 in younger and middle-aged but not in older adults. Although information linking very mild memory 387
334 A younger smoker had a 1.88 (95% CI [1.60, 2.20]) symptoms to healthy behaviors is limited, previous 388
335 increase in the odds of reporting memory problems research has focused on healthy behaviors and 389
336 compared to a younger nonsmoker, and a middle- more advanced cognitive declines, such as mild 390
337 aged smoker had a 1.28 (95% CI [1.10, 1.48]) cognitive impairment, a risk state for dementia. A 391
338 increase in the odds of reporting memory problems diet high in processed foods has been associated 392
339 compared to a middle-aged nonsmoker. with more severe cognitive deficits in patients with 393
340 Reports of physical exercise were associated mild cognitive impairment (Torres et al., 2012). 394
341 with better memory in the middle-aged and older Exercise interventions also have been associated 395
342 groups, but not in the younger group. A middle- with positive changes in vascular risk factors related 396
343 aged person who did not report exercising regularly to cognitive decline and vascular disease in older 397
344 had a 1.38 (95% CI [1.21, 1.58]) increase and adults with mild cognitive impairment (Uemura 398
345 an older adult had a 1.51 (95% CI [1.30, 1.76]) et al., 2012). Other studies have shown evidence 399
346 increase in the odds of reporting memory problems that physical activity and cognitive exercise may 400
347 compared to a person in the same age group improve memory and executive functions in older 401
348 who reported exercising regularly (controlling for people with mild cognitive impairment (Teixeira 402
349 the other factors). Obesity also was a significant et al., 2012). 403
350 predictor of memory problems in the middle-aged It is noteworthy that older age was associated 404
351 and older groups, but not in the younger group. with healthier behaviors, which counters the 405
352 Controlling for the other factors, a middle-aged stereotype of aging as a time of life characterized 406
353 obese adult had a 1.21 (95% CI [1.06, 1.39]) by immobility, dependence, and both physical and 407
354 increase and an older obese adult had an 1.16 (95% mental decline (Kotter-Grühn et al., 2012). Young 408
 6 G. W. Small et al.

409 adults often engage in unhealthy behaviors because et al., 2008; Wen et al., 2011). Smoking in 466
410 of their sense of invincibility (El Ansari et al., middle-aged respondents had a relatively modest 467
411 2011): many are able to smoke, overeat, and engage association with memory symptoms, which is 468
412 in other unhealthy behaviors without experiencing consistent with a previous study showing a 469
413 immediate health consequences, whereas middle- statistically significant but weak association between 470
414 aged and older adults are more likely to suffer smoking and the presence of memory symptoms in 471
415 the consequences of unhealthy behaviors. As they people aged 45–64 years (Paradise et al., 2011). 472
416 develop such age-related illnesses as cardiac disease, Our findings that reports of physical inactivity 473
417 hypertension, and diabetes, their doctors may advise increased the probability of memory symptoms 474
418 them to eat a healthy diet, lose weight, stop smoking, in middle-aged and older adults agree with other 475
419 and begin exercising. Also, health information work indicating associations between cardiovascular 476
420 through television, newspapers, magazines, and conditioning and cognitive health (Etgen et al., 477
421 other media may influence older adults more than 2010). Regular aerobic conditioning results in 478
422 younger adults. Another possible explanation for physiological effects that benefit cognitive function, 479
423 the healthier behaviors reported in middle-aged and such as increased cerebral blood flow, neuronal 480
424 older adults is that people with unhealthy behavior growth, and brain-derived neurotrophic factor 481
425 habits have short life expectancies and do not expression, which enhances brain plasticity (Merrill 482
426 survive to older age groups or are more likely to and Small, 2011). Cardiovascular conditioning also 483
427 be institutionalized and not accessible to surveyors increases hippocampal volume (Erickson et al., 484
428 (Shavelle et al., 2008; Wen et al., 2011). 2011) and is associated with lower levels of brain 485
429 Older adults were more likely to report memory amyloid in people without dementia at genetic risk 486
430 problems, but 14% of younger adult respondents for AD (Head et al., 2012). 487
431 reported memory symptoms. Other studies have We found that 26% of respondents age 65 488
432 shown that young adults do experience memory years and older reported memory problems, which 489
433 symptoms, but such symptoms are qualitatively is lower than rates reported from other studies. 490
434 different from those of older adults and not likely For example, Schofield et al. (1997) found that 491
435 to indicate neurodegeneration (Ginó et al., 2010). 31% of normal community-dwelling elderly had 492
436 Regardless of age, respondents who did not memory complaints. It is possible that in the present 493
437 report healthy eating habits had a 26% increase survey older subjects minimized their memory 494
438 in the odds of reporting memory problems symptoms or else avoided the survey because of 495
439 compared with those reporting healthier eating such symptoms. However, other recent studies 496
440 habits. This finding is consistent with previous have found comparable frequencies of memory 497
441 studies suggesting cognitive benefits from intake of complaints in older populations ranging from 21% 498
442 antioxidant fruits and vegetables (Hughes et al., (Minett et al., 2008) to 25.5% (Dik et al., 2001). 499
443 2010), omega-3 fatty acids (Mazereeuw et al., Gallup’s interviewers are professionally trained to 500
444 2012), and the Mediterranean diet (Gu et al., terminate calls if the respondent seems unable to 501
445 2010). In our analysis, obesity, a surrogate of understand or respond to questions so that potential 502
446 unhealthy eating, was a significant predictor of respondents with apparent memory difficulties 503
447 memory symptoms in the middle-aged and older could have been weeded out, which also may 504
448 groups. We defined obesity as a BMI > 30, have explained the relatively low rates of memory 505
449 and BMI has been found to correlate with levels problems in the older respondent group. Despite the 506
450 of cognitive decline (Coin, 2012). Other studies relatively low rate of complaints in older subjects, 507
451 indicate a link between midlife obesity and later complaints of memory problems still increased with 508
452 risk for developing dementia (Fitzpatrick et al., age as expected from previous research. 509
453 2009); however, adiposity rather than BMI may Although psychometric data from respondents 510
454 be a better measure of vascular, metabolic, and were not available, previous studies have demon- 511
455 neurodegenerative risks (De Lorenzo et al., 2011). strated correlations between subjective reports 512
456 Consistent with previous research, we found of memory and objective neuropsychological 513
457 that nonsmokers had fewer memory symptoms performance scores. For example, Zelinski et al. 514
458 (Heffernan et al., 2010). Why this association was (1990) found moderate concurrent validity for 515
459 present in younger and middle-aged and not older self-reports of memory and objective memory 516
460 adults is not clear, but could reflect the influence measures in a study of 287 adults aged 50 years 517
461 of alcohol abuse and other unhealthy behaviors and older. Eckerström et al. (2013) found that 518
462 associated with smoking, which was not considered a self-reported cognitive impairment questionnaire 519
463 in this analysis (De Leon et al., 2007). Differential effectively discriminated between older controls 520
464 survival rates due to unhealthy behaviors may and patients seeking care at a memory clinic, 521
465 contribute to such age-related differences (Shavelle and showed medium to high correlations between 522
 Healthy behavior and memory 7

523 questionnaire scores and a single question on individual and societal health and reducing medical 580
524 memory functioning. expenditures. 581
525 Other factors could have influenced these results. These findings also reinforce the importance 582
526 For example, subjective memory complaints have of educating young and middle-age individuals 583
527 been associated with symptoms of depression and to take greater responsibility in preserving their 584
528 anxiety in healthy cognitively normal older adults memory and mitigating potential future symptoms 585
529 (Balash et al., 2012). It is also possible that of dementia by practicing positive lifestyle behaviors 586
530 respondents without memory complaints were less prior to becoming older adults. Ultimately, if we are 587
531 inclined to report healthy behaviors. In addition, to prepare for the aging of society and a doubling 588
532 even though the HBI is associated with external of the older population by 2040 (Kinsella and He, 589
533 metrics of health risk factors (further information 2009), it will behoove government and individuals 590
534 is available at http://www.well-beingindex.com), to draw lessons from the results of this study. A 591
535 such questions as “eat healthy all day yesterday” recent analysis concluded that the projected effect 592
536 could have varied meanings to respondents, which of a 25% risk factor reduction would result in 593
537 could influence survey results. Another potential three million fewer dementia cases in the US and 594
538 weakness of this study is that these relationships 17 million fewer cases worldwide (Barnes and Yaffe, 595
539 between behavioral habits, memory symptoms, 2011). Thus, encouragement of healthy behaviors 596
540 and other variables are associations and do not in all age groups has the potential for significant 597
541 prove causation. Moreover, the variables were self- public health impact in limiting and forestalling 598
542 reports, which may be influenced by subjective morbidities associated with age-related cognitive 599
543 factors that distort true objective measures. Previous decline and neurodegeneration. 600
544 studies, however, have demonstrated that subjective
545 memory measures are not only correlated with Conflict of interest 601
546 objective neuropsychological test results (Troyer
547 and Rich, 2002), but are also associated with The University of California, Los Angeles, owns 602
548 subsequent cognitive decline (Schofield et al., a US patent (6274119) entitled “Methods for 603
549 1997), AD genetic risk (Small et al., 1999), and Labeling β-Amyloid Plaques and Neurofibrillary 604
550 lower cerebral metabolic rates measured by PET Tangles.” Dr. Small is among the inventors, has 605
551 scanning (Ercoli et al., 2006). Recent research received royalties, and may receive royalties on 606
552 also indicates an association between subjective future sales. Dr. Small reports having served as 607
553 memory symptoms and PET scan measures of brain a consultant and/or having received lecture fees 608
554 amyloid plaques and tangles in persons without from Pfizer, Janssen, Novartis, and Lilly. Dr. Small 609
555 dementia (Merrill et al., 2012). Thus, the memory also reports having received grant funds from 610
556 symptoms reported in the present analysis could POM Wonderful. Drs. Siddarth, Ercoli, Chen, 611
557 reflect accumulation of brain pathology in middle- Merrill, and Torres-Gil have no financial conflicts 612
558 aged and older adults without dementia, suggesting of interest. 613
559 the presence of a prodromal stage of AD in some
560 respondents. Description of authors’ roles 614
561 Strengths of the present study are that the
562 sample is representative of the US population, All authors designed the study, revised internal 615
563 includes respondents from a range of age groups, versions of the paper, and approved the final draft. 616
564 and is large enough to provide meaningful results G. W. Small and P. Siddarth wrote the initial 617
565 in different age groups. It thus provides insights draft of the paper and P. Siddarth performed the 618
566 into relationships between healthy behaviors and statistical analyses. 619
567 memory symptoms that could stimulate future
568 investigations designed to elucidate hypothesized
569 causal relationships, stimulate clinical interventions Acknowledgments 620
570 for people at risk for memory symptoms and We thank Dan Witters and Mark Bartels of the 621
571 neurodegeneration, and eventually drive public Gallup Organization, Jim Pope of Healthways 622
572 policy. Our findings have implications for how Corporation, and Beverly Cosand for their 623
573 we influence personal behavior, its attendant assistance in study design, execution, and analysis. 624
574 impact on healthcare costs and expenditures, We also thank the Gallup Organization and 625
575 and the importance of health wellness and Healthways Corporation for access to the survey 626
576 prevention, components of the Affordable Care results. This work was supported by the Gallup 627
577 Act. To the extent that we can promote healthy Organization, the Parlow-Solomon Professorship 628
578 lifestyle behaviors, we can reinforce the central on Aging, the Ahmanson Foundation, the Fran 629
579 tenets of healthcare reform: namely, improving and Ray Stark Foundation Fund for Alzheimer’s 630
 8 G. W. Small et al.

631 Disease Research, the Semel Institute, and the Gu, Y. et al. (2010). Mediterranean diet, inflammatory and 689
632 UCLA Longevity Center. Dr. Siddarth had full metabolic biomarkers, and risk of Alzheimer’s disease. 690
633 access to all of the data in the study and takes Journal of Alzheimers Disease, 22, 483–492. 691
634 responsibility for the integrity of the data and the Haibach, J. P. et al. (2013). A longitudinal evaluation of fruit 692
635 accuracy of the data analysis. and vegetable consumption and cigarette smoking. Nicotine 693
and Tobacco Research, 15, 355–363. 694
Hamer, M. and Chida, Y. (2009). Physical activity and risk 695
of neurodegenerative disease: a systematic review of 696
636 References prospective evidence. Psychological Medicine, 39, 3– 697
11. 698
637 Alzheimer’s Association (2012). 2012 Alzheimer’s disease Head, D. et al. (2012). Exercise engagement as a moderator 699
638 facts and figures. Alzheimer’s Dementia, 8, 131–168. of the effects of APOE genotype on amyloid deposition. 700
639 Balash, Y. et al. (2012). Subjective memory complaints in Archives of Neurology, 69, 636–643. 701
640 elders: depression, anxiety, or cognitive decline? Acta Heffernan, T. et al. (2010). Smoking and everyday 702
641 Neurologica Scandinavica, Dec 6. doi:10.1111/ane.12038. prospective memory: a comparison of self-report and 703
642 [Epub ahead of print]. objective methodologies. Drug and Alcohol Dependence, 112, 704
643 Barnes, D. E. and Yaffe, K. (2011). The projected effect of 234–238. 705
644 risk factor reduction on Alzheimer’s disease prevalence. Hughes, T. F. et al. (2010). Midlife fruit and vegetable 706
645 Lancet Neurology, 10, 819–828. consumption and risk of dementia in later life in Swedish 707
646 Cataldo, J. K. et al. (2010). Cigarette smoking is a risk factor twins. American Journal of Geriatric Psychiatry, 18, 413– 708
647 for Alzheimer’s disease: an analysis controlling for tobacco 420. 709
648 industry affiliation. Journal of Alzheimer’s Disease, 19, Joseph, J. et al. (2009). Nutrition, brain aging, and 710
649 465–480. neurodegeneration. Journal of Neuroscience, 29, 711
650 Coin, A. et al. (2012). Nutritional predictors of cognitive 12795–12801. 712
651 impairment severity in demented elderly patients: the key Kinsella, K. and He, W. (2009). An Aging World: 2008: 713
652 role of BMI. Journal of Nutrition and Health Aging, 16, International Population Reports. U.S. Census Bureau, issued 714
653 553–556. June 2009. Available at: 715
654 De Leon, J. et al. (2007). Association between smoking and http://www.census.gov/prod/2009pubs/p95-09-1.pdf. 716
655 alcohol use in the general population: stable and unstable Knopman, D. S. et al. (2001). Practice parameter: diagnosis 717
656 odds ratios across two years in two different countries. of dementia (an evidence-based review). Report of the 718
657 Alcohol and Alcoholism, 42, 252–257. quality standards subcommittee of the American Academy 719
658 De Lorenzo, A. et al. (2011). Adiposity rather than BMI of Neurology. Neurology, 56, 1143–1153. 720
659 determines metabolic risk. Journal of Cardiology, Nov 14. Kotter-Grühn, D. and Hess, T. M. (2012). The impact of 721
660 [Epub ahead of print]. age stereotypes on self-perceptions of aging across the adult 722
661 Dik, M. D. et al. (2001). Memory complaints and lifespan. Journal of Gerontology B Psychological Sciences, 67, 723
662 APOE-epsilon4 accelerate cognitive decline in cognitively 563–571. 724
663 normal elderly. Neurology, 57, 2217–2222. Mazereeuw, G. et al. (2012). Effects of omega-3 fatty acids 725
664 Eckerström, M. et al. (2013). Sahlgrenska Academy on cognitive performance: a meta-analysis. Neurobiol of 726
665 Self-reported Cognitive Impairment Questionnaire Aging, 33, 1482. e17–e29. 727
666 (SASCI-Q)—a research tool discriminating between Merrill, D. A. and Small, G. W. (2011). Prevention in 728
667 subjectively cognitively impaired patients and healthy psychiatry: effects of healthy lifestyle on cognition. 729
668 controls. International Psychogeriatrics, 25, 420–430. Psychiatric Clinics of North America, 34, 249–261. 730
669 El Ansari, W. et al. (2011). Health promoting behaviours Merrill, D. A. et al. (2012). Self-reported memory 731
670 and lifestyle characteristics of students at seven universities impairment and brain PET of amyloid and tau in 732
671 in the UK. Central European Journal of Public Health, 19, middle-aged and older adults without dementia. 733
672 197–204. International Psychogeriatrics, 24, 1076–1084. 734
673 Ercoli, L. M. et al. (2006). Perceived loss of memory ability Minett, T. S. et al. (2008). Subjective memory complaints in 735
674 and cerebral metabolic decline in persons with the an elderly sample: a cross-sectional study. International 736
675 apolipoprotein E-4 genetic risk for Alzheimer’s disease. Journal of Geriatric Psychiatry, 23, 49–54. 737
676 Archives of General Psychiatry, 63, 442–448. Paradise, M. B. et al. (2011). Subjective memory 738
677 Erickson, K. I. et al. (2011). Exercise training increases size complaints, vascular risk factors and psychological distress 739
678 of hippocampus and improves memory. Proceedings of the in the middle-aged: a cross-sectional study. BMC 740
679 National Academy of Sciences USA, 108, 3017–3022. Psychiatry, 11, 108. Available at: 741
680 Etgen, T. et al. (2010). Physical activity and incident http://www.biomedcentral.com/1471-244X/11/108. 742
681 cognitive impairment in elderly persons: the INVADE Petersen, R. C. (2004). Mild cognitive impairment as a 743
682 study. Archives of Internal Medicine, 170, 186–193. diagnostic entity. Journal of Internal Medicine, 256, 744
683 Fitzpatrick, A. L. et al. (2009). Midlife and late-life obesity 183–194. 745
684 and the risk of dementia: cardiovascular health study. Reisberg, B. and Guathier, S. (2008). Current evidence for 746
685 Archives of Neurology, 66, 336–342. subjective cognitive impairment (SCI) as the pre-mild 747
686 Ginó, S. et al. (2010). Memory complaints are frequent but cognitive impairment (MCI) stage of subsequently manifest 748
687 qualitatively different in young and elderly healthy people. Alzheimer’s disease. International Psychogeriatrics, 20, 749
688 Gerontology, 56, 272–277. 1–16. 750
 Healthy behavior and memory 9

751 Schofield, P. W. et al. (1997). Association of subjective The American Association for Public Opinion Research 777
752 memory complaints with subsequent cognitive decline in (2008). Standard Definitions: Final Dispositions of Case Codes 778
753 community-dwelling elderly individuals with baseline and Outcome Rates for Surveys, 5th edn. Lenexa, KS: 779
754 cognitive impairment. American Journal of Psychiatry, 154, AAPOR. 780
755 609–615. Torres, S. J. et al. (2012). Dietary patterns are associated 781
756 Shavelle, R. M. et al. (2008). Smoking habit and mortality: a with cognition among older people with mild cognitive 782
757 meta-analysis. Journal of Insurance Medicine, 40, 170– impairment. Nutrients, 4, 1542–1551. 783
758 178. Troyer, A. K. and Rich, J. B. (2002). Psychometric 784
759 Singh-Manoux, A. et al. (2011). Timing of onset of properties of a new metamemory questionnaire for older 785
760 cognitive decline: results from Whitehall II prospective adults. Journal of Gerontology B Psychological and Social 786
761 cohort study. British Medical Journal, 344, d7622. Sciences, 57, P19–P27. 787
762 doi:10.1136/bmj.d7622. Uemura, K. et al. (2012). Effects of exercise intervention on 788
763 Small, G. W. et al. (1999). Memory self-appraisal in vascular risk factors in older adults with mild cognitive 789
764 middle-aged and older adults with the apolipoprotein E-4 impairment: a randomized controlled trial. Dementia and 790
765 allele. American Journal of Psychiatry, 156, 1035–1038. Geriatric Cognitive Disorders Extra, 2, 445–455. 791
766 Small, G. W. et al. (2012). Prediction of cognitive decline by Waldorff, F. B. et al. (2012). Subjective memory complaints 792
767 positron emission tomography of brain amyloid and tau. in general practice predicts future dementia: a 4-year 793
768 Archives of Neurology, 69, 215–222. follow-up study. International Journal of Geriatric Psychiatry, 794
769 Sofi, F. et al. (2010). Accruing evidence on benefits of doi:10.1002/gps.3765. [Epub ahead of print]. 795
770 adherence to the Mediterranean diet on health: Wen, C. P. et al. (2011). Minimum amount of physical 796
771 an updated systematic review and meta-analysis. activity for reduced mortality and extended life expectancy: 797
772 American Journal of Clinical Nutrition, 92, 1189–1196. a prospective cohort study. Lancet, 378, 1244–1253. 798
773 Teixeira, C. V. et al. (2012). Non-pharmacological Zelinski, E. M. et al. (1990). Memory Functioning 799
774 interventions on cognitive functions in older people with Questionnaire: concurrent validity with memory 800
775 mild cognitive impairment (MCI). Archives of Gerontology performance and self-reported memory failures. Psychology 801
776 and Geriatrics, 54, 175–180. and Aging, 5, 388–399. 802