The Alameda County Study

302 American Journal of Health Education — Sept/Oct 2005, Volume 36, No. 5

INTRODUCTIONIn 1965, life expectancy reached a point

at which quality, not merely existence, de-served attention.1 In an effort to discoverthe effect of personal health habits on qual-ity of life, chronic conditions, and mortal-ity, several researchers in California devel-oped the Human Population Laboratory.The group of researchers decided on a de-sign to measure select health practicesamong a probability sample of the popula-tion of Alameda County in California. Theparticipants answered initial survey ques-tions concerning their lifestyle habits in1965 with subsequent collections takingplace in 1973, 1985, 1988, 1994, and 1999.

DEVELOPMENT OF THE “ALAMEDA 7”The 1965 panel, known as the Health

and Ways of Living panel, included LesterBreslow, Nedra Belloc, and George A.Kaplan. Breslow and Kaplan became theprincipal investigators of the Health and

Ways of Living Study, with Belloc makingmajor contributions to initial studies. Muchof the continued study of health behaviorsoccurred at the Human Population Labo-ratory in Berkeley, California.

In an attempt to assess the effects ofhealth habits and social relationships onphysical and mental health, Belloc and col-leagues1 obtained information from 6,928respondents in Alameda county. The prob-ability sample included 3,158 men and3,770 women. The sample included 360men and 530 women over the age of 65.This sample would become known as the1965 Alameda cohort. Each participant an-swered surveys regarding marital and lifesatisfaction, parenting, physical activities,employment, childhood experiences, anddemographic data. In addition, partici-pants were asked to report levels of disabil-ity “without complaints,” “symptomatic,”“chronic conditions,” “disability-less,” and“disability-severe.” To summarize physical

health status of groups of individuals,weighted proportions were necessary.Therefore, each group was classified by aridit, or Relative to an Identified Distribu-tion, allowing feasible and meaningfulcomparisons between groups.

Belloc and colleagues1 published the ini-tial set of findings from the 1965 Alamedacohort. Self-reported disability data re-vealed fewer men were disabled thanwomen, but the proportion of chronic dis-eases was nearly equal. Occurrence of dis-ability and chronic disease increased with

The Alameda County Study:A Systematic, Chronological Review

Jeff Housman and Steve Dorman

Jeff Housman, MEd, is a graduate assistant,Texas A&M University Department of Healthand Kinesiology, TAMU Mail Stop 4243, Col-lege Station, TX 77843; E-mail: [email protected]. Steve Dorman, PhD, MPH, ischair and professor, Texas A&M University De-partment of Health and Kinesiology, TAMUMail Stop 4243, College Station, TX 77843-4243.

ABSTRACT

This study is a systematic review of the Alameda County study findings and their importance in establishing a link

between lifestyle and health outcomes. A systematic review of literature was performed and data indicating impor-

tant links between lifestyle and health were synthesized. Although initial studies focused on the associations be-tween health outcomes and personal health habits known as the “Alameda 7,” subsequent studies focused on the

relationships between social variables, religiosity, several chronic health problems, and long-term health. Signifi-

cant findings during periodic assessments of the original 1965 cohort yielded strong support for a link betweenlifestyle habits and long-term health outcomes. Additionally, social networks, religiosity, and several demographic

variables were found to be associated with chronic disease development.


American Journal of Health Education — Sept/Oct 2005, Volume 36, No. 5 303

age, and high-energy levels were foundmostly in younger groups. In an overallcomparison between groups, men werehealthier than women, younger people (45years or less) were healthier than olderpeople (over 45 years), and individuals withinadequate income were less healthy thanindividuals with adequate income. Further-more, those who were employed werehealthier than those who were unemployedor retired. White and black persons wereequally healthy, but Chinese and Japaneseindividuals displayed a favorable status notrelated to age, sex, or income. Persons withhigher education levels were healthier thanthose with less education, and separatedpersons were less healthy than those whowere married. Several of these health dis-parities including educational level andmarital status continue today.

Belloc and colleagues2 published a fol-low-up study that examined the relation-ship between physical health status andhealth practices. Using data from the 1965Alameda cohort, Belloc and colleagues2

examined nightly hours of sleeping, regu-larity of meals, physical activity, alcoholconsumption, and smoking. Additionalanalyses were performed to determine ifthese health behaviors had independent orcumulative effects on health outcomes. Theresults revealed that sleeping seven to eighthours per night, eating regular meals, par-ticipating in regular exercise, limiting alco-hol consumption, and not smoking werehighly correlated with healthier individu-als. In contrast to previous studies, socio-economic status was found to have no as-sociation with health. Further data analysessuggested a cumulative effect of these be-haviors. This study provided initial empiri-cal support for the link between lifestyle andhealth outcomes.

In a 5-1/2 year follow up of the 1965Alameda cohort, Belloc3 investigated the re-lationship between health practices andmortality. Health practices included sleep,weight, smoking, eating, alcohol consump-tion, physical activity, and other health prac-tices. Analysis of results revealed that thosewho ate regular meals including breakfast,

received adequate sleep (7–8 hours), main-tained a healthy weight for their height, didnot smoke, limited alcohol consumption,and participated in regular physical activitylived longer than those who did not practicethese behaviors. These seven healthy behav-iors would become known as the “Alameda7.” In a final analysis, men and women prac-ticing six of the seven health behaviors lived11 and 7 years longer, respectively, than thosepracticing fewer than 6 health behaviors.Belloc3 concluded that there was a strikinginverse correlation between the number ofhealth practices and mortality levels forolder age groups.

These initial studies provided data indi-cating a relationship between personalhealth habits (Alameda 7) and health out-comes. Additionally, data indicated healthdisparities based on demographic variablesincluding socioeconomic status, ethnicity,age, and educational level. Analyses of sub-sequent data collections in 1973, 1985, 1988,1994, and 1999 would continue to supportthe conclusions. Additional studies wouldexpand on these findings to determine linksbetween social interactions, religiosity, obe-sity, and other chronic conditions.

FOLLOW-UP STUDIESIn an attempt to further establish under-

standing of the relationship between healthbehaviors and quality of life, Gottleib andcolleagues4 examined the “Alameda 7”health behaviors, life events, and social net-works. Data from the 1965 Alameda cohortwere analyzed in an attempt to correlateincome, educational level, age, five healthpractices, social networks, and life events.Although some of the analyses were incon-clusive, there was a positive relationshipbetween social networks and health prac-tices for both men and women. Further-more, church participation and marriagewere positively correlated with health out-comes. These findings supported the beliefthat social networks and certain elementsof spirituality were associated with long-term health outcomes.

In a 9-1/2 year follow up of the 1965Alameda cohort, Breslow and colleagues5

examined the “Alameda 7” health habits andmortality. The results supported the hy-pothesis that good health practices and notthe initial health status of the survey respon-dents are largely responsible for the ob-served mortality rates. Although no healthpractice behaviors had been measured infive years, it was assumed that most indi-viduals were consistent with regard tohealth practices. In a similar follow-upstudy, Wiley and colleagues6 found signifi-cant correlations between the “Alameda 7”health behaviors and positive health out-comes.

Roberts and colleagues7 used data fromthe 1965 cohort to specifically differentiatehealth practices based on ethnicity. Thehealth practices of Anglo, African-Ameri-can or African, and Chicano people werecompared within the 1965 Alameda cohort.Age, sex, family income, education, maritalstatus, perceived health status, and physicalhealth status were assessed. In general,Chicanos reported less disability, fewerchronic conditions, and fewer symptoms ofailments. However, in contrast to other eth-nic groups, higher levels of severe mortal-ity were found among Chicano women.Overall, Chicanos health practices and con-ditions compared favorably to Anglos andpeople of African descent. Furthermore, thedata analyses supported previous hypoth-eses that good health practices were associ-ated with a longer and better quality of life.

Using a multivariate analysis of the sevenhealth behaviors and seven demographicvariables identified by previous HumanPopulation Laboratory studies, Wingardand colleagues8 converted nine-year mor-tality rates and health practice ridits intologits (log odds units). By converting theprevious ridit scores to logits, researcherswere able to make linear comparisons. Innearly all age groups and health practicegroups, five of seven health behaviors weresignificant and independently associatedwith mortality. In contrast to previous stud-ies, eating breakfast and snacking betweenmeals had no substantial association withmortality. The linear model supported pre-vious findings, indicating regular exercise,



limited alcohol consumption, abstinencefrom smoking, sleeping 7–8 hours a night,and maintenance of a healthy weight playan important role in promoting longevityand delaying illness and death.

Mortality, behavioral, and demographicrisk factors among older people (over 65years) in the 1965 Alameda cohort wereexamined in 1987. Kaplan and colleagues9

reexamined health practices of the olderpeople (>65 years of age) in the 1965 co-hort and compared current levels of healthpractices and demographic factors tobaseline data. Results indicated many be-havioral and demographic risk factors re-mained predictors of seventeen-year mor-tality risk, even at older ages. In amultivariate analysis of the “Alameda 7”health behaviors, Kaplan and colleagues9

found strong negative associations betweenthe “Alameda 7” health behaviors and can-cer, heart disease, stroke, diabetes, highblood pressure, and trouble breathing. Eth-nic disparities in mortality risk decreasedwith age, and eating breakfast was morestrongly associated with positive health out-comes in older groups. This study providedevidence that the relationship betweenhealth practices and mortality was consis-tent over time.

In the most recent studies concerningthe “Alameda 7” health behaviors and mor-tality, Strawbridge and colleagues10 andBeebe-Dimmer and colleagues11 examinedself-rated health and disease burden fac-tors during childhood, and the associationbetween socioeconomic and mortalityamong adults in the 1965 Alameda cohort,respectively. Strawbridge and colleagues10

tested the hypothesis that personal healthbehaviors could not predict mortality. Af-ter current conditions of the 1965 Alamedacohort were discovered and analyzed, re-searchers concluded mortality could not bepredicted by health behaviors alone. How-ever, personal health practices were still thelargest predictor of mortality. Beebe-Dim-mer and colleagues11 concluded lowerchildhood socioeconomic status was asso-ciated with an increased mortality due tocardiovascular disease, but was unrelated

to death due to other causes. Overall mor-tality rates were highest among womenwith low educational levels, and low house-hold income was associated with highercardiovascular disease. Furthermore, lowsocioeconomic status in early and later lifecontributed to an increased mortality riskin women. These effects were stronger forcardiovascular mortality than non-cardio-vascular mortality.

From 1979 to 2004, continued analysesof subsequent data collections from the1965 cohort continued to support the hy-pothesis that the “Alameda 7” health behav-iors are strongly associated with long-termhealth outcomes. Although recent studieshave found no significant correlations be-tween not eating breakfast or snacking be-tween meals and health outcomes, the re-maining five have consistently been shownto be associated with good health.

RELATED STUDIESSeveral researchers attempted to deter-

mine the generalizability of the Alamedacounty study findings using regional andnational samples. Brock and colleagues12 at-tempted to replicate the Alameda longitudi-nal study in Michigan. A statewide sampleof 3,259 adult Michigan residents were sur-veyed regarding their health practices viatelephone. Consistent relationships werefound between physical health status andindividual health practices, including sleeppatterns, eating breakfast, eating betweenmeals, smoking, weight, and physical activ-ity. However, some of the findings, such assleeping 7–8 hours, eating breakfast and eat-ing between meals, were not found to be sta-tistically significant. Although not all healthpractices were significant, the results dem-onstrated the generalizability of the Alamedacounty study.

In an effort to identify prevalence of the“Alameda 7” health practices nationwide,Schoenborn13 reported results from the1985 National Health Interview Survey(NHIS). Questions from the NHIS asked anationwide sample about their exercise hab-its, eating habits, sleeping habits, alcoholconsumption, body weight, and demo-

graphic characteristics. Although some vari-ables were defined slightly differently, theauthor reported results regarding the“Alameda 7” health behaviors. Simpleprevalence statistics, unadjusted for age orother sociodemographic characteristics,were used in the analysis. Results of the sur-vey revealed 12 percent of men and 11 per-cent of women practiced six or seven goodhealth habits, more than half of both menand women reported 4 or 5 “good health”habits, and 37 percent of men and 33 per-cent of women reported 0 to 3 “goodhealth” habits. Men were more likely tosmoke, consume alcohol, and exercise thanwomen. Younger people (18–44 years)were more likely to skip breakfast, snackbetween meals, and drink alcohol thanolder persons (over 45 years). Caucasianswere more likely to eat breakfast, sleep 7–8 hours, and drink five or more drinks atone sitting than African-Americans. Addi-tionally, persons in socially and economi-cally disadvantaged groups were less likelyto have “good health” habits. Persons inolder groups were more likely to have agreater number of “good health” habits,and African-Americans tended to havefewer “good health” habits than Cauca-sians. These results showed disparitiesamong social, economic, ethnic, and agegroups with regard to health practices.

The results of these studies supportedprevious findings using data from the 1965Alameda cohort. Positive correlations werefound between the “Alameda 7” health be-haviors and positive health outcomes. Ad-ditionally, similar disparities were foundbased on ethnicity, gender, socioeconomicstatus, and educational level. These studiesindicated the generalizability of theAlameda county study findings, and furtherestablished personal health practices asmajor factors in long-term health.

In addition to establishing the linkbetween personal health practices andhealth outcomes, researchers have attemptedto determine the relationship between so-cial interactions, religiosity, depression,obesity, hearing and vision loss, and otherchronic conditions.



SOCIAL/MARITAL RELATIONSHIPSSeveral follow-up studies involving the

1965 cohort focused on the relationshipsamong marriage, social interactions, andmortality. Kotler and colleagues14 concludedmarital status is associated with health out-comes. Married individuals, especially men,had lower mortality risk than single indi-viduals, and divorced or separated individu-als had highest risk. Data analyses per-formed by Reynolds and colleagues15

indicated a negative relationship betweensocial connections, incidence of mortality,and prognosis of cancer. Although thisstudy was limited by the complexity of thevariables involved, the relationship betweensocial connections and reduced risk for can-cer was found significant. In addition, Yenand colleagues16 indicated lower-qualitysocial environments were associated with anincreased risk of death during an eleven-year follow up. The association remainedafter adjustments for age, sex, income, edu-cation, race/ethnicity, smoking, body massindex, alcohol consumption, and perceivedhealth status were made.

RELIGIOSITYIn addition to studies tracking specific

health behaviors of the Alameda cohort,several authors have examined social, eco-nomic, and psychological factors related tohealth practices. Strawbridge and col-leagues17 and Oman and colleagues18 stud-ied religious attendance (weekly, monthly,yearly, never) and its association with mor-tality and survival. Using data collectionsfrom 1965, 1973, 1985, 1988, and 1994, re-searchers examined spirituality, religion,and mortality. Results of these studies in-dicated high levels of religious involvementare associated with lower rates of death byspecific causes including circulatory dis-eases, digestive diseases, respiratory diseases,and all causes combined. Additionally, wideranges of other chronic diseases were in-versely correlated with attendance of a reli-gious event (weekly, monthly, yearly, never).Results indicated that for women the pro-tective effect of weekly attendance at a reli-gious event was strong and fell roughly

between never smoking cigarettes and regu-lar physical activity. More moderate effectswere found for men. In support of thesefindings, Strawbridge and colleagues19 con-cluded that those reporting weekly religiousattendance were more likely to improvepoor health behaviors and maintain goodhealth behaviors. Weekly religious atten-dance was also associated with good men-tal health and social relationships. Again, therelationship was stronger among women.

DEPRESSION AND OBESITYSeveral researchers have attempted to

determine the relationship between healthstatus and psychological disorders. Afterreviewing data from the 1965 Alameda co-hort, Roberts and colleagues20 concludedthere was no evidence to suggest that de-pression is associated with an increase in all-cause mortality. In contrast, Camacho andcolleagues21 stated that men and womenwith low activity levels at baseline were at asignificantly greater risk for depression atthe 20-year follow-up than those who re-ported high activity levels. Yen and col-leagues22 indicated that residence in a pov-erty area was associated with decliningperceived health, but risk for developinghigh levels of depressive symptoms was notsignificantly different for those not livingin a poverty area.

The most recent studies regarding de-pression focused on the relationships be-tween physical activity, obesity, and depres-sion. Using data collected from the 1965cohort in 1994 and 1995, Roberts and col-leagues23 indicated mixed results regardingthe relationship between obesity and de-pression. Researchers indicated greater oddsfor depression in obese individuals in 1994,and obesity in 1994 predicted depression in1995. Although the results of the prospec-tive analyses were not significant, the resultssuggested an association between obesityand depression.

Strawbridge and colleagues24 used datafrom 1994 and 1999 to access the relation-ship between physical activity and depres-sion in older adults (50 to 94 years). Afteradjusting for age, sex, ethnicity, socioeco-

nomic status, chronic conditions, disabil-ity, body mass index, alcohol consumption,smoking, and social relations, authors re-vealed that physical activity was protectivefor both prevalent and incident depression.Using data collected in 1995 and 1999, Rob-erts and colleagues25 investigated the recip-rocal effect of depression on obesity. Resultsindicated obesity in 1995 was associatedwith an increased risk for depression in1999, but depression did not increase therisk for future obesity.

HEARING AND VISION LOSSResearch suggests hearing and vision loss

is increasingly common among older per-sons and is negatively associated with well-being.26 Using data collected in 1994 and1999, researchers assessed the impact ofhearing and vision loss on subsequent dis-ability, physical functioning, mental health,and social functioning.27 Both hearing andvision loss had significant negative impactson quality of life. Specifically, physical func-tioning and social interaction abilities weregreatly impaired. Although this study sup-ported previous findings,28 little was knownabout the effects of hearing loss on one’sspouse.

Wallhagen and colleagues29 investigatedthe relationship between a spouse’s hearingloss and his or her partner’s physical, psy-chological, and social well-being. Using datacollected in 1994 and 1999, researchers con-cluded that a husband’s hearing loss greatlyincreased the likelihood of subsequent de-creases in physical, psychological, and so-cial well-being in their spouses. The rela-tionship between wives’ hearing loss andhusbands’ subsequent decreases in well-being was weaker, but significant.

SLEEP DISTURBANCESleep problems are relatively common

among older persons and may have a sig-nificant negative impact on well-being.30

Roberts and colleagues31 analyzed data col-lected in 1995 and 1999 from the 1965cohort to assess the prevalence of sleep com-plaints and the relationship between sleepproblems and health outcomes. Insomnia



was reported by 23.4% of participants in1994 and incidence of insomnia and hyper-somnia (too much sleep) increased withage. Women reported greater sleep distur-bance and insomnia was strongly correlatedwith chronic disease. Recently, Strawbridgeand colleagues32 investigated the impact ofa spouse’s sleep problems on his or her part-ner. Data collected in 1999 from the 1965cohort were analyzed to determine the ef-fects on spousal sleep disturbance on part-ners’ physical health, mental health, well-being, social involvement, and maritalquality. Although associations betweensleep disturbance and one’s own health out-comes were stronger, spousal sleep prob-lems were associated with a partner’s poorhealth, depression, unhappiness with socialrelationships, and unhappy marriages.

CHRONIC DISEASESSome of the most recent findings from

the 1965 cohort have provided further evi-dence for the relationship between chronicdiseases and the “Alameda 7” health behav-iors. Seavey and colleagues33 examined riskfactors associated with self-reported arthri-tis symptoms in a 20-year follow-up. Au-thors found significant associations be-tween arthritis and age (>45 years of age),BMI, sex (female), and depressive symp-toms. Physical activity was found to haveprotective effects on development of arthri-tis. Kotz and colleagues34 investigated theeffect of osteoporosis on physical and men-tal outcomes in the 1965 cohort. Partici-pants with osteoporosis were more likely toreport frailty, difficulty with balance, weak-ness, fair/poor perceived health, and notenjoying free time. Research suggests frailtyand weakness are associated with reducedphysical activity, poorer mental health, andlower quality of life.35

CONCLUSIONAlthough the last data collection of the

1965 Alameda cohort occurred in 1999,additional current analyses continue to pro-vide supporting results indicating a linkbetween personal health behaviors, socialinteractions, socioeconomic status, educa-

tional level, and long-term health outcomes,quality of life, and mortality. Initial find-ings of the Alameda county study alongwith subsequent studies form the basis formuch of what we know and practice inhealth education and promotion. This workhas firmly established lifestyle as a majordeterminant of health outcomes in theUnited States and reinforces the beliefs ofhealth professionals that healthy behaviorsare necessary in maintenance and improve-ment of health status. Breslow, a principalinvestigator of the Alameda county study,stated:

“A step beyond treatment and even theprevention of disease is coming onto thehealth agenda: health promotion or theadvancement of well-being and theavoidance of health risks by achievingthe optimal levels of the behavioral, so-cietal, environmental and biomedicaldeterminants of health. Health promo-tion is aimed at maintaining the level ofhealth and, insofar as possible, strength-ening the potential resources forhealth.”36

Studies using data from the 1965 cohortsince these comments by Breslow continueto support healthy behaviors as a preventa-tive factor in long term health outcomes.Further data analyses over the past 5 yearshave expanded our knowledge of the origi-nal ‘Alameda 7’ and have shown the impactof social interactions, elements of spiritu-ality, hearing/vision loss, and sleep distur-bance on health outcomes.

Health promotion as a profession con-tinues to develop and expand as findingsfrom the Alameda county study reinforcelifestyle as a determinant in long-termhealth. Health professionals continue to fo-cus on these health behaviors, including the“Alameda 7.” Other variables identified asbeing associated with a healthy lifestyle,such as social, spiritual, and demographicvariables have begun to receive greater at-tention. Although efforts of health promot-ers and other health professionals have im-pacted some behaviors, other negativehealth behaviors remain prevalent. Surveys

indicate declining rates of smoking and useof other tobacco products since 1983.37

Mixed results are seen in other areas, suchas physical activity and nutrition. For ex-ample, recent studies regarding programssuch as the coordinated approach to childhealth (CATCH) indicate improvement ineating habits and physical activity level insome school-aged children38. However,77.4% of adults report consuming fewerthan 5 servings of fruits and vegetablesdaily,39 and 73.7% of adults do not meetrecommendation for physical activity.40 Re-cent data indicate that the incidence of obe-sity continues to rise in all age groups,41 andinsufficient sleep is becoming more com-mon with adults, who are averaging 6.9hours per night.42

Other variables related to long-termhealth such as demographic variables (e.g.,age, gender, etc.), social networks, and spiri-tuality have not been fully addressed.Buchanan43 suggests it is our social sur-roundings that impact us most. Therefore,healthy individuals will develop from a so-ciety that values health. It may be the lackof societal value placed on preventativehealth behaviors that encourages negativehealth practices. Efforts forged by healthprofessionals to raise awareness of healthissues have been successful in some areas(i.e., cancer screenings), but have had lim-ited impact in others (i.e., regular exercise,fruit and vegetable consumption).43 In thefuture it will be necessary for health pro-fessionals to advocate for healthier policies,and to bring greater awareness of healthybehaviors to the general public.

As researchers continue to discover rela-tionships between lifestyle and health out-comes, it is imperative that health promot-ers and other health professionals focus onthe most pressing issues. Obesity, physicalinactivity, poor dietary habits, and insuffi-cient sleep are becoming more prevalent.The relationships among diet, exercise, andbody weight are well established, and resultsfrom several recent studies suggest inad-equate sleep as a factor in an unhealthy bodyweight. With fewer than half of Americansreporting sufficient sleep,44 the relationship

p



between sleep and body weight may be vi-tal to solving the obesity problem in theUnited States.

The various studies associated with theAlameda county project helped to form thebasis of a major public health shift in ourapproach to disease prevention and longev-ity. As more has been learned about theimpact of lifestyle on disease and death,public health programming has becomemore focused on helping the public achievethese lifestyle objectives. There is still muchwork to be done. While the Alameda countyproject has had an impact on our past, itsfindings must also inform our future pub-lic health activities. In the future, healthprofessionals should continue to improveprograms to raise awareness of prevalenthealth issues and measures that may betaken to prevent negative health outcomes.Additionally, health professionals shouldfocus on reducing negative health outcomesby attempting to provide methods aimedat increasing the prevalence of the “Alameda7” health behaviors.

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Documents

The Alameda County Study