Preventive Medicine 49 (2009) 418–423

Contents lists available at ScienceDirect

Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y p m e d

The relationship between lifestyle and self-reported health in a general population

The Inter99 study
Charlotta Pisinger ⁎, Ulla Toft, Mette Aadahl, Charlotte Glümer, Torben Jørgensen
Research Centre for Prevention and Health, The Capital Region of Denmark

a r t i c l e i n f o a b s t r a c t

Available online 28 August 2009 Objectives. The aim of this paper is to describe the relationship between smoking status, dietary habits,
physical activity and alcohol intake, and mental and physical self-reported health in a general population.
Keywords: Measures. A large population-based study Inter99, Copenhagen, Denmark, 1999-2006. Self-reported
Life style health-related quality of life was measured by Short Form 12 (SF-12). Mental and physical health component
Quality of life
scores were computed.
Health status
Short form 12
Results. At baseline, SF-12 was completed by 6305 (92.3%) participants in the intervention groups, and
SF-12 3017 (72.4%) persons in the control group. In cross-sectional analyses, persons with an unhealthy lifestyle
Mental health reported significantly worse physical and mental health than persons with a healthier lifestyle.
Public health In longitudinal data, using adjusted multivariate analyses (N = 3,084), we found an association between
Screening increased physical activity at five-year follow-up and improvement in physical health ( odds ratio = 2.30
Intervention (95% confidence interval = 1.7-3.2)) in the high-intensity intervention group. Improvement in mental health
Inter99 was associated with a much healthier diet at 5-year follow-up than at baseline ( odds ratio = 1.68 (95%
confidence interval = 1.1–2.5)).
Conclusions. This study describes the negative relationship between unhealthy lifestyle and self-
reported mental and physical health in a general population. Also, it shows the impact of improvements in
lifestyle on self-reported health in a general population, which has not been investigated before.
© 2009 Elsevier Inc. All rights reserved.

Introduction
A European Health Report concluded that just seven risk factors—
tobacco, alcohol consumption, high cholesterol, overweight, physical
inactivity and low fruit and vegetable intake—are responsible for the
major burden of disease in Europe (WHO 2005). In a recent
prospective study including over 20,000 participants, four health
behaviours combined (non-smoker, physically active, high fruit
intake, moderate alcohol intake) predicted a 4-fold reduction in all-
cause mortality, with an estimated impact equivalent to 14 years in
chronological age (Khaw et al., 2008). Furthermore, unhealthy lifestyle
is not only responsible for excess mortality and disability, but is also a
heavy burden on society through medical costs and loss of productivity
(Kiiskinen et al., 2002).
Questionnaires on health-related quality of life measure the extent
and impact of mental and physical health problems, as perceived by
the individual. Some of these health problems may be difficult to
observe and measure objectively. Self-evaluations of health status
have been shown to predict mortality, even better than prediction
made by the presence of health problems and biological or lifestyle
risk factors (Idler and Kasl, 1991; Lee, 2000; McGee et al., 1999). Self-
reported health is primarily found to be associated with deaths caused
by lifestyle-related diseases as diabetes, respiratory diseases, heart
diseases, stroke and cancer (Benjamins et al., 2004).
We know little about the association between lifestyle and self-
rated mental and physical health in a general population (Kruger et al.,
2007; Riise et al., 2003; Van Dijk et al., 2004; Wendel-Vos et al., 2004).
The aim of this paper is to describe the relationship between
smoking status, dietary habits, physical activity and alcohol intake and
mental and physical self-reported health in a general population.
Furthermore, we will investigate whether self-reported change in
lifestyle is associated with improved self-reported mental and
physical health over 5 years in persons participating in a popula-
tion-based lifestyle-intervention study. To our knowledge, this has
never been investigated before.
Methods

⁎ Corresponding author. Forskningscenter for Forebyggelse og Sundhed, Nordre The Inter99 is a randomised population-based intervention study.
Ringvej, Glostrup University Hospital, Bygning 84/85, DK-2600 Glostrup, Denmark. The study was performed at the Research Centre for Prevention and
Fax.: +45 43 23 32 83. Health, Denmark, approved by The Copenhagen County Ethical Committee
E-mail address: chpi@glo.regionh.dk (C. Pisinger). (KA 98155) and registered in the Clinical Trials.gov (NCT00289237).

0091-7435/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2009.08.011
 C. Pisinger et al. / Preventive Medicine 49 (2009) 418–423
The study design is described in detail elsewhere (Jorgensen et al., 2003).
The overall aim of the study was to prevent cardiovascular disease (CVD)
by non-pharmacological intervention.
The individuals were drawn from the Civil Registration System in which a
unique ten-digit number registers all inhabitants in Denmark. The age- (30 to
60 years) and sex-stratified study population (N = 61,301) was drawn from a
defined area of Copenhagen. From this study population a random sample
was drawn for the present intervention (Fig. 1). The sample was pre-
randomised into two intervention groups comprising high-intensity inter-
vention group A, and low-intensity intervention group B. A total of 6,784
persons (52.5%) were included in the two intervention groups.
For control group C, a random sample was drawn from the remaining
individuals in the study population (Fig. 1). A total of 3321 persons (63.1%)
were included in the control group.
All participants in the intervention groups completed self-administered
questionnaires, including questions on previous diseases, symptoms, lifestyle
and change of lifestyle, physical and mental health, and socio-demographic
conditions. They underwent a medical health-examination (height, weight,
waist- and hip circumference, blood pressure, spirometri, electrocardiogra-
phy, glucose tolerance test, blood samples) at our Research Centre and were
given an individual cardiovascular risk assessment, estimated by the
Copenhagen Risk Score, using a computer programme, PRECARD® (Thomsen
et al., 2001).
All participants received a lifestyle consultation encouraging them to a
healthy lifestyle (focusing on smoking, diet, physical activity and alcohol
consumption).
Participants in the high-intensity intervention group, who were at high
risk of CVD (daily smoking, obesity, high cholesterol, high blood pressure,
Fig. 1. Flowchart of the Inter99 study (1999-2006).
419
diabetes, impaired glucose tolerance) were offered participation in a smoking
cessation group or/and a diet-and-exercise group and re-invited after one
and three years for the same intervention (Jorgensen et al., 2003; The Inter99
Steering Committee, 2008) (Fig. 1). Participants at low risk of CVD were
followed by questionnaires. All participants were re-invited for health
examination and lifestyle consultation at 5-year follow-up.
The control group completed questionnaires only.
We have previously published results showing a beneficial long-term
effect of the Inter99 intervention (quitting smoking, improved diet, increased
physical activity (PA) and decreased alcohol consumption) (Pisinger et al.,
2008; Toft et al., 2008; von Huth et al., 2008).
Dietary quality score: a three-class variable was generated for each of the
four food-groups/nutrients (fish, vegetable, fruit and fat) from a 52-item food
frequency questionnaire (reference period: one week). The score has been
validated (Toft et al., 2007).
Physical activity at baseline was based on self-reported commuting and
leisure time physical activities and measured as minutes per week (von Huth
et al., 2007).
Alcohol consumption at baseline was self-reported as mean consumption of
units of beer/strong beer, wine and spirits per week. One beer or one glass of
wine or 4 cl. of spirits = 1 unit (approximately 12 g alcohol). Strong beer= 1 1/2
unit. “Recommended” = less than 15 units of alcohol weekly for women, and 22
units for men. “Above recommendations” = more than recommended but less
than 5 units per day. “Heavy use” = minimum of 5 units per day.
Smoking status, vocational training and employment status at baseline and
change in diet, physical activity, smoking status and alcohol consumption from
baseline to 5 years follow-up were self-reported. Self-reported change in PA
has in the Inter99 study been found to be associated with the expected
420 C. Pisinger et al. / Preventive Medicine 49 (2009) 418–423

changes in cardiovascular risk factors (weight, waist circumference, diastolic
blood pressure and serum lipids) after 5 years (Aadahl et al., 2009).
Health-related quality of life was measured by the 12-item Short Form 12
(SF-12), version 1 (Ware et al., 1995). SF-12 has been found to produce both
the mental and physical components with considerable accuracy and has in
many countries and settings been established as a valid, practical and reliable
alternative to the 36-item Short Form 36 (SF-36) (Gandek et al., 1998;
Jenkinson et al., 1997; Jenkinson and Layte, 1997; Kontodimopoulos et al.,
2007; Ware et al., 1996).
The mental health component scores (MCS) and physical health
component scores (PCS) are computed by multiplying each indicator variable
by its respective regression weight and summing the products. The summary
scores are then transformed to norm-based scoring; where the mean is set to
50 and the SD to 10 (range 0 to 100) (Bjorner et al., 1997; Ware et al., 1995).
Higher scores indicate better health.
SF-12 was measured at baseline and at every follow-up and a score was
calculated only if all questions were completed.
Improved SF-12 score was defined as score at 5-year follow-up higher than
at baseline (yes/no).
Statistical analyses
All data processing was done with the SPSS 17.0 software (SPSS Inc.,
Chicago, IL, USA).
To look at mean scores at baseline we included cross-sectional data from
both the intervention groups and the control group (Fig. 1). At baseline, SF-12
was completed by 6305 (92.9%) out of 6784 participants in the intervention
groups, and 3017 (90.8%) out of 3324 participants in the control group. One-
way ANOVA-analyses were used to show mean scores at baseline for persons
with different lifestyle. Measurements of MSC and PSC were heavily left
skewed. To compensate for this, we chose transformation parameters of 4 for
MSC and 5 for PSC. In Univariate Analyses of Variance we tested whether the
SF-12 scores at baseline were significantly different in people with different
smoking status, dietary quality, physical activity and alcohol consumption; all
analyses were adjusted for age, sex, vocational training and employment
status.
In order to test whether change in lifestyle was associated with improved
SF-12 scores we used Logistic regression analyses. This analysis was chosen
instead of Linear regression because of the transformation of MCS and PCS.
For these analyses we used baseline and 5-year data from participants in
group A only; partly, because some of the questions were not answered in the
other groups and partly, to have a more homogenous group. In group A, SF-12
was completed by 5664 (93.0%) out of 6091 participants at baseline and by
4440 (72.9%) at 5-year follow up (4212 complete cases). First, we entered
improvement (yes/no) in SF-12 score as a dependent variable with self-
reported change in lifestyle as an independent variable, adding baseline-SF-
12 score, age, sex, vocational training and employment status as confounders.
We tested for interaction between sex and change in lifestyle.
In model two, we entered all four variables describing change in lifestyle
in the same model, with the previously mentioned confounders.
Hosmer and Lemeshow Tests were used as model control. Significance
level was set to 5% in all analyses.
Results
Characteristics of non-responders at 5-year follow-up in group A:
more frequently women, younger persons, daily or ex-smokers, no/
heavy use of alcohol, more sedentary, higher body mass index (BMI),
no/short education, and high risk of CVD at baseline.
Persons with an unhealthy lifestyle had both lower mean PCS and
MCS at baseline (Figs. 2 and 3). In general, the healthier lifestyle, the
better was the self-reported health.
Never smokers, physically active persons and persons drinking
alcohol within recommendations reported the highest PCS (Fig. 2).
Total abstainers from alcohol had the lowest PCS and there was almost
no difference in PCS for persons with average or healthy dietary
habits. The difference in mean scores within each lifestyle remained
significant, when adjusted for socio-demographic factors.
In group A 44.2% of the participants reported a higher PCS and
51.9% of the participants reported a higher MCS at 5-year follow-up
than at baseline.
In regression analyses, looking at each lifestyle separately, we
found a significant association between improved PCS and increased
physical activity and a much healthier diet from baseline to 5 years.

Fig. 2. The relationship between lifestyle and mean physical health component scores (PCS) at baseline in a general population. The Inter99 study (1999–2006), Copenhagen,
Denmark. Results are based on cross-sectional baseline data from persons in both the intervention groups and the control group of the Inter99 study. A higher score = better self-
reported physical health. Scores tend to decrease with age. Differences in mean score, adjusted for sex, age, employment status and length of vocational training: smoking status
(N = 9292): p b 0.001; dietary habits (N = 7065): p b 0.001; physical activity (N = 8843): p b 0.001; alcohol intake (N = 6548): p b 0.001.
 C. Pisinger et al. / Preventive Medicine 49 (2009) 418–423 421

Fig. 3. The relationship between lifestyle and mean mental health component scores (MCS) at baseline in a general population. The Inter99 study (1999–2006), Copenhagen,
Denmark. Results are based on cross-sectional baseline data from persons in both the intervention groups and the control group of the Inter99 study. A higher score = better self-
reported mental health. Scores tend to increase with age. Differences in mean score, adjusted for sex, age, employment status and length of vocational training: smoking status
(N = 9292): p b 0.001; dietary habits (N = 7065): p b 0.001; physical activity (N = 8843): p b 0.001; alcohol intake (N = 6548): p b 0.001.

When all four lifestyles were included at the same time, the
association with diet disappeared, but the association with physical
activity remained significant, showing a linear trend between increase
in physical activity and improvement in physical health at 5-year
follow-up (Table 1).
Alcohol intake above recommendations, but less than 5 units per
day, was associated with high MCS (Fig. 3). Persons without any
alcohol intake had the lowest mental scores. The difference in mean
scores within each lifestyle remained significant, when adjusted for
socio-demographic factors. Occasional smokers and daily smokers
had lower MCS than never and ex-smokers.
In regression analyses, looking at each lifestyle separately, we
found a significant association between improved MCS and very
increased physical activity and very improved diet.
When all four lifestyles were included at the same time, only the
association with diet remained significant, showing a significant

Table 1
Association between improved⁎ physical health component scores (PCS) and self-reported change in health behaviour at 5-year follow-up.

N Improved PCS, Model 1 Improved PCS, Model 2

OR (95% CI) OR (95% CI)

Smoking status at 5-year follow-up

Daily smoker 616 1 1
Occasional smoker 114 0.94 (0.6–1.4) 1.23 (0.8–1.9)
Has quit since start of study 315 1.01 (0.8–1.3) 1.09 (0.8–1.5)
Has quit before study start 751 0.98 (0.8–1.2) 1.04 (0.8–1.3)
Never smoker 1288 1.07 (0.9–1.3) 1.22 (1.0–1.5)
Change in dietary habits
Much more/ a little more unhealthy 214 1 1
Unchanged diet 1452 1.11 (0.8–1.5) 0.85 (0.6–1.2)
A little healthier diet 1080 1.13 (0.8–1.5) 0.80 (0.6–1.1)
Much healthier diet 338 1.44 (1.0–2.0) 0.97 (0.6–1.5)
Change in physical activity
Much more/ a little more inactive 709 1 1
Unchanged 1366 1.57 (1.3–1.9) 1.51 (1.2–1.9)
A little more active 688 1.96 (1.6–2.4) 1.92 (1.5–2.5)
Much more active 321 2.39 (1.8–3.1) 2.30 (1.7–3.2)
Change in alcohol consumption
Much more/ a little more alcohol 249 1 1
Unchanged 2365 0.79 (0.6–1.5) 0.74 (0.6–1.0)
A little less alcohol 344 0.74 (0.5–1.1) 0.70 (0.5–1.0)
Much less alcohol 126 0.94 (0.6–1.5) 0.84 (0.5–1.4)

Model 1: each lifestyle variable analysed separately. Adjusted for baseline PCS, age, sex, employment status and vocational training.
Model 2: all lifestyle variables in one analysis. Adjusted for baseline PCS, age, sex, employment status and vocational training (N = 3084).
Underscore = p b 0.05.
The Inter99 study, Denmark, 1999–2006. Data from intervention group A.
⁎ Score higher at 5-year follow-up than at baseline.
422 C. Pisinger et al. / Preventive Medicine 49 (2009) 418–423

Table 2
Association between improved⁎ mental health component scores (MCS) and self-reported change in health behaviour at 5-year follow-up.

N Improved MCS, Model 1 Improved MCS, Model 2

OR (95% CI) OR (95% CI)

Smoking status at 5-year follow-up

Daily smoker 616 1 1
Occasional smoker 114 0.94 (0.6–1.4) 0.82 (0.5–1.3)
Has quit since start of study 315 1.10 (0.8–1.4) 1.01 (0.7–1.4)
Has quit before study start 751 1.19 (1.0–1.5) 1.10 (0.9–1.4)
Never smoker 1288 1.02 (0.9–1.5) 0.94 (0.8–1.2)
Change in dietary habits
Much more/a little more unhealthy 214 1 1
Unchanged diet 1452 1.26 (0.9–1.7) 1.32 (1.0–1.8)
A little healthier diet 1080 1.21 (0.9–1.6) 1.29 (1.0–1.7)
Much healthier diet 338 1.68 (1.2–2.4) 1.68 (1.1–2.5)
Change in physical activity
Much more/a little more inactive 709 1 1
Unchanged 1366 0.97 (0.8–1.2) 0.92 (0.7–1.1)
A little more active 688 1.11 (0.9–1.4) 1.02 (0.8–1.3)
Much more active 321 1.31 (1.0–1.7) 1.13 (0.8–1.5)
Change in alcohol consumption
Much more/a little more alcohol 249 1 1
Unchanged 2365 1.20 (0.9–1.6) 1.19 (0.9–1.6)
A little less alcohol 344 1.14 (0.8–1.6) 1.05 (0.7–1.5)
Much less alcohol 126 1.17 (0.7–1.9) 1.06 (0.6–1.7)

Model 1: each lifestyle variable analysed separately. Adjusted for baseline MCS, age, sex, employment status and vocational training.
Model 2: all lifestyle variables in one analysis. Adjusted for baseline MCS, age, sex, employment status and vocational training (N = 3084).
Underscore = p b 0.05.
The Inter99 study, Denmark, 1999-2006. Data from intervention group A.
⁎ Score higher at 5-year follow-up than at baseline.

association between much healthier diet and improvement in mental
health at 5-year follow-up (Table 2).
There was no significant association between neither MCS nor PCS
and smoking status or change in alcohol consumption at 5-year
follow-up.
Discussion
In a general population we found that persons with an unhealthy
lifestyle reported worse physical and mental health than persons with
a healthier lifestyle. At 5-year follow-up, we found an association
between increased physical activity and improvement in self-reported
physical, but not mental, health. A much healthier diet at 5-year
follow-up was associated with improvement in self-reported mental
health.
Mean scores of self-reported health have been published showing
differences in nationality, race, age, sex and socio economic status
(Bjorner et al., 1997; Gandek et al., 1998; Howard et al., 2006;
Kontodimopoulos et al., 2007). However, few population-based studies
have looked at the association between lifestyles and self-reported
health. These few studies have, comparable with our study, shown a
significant relationship between unhealthy lifestyle and self-reported
poor health. To our knowledge, only one of these studies has looked at
several lifestyle factors (Riise et al., 2003), one has used the SF-12
(Wendel-Vos et al., 2004), and two used prospective data (Wendel-Vos
et al., 2004; Wilson et al., 2007), as we did. Three other studies
used cross-sectional data (Kruger et al., 2007; Van Dijk et al., 2004;
Wendel-Vos et al., 2004.
We found an inverse U-shaped relationship for alcohol consump-
tion and self-reported health, which also has been described in two
other cross-sectional studies (Riise et al., 2003; Van Dijk et al., 2004).
Higher mental scores for persons drinking more alcohol than
recommended, without being alcoholics, might reflect the “jolly
drinkers,” comparable with the “jolly fat” effect—an inverse relation-
ship between BMI and depression (Palinkas et al., 1996). Moderate
drinking has also been found to be associated with other beneficial
health-related lifestyle factors (Fillmore et al., 1998). Individuals
without any intake of alcohol had the lowest mental and physical
scores, indicating that those with poor health may tend to reduce their
alcohol consumption.
We found higher physical activity at baseline to be associated with
better self-reported health and improved physical activity to be
associated with improved physical health at 5-year follow-up. A
Dutch study looking at leisure time physical activity and health-
related quality of life (HRQOL) found that cross-sectional associations
were mainly found for physical components, whereas longitudinal
associations were predominantly observed for mental components
(Wendel-Vos et al., 2004). Even though we adjusted for baseline
health scores, we cannot rule out that physical health improved first,
and enabled the participants to be more active, but increased physical
activity may as well have improved their physical well-being.
Healthier diet at baseline was associated with better mental and
physical self-reported health. A much healthier diet was associated
with improved mental health after 5 years. To our knowledge, no
previous studies have described this, but a cross-sectional study found
an inverse U-shaped relationship for BMI and self-reported mental
health (Riise et al., 2003).
Participants who had quit smoking at 5-year follow-up had neither
improved mental nor physical health. This could be explained by the
“sick quitter” effect; smoking-related health problems increase the
probability of smoking cessation. Also, the smoking status variable at
5 years did not reflect a change in lifestyle in the same way as the
other lifestyle factors. Alternatively, we could have looked at quitters
and non-quitters only, but then we would not have been able to
include baseline ex- and never-smokers in the multivariate analyses.
A prospective study found that compositional characteristics of indi-
viduals (e.g. smoking) were the key factors affecting change in self-
reported health, as opposed to contextual (e.g. neighbourhood) or
collective (e.g. marital status) factors (Wilson et al., 2007).
An important weakness of our study is that lifestyle data are self-
reported. Participants may have given a more optimistic score or
reported a positive change in lifestyle, due to our expectations of
success. Due to low participation rates at baseline selection bias
cannot be ruled out. However, overall, the intervention groups have
been found to be representative for the general population at baseline
(Jorgensen et al., 2003). The results of the baseline cross-sectional
 C. Pisinger et al. / Preventive Medicine 49 (2009) 418–423
analyses, including both intervention and control groups are probably
representative for a general population, but when interpreting the
longitudinal results from intervention group A, we must remember
the selection in drop-out. Yet, we believe that drop-out is a minor
problem in these analyses, as we look at associations for persons with
complete data, not for e.g. prevalence of a disease.
We expect that there has been some regression towards mean. We
have tried to solve this problem by controlling for baseline values
when looking at improvement in health scores.
The strengths of this study are the large study population size, the
setting in a general population, the long follow-up, and the use of a
validated measure of self-reported health (Gandek et al., 1998;
Kontodimopoulos et al., 2007; Luo et al., 2003; Salyers et al., 2000) and
the inclusion of relevant confounders in the statistical analyses.
The large Inter99 study is the first to show the impact of change of
different lifestyles on physical and mental self-reported health in a
general population.
Funding
Danish Medical Research Council, The Danish Centre for Evaluation
and Health Technology Assessment, Novo Nordisk, Copenhagen
County, Danish Heart Foundation, The Danish Pharmaceutical Asso-
ciation, Augustinus Foundation, Becket Foundation, Ib Henriksens
Foundation.
Contributors
CP and TJ contributed to the design of the study, collection and
assembly of the data, analysis and interpretation of data, and drafting
the article. UT, MA and CG took part in the interpretation of data and
drafting of the article. All authors approved the final manuscript. CP is
the guarantor. The guarantor accepts full responsibility for the con-
duct of the study, had access to the data, and controlled the decision
to publish.
Conflict of interest statement
All authors state that they have nothing to declare.
Acknowledgments
The Steering Committee of the Inter99 study: D.M.Sci. Torben
Jorgensen (principal investigator), D.M.Sci. Knut Borch-Johnsen
(principal investigator on the diabetes part), Ph.D. Charlotta Pisinger.
Also, we thank the staff of the Inter99 study.
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