the chs enrolled 5,201 ambulatory men and women age  65 years who were randomly selected from medicare eligibility lists in 4 u.s . communities in 1989 to 1990
baseline evaluation included standardized physical examination , diagnostic tests , and questionnaires to determine health status , medical history , and lifestyle risk factors .
for this analysis , participants were excluded if they had prevalent hf or moderate and/or severe mitral or aortic regurgitation at baseline ( n  = 698 ) , missing information on lifestyle risk factors , or implausible ( < 500 or > 4,000 kcal / day ) energy intake ( n  = 700 ) . participants with prevalent hypertension , diabetes , and coronary heart disease ( chd ) were included to maintain generalizability ; we also evaluated effect modification by these factors .
we evaluated dietary patterns , physical activity , alcohol use , smoking , and adiposity ( body mass index [ bmi ] and waist circumference ) .
diet was assessed in 1989 to 1990 using a validated 99-item food frequency questionnaire ( national cancer institute ) ( 11 ) , and again in 1995 to 1996 using a validated willett food frequency questionnaire ( 12 ) .
dietary patterns were evaluated as a time - varying exposure , with the cumulative average of intakes from the 2 food frequency questionnaires used to reduce within - person variation and obtain the best estimates of long - term dietary intake .
four dietary patterns were evaluated : alternative healthy eating index ( ahei ) , dash , a score based on the american heart association 2020 dietary goals ( aha 2020 ) ( 13 ) , and a biologic pattern constructed based on a priori knowledge of chd risk factors . dietary components and scoring algorithms are presented in online table  1 ; scoring for the ahei and dash patterns has been described previously ( 1416 ) . walking habits , including average pace and distance ,
were assessed by self - report at baseline and annually at each follow - up , and leisure - time activity ( modified minnesota leisure - time activities questionnaire ) and exercise intensity ( low , medium , or high ) by self - report at the baseline , third , and seventh annual visits .
trained personnel used standardized methods to measure weight at each annual visit , and height and waist circumference at the baseline , third , and seventh annual visits . to minimize potential misclassification from measurement error and changes in lifestyle , repeated measures were used to update lifestyle exposures using time - varying covariates with cumulative averaging .
participants were followed by annual study clinic examinations with interim telephone contacts for 10 years and telephone every 6 months thereafter .
incident hf was adjudicated by a centralized events committee using outpatient and inpatient medical records , diagnostic tests , clinical consultations , and interviews .
confirmation of hf required : 1 ) diagnosis by a treating physician ; 2 ) hf symptoms ( shortness of breath , fatigue , orthopnea , or paroxysmal nocturnal dyspnea ) plus signs ( edema , rales , tachycardia , gallop rhythm , or displaced apical impulse ) or supportive findings on echocardiography , contrast ventriculography , or chest radiography ; and 3 ) medical therapy for hf , defined as diuretics plus either digitalis or a vasodilator . because data on hf subtypes were incomplete for many participants , hf
cox proportional hazards were used to estimate hazard ratios ( hrs ) for quintile groups of each exposure , with time at risk until hf , death , or most recent follow - up date .
the proportional hazards assumption was tested by evaluating the product of each exposure times the natural log time in the model .
missing covariate information on education ( < 1% missing ) and income ( 6% missing ) were imputed using data on age , sex , race , and enrollment site . to assess the independent effect of a given lifestyle factor , multivariate models were mutually adjusted for each of the other lifestyle factors , plus age , sex , race , enrollment site , education , and income .
lifestyle factors were evaluated in combination to estimate the proportion of cases in the population that might be attributable to suboptimal levels of these factors ( population attributable risk ) .
the population attributable risk was calculated as : p(rr  1)/(1  + p[rr  1 ] ) , where p is the prevalence of individuals not in the low - risk group and rr is the associated multivariable - adjusted relative risk .
upper and lower 95% cis of the population attributable risk were derived using this formula as well as the upper and lower 95% ci estimates of the multivariable - adjusted relative risk .
effect modification was evaluated in analyses stratified by age , sex , race , bmi , baseline drug - treated hypertension , diagnosed diabetes , and baseline chd , with significance assessed using the wald test , which was adjusted using the bonferroni test for multiple comparisons .
sensitivity analyses restricted to those without prevalent chd at baseline , and to participants with good , very good , or excellent self - reported health were conducted . a sensitivity analysis adjusting for baseline n - terminal pro 
analyses were conducted using stata se ( version 12 , statacorp , college station , texas ) , with a 2-tailed   = 0.05 .
the chs enrolled 5,201 ambulatory men and women age  65 years who were randomly selected from medicare eligibility lists in 4 u.s . communities in 1989 to 1990
baseline evaluation included standardized physical examination , diagnostic tests , and questionnaires to determine health status , medical history , and lifestyle risk factors .
for this analysis , participants were excluded if they had prevalent hf or moderate and/or severe mitral or aortic regurgitation at baseline ( n  = 698 ) , missing information on lifestyle risk factors , or implausible ( < 500 or > 4,000 kcal / day ) energy intake ( n  = 700 ) . participants with prevalent hypertension , diabetes , and coronary heart disease ( chd ) were included to maintain generalizability ; we also evaluated effect modification by these factors .
we evaluated dietary patterns , physical activity , alcohol use , smoking , and adiposity ( body mass index [ bmi ] and waist circumference ) .
diet was assessed in 1989 to 1990 using a validated 99-item food frequency questionnaire ( national cancer institute ) ( 11 ) , and again in 1995 to 1996 using a validated willett food frequency questionnaire ( 12 ) .
dietary patterns were evaluated as a time - varying exposure , with the cumulative average of intakes from the 2 food frequency questionnaires used to reduce within - person variation and obtain the best estimates of long - term dietary intake .
four dietary patterns were evaluated : alternative healthy eating index ( ahei ) , dash , a score based on the american heart association 2020 dietary goals ( aha 2020 ) ( 13 ) , and a biologic pattern constructed based on a priori knowledge of chd risk factors . dietary components and scoring algorithms are presented in online table  1 ; scoring for the ahei and dash patterns has been described previously ( 1416 ) . walking habits , including average pace and distance , were assessed by self - report at baseline and annually at each follow - up , and leisure - time activity ( modified minnesota leisure - time activities questionnaire ) and exercise intensity ( low , medium , or high ) by self - report at the baseline , third , and seventh annual visits . alcohol use and smoking status
were assessed at each annual visit . trained personnel used standardized methods to measure weight at each annual visit , and height and waist circumference at the baseline , third , and seventh annual visits . to minimize potential misclassification from measurement error and changes in lifestyle , repeated measures were used to update lifestyle exposures using time - varying covariates with cumulative averaging .
participants were followed by annual study clinic examinations with interim telephone contacts for 10 years and telephone every 6 months thereafter .
incident hf was adjudicated by a centralized events committee using outpatient and inpatient medical records , diagnostic tests , clinical consultations , and interviews .
confirmation of hf required : 1 ) diagnosis by a treating physician ; 2 ) hf symptoms ( shortness of breath , fatigue , orthopnea , or paroxysmal nocturnal dyspnea ) plus signs ( edema , rales , tachycardia , gallop rhythm , or displaced apical impulse ) or supportive findings on echocardiography , contrast ventriculography , or chest radiography ; and 3 ) medical therapy for hf , defined as diuretics plus either digitalis or a vasodilator . because data on hf subtypes were incomplete for many participants , hf
cox proportional hazards were used to estimate hazard ratios ( hrs ) for quintile groups of each exposure , with time at risk until hf , death , or most recent follow - up date .
the proportional hazards assumption was tested by evaluating the product of each exposure times the natural log time in the model .
missing covariate information on education ( < 1% missing ) and income ( 6% missing ) were imputed using data on age , sex , race , and enrollment site . to assess the independent effect of a given lifestyle factor , multivariate models were mutually adjusted for each of the other lifestyle factors , plus age , sex , race , enrollment site , education , and income .
lifestyle factors were evaluated in combination to estimate the proportion of cases in the population that might be attributable to suboptimal levels of these factors ( population attributable risk ) .
 1)/(1  + p[rr  1 ] ) , where p is the prevalence of individuals not in the low - risk group and rr is the associated multivariable - adjusted relative risk .
upper and lower 95% cis of the population attributable risk were derived using this formula as well as the upper and lower 95% ci estimates of the multivariable - adjusted relative risk .
effect modification was evaluated in analyses stratified by age , sex , race , bmi , baseline drug - treated hypertension , diagnosed diabetes , and baseline chd , with significance assessed using the wald test , which was adjusted using the bonferroni test for multiple comparisons .
sensitivity analyses restricted to those without prevalent chd at baseline , and to participants with good , very good , or excellent self - reported health were conducted . a sensitivity analysis adjusting for baseline n - terminal pro 
analyses were conducted using stata se ( version 12 , statacorp , college station , texas ) , with a 2-tailed   = 0.05 .
at baseline , 61% of participants were women , and the mean age was 72 years .
adherence to most dietary pattern scores was modest , with mean scores ranging from 46 ( ahei ) to 66 ( aha 2020 ) of a maximum 100 points . across quintiles for all patterns , characteristics associated with higher scores ( indicating healthier diets ) included female sex , higher educational attainment , and higher income .
similarly , physical activity ( leisure activity , walking pace ) , never or former smoking , and modest alcohol use were associated with higher scores .
baseline blood pressure and diagnosed diabetes showed inverse relations across quintiles of diet scores ; prevalent hypertension medication use and chd showed no consistent pattern across scores . during 51,850 person - years ( maximum follow - up : 21.5 years ) , 1,380 hf cases occurred .
after adjustment for demographic and lifestyle variables , no dietary pattern was associated with incident hf ( table  2 ) .
results were not materially different when energy - unadjusted patterns were analyzed or when dietary scores were evaluated continuously ( data not shown ) .
in contrast , physical activity measures ( exercise intensity , walking pace , leisure activity , and walking distance ) were each associated with lower hf incidence in demographic - adjusted multivariate models . when mutually adjusted for other lifestyle variables , including other physical activity metrics , the highest category of walking pace and leisure activity , but not exercise intensity and walking distance ,
after multivariable adjustment , smoking , modest alcohol intake , bmi , and waist circumference were each independently associated with incident hf , with 37% , 30% , 37% , and 20% lower risk among older adults in the lowest risk groups , respectively ( online table  3 ) . because bmi was more strongly associated with hf than waist circumference , bmi ( low risk group  < 30 kg / m ) was evaluated with other low - risk lifestyle factors ( 2 mph walking pace , leisure activity  845 kcal / week , no current smoking , 1  alcohol drink / week ) to assess combined associations with incident hf . compared with individuals with 0 or 1 low - risk lifestyle factors ,
participants had lower risk of hf if they had 2 ( hr : 0.78 ; 95% ci : 0.62 to 0.97 ) , 3 ( hr : 0.64 ; 95% ci : 0.52 to 0.80 ) , 4 ( hr : 0.56 ; 0.44 to 0.70 ) , or 5 ( hr : 0.55 ; 95% ci : 0.42 to 0.74 ) low - risk lifestyle factors ( figure  1 ) . compared with the low - risk group for each , each lifestyle factor was estimated to explain between 5% ( smoking ) and 18% ( alcohol use ) of the population risk of developing hf in older adults ( table  3 ) .
lack of adherence to an overall healthy diet pattern had no associated attributable risk in older adults .
heterogeneity in the association between diet and  hf was not observed by any of the potential effect modifiers ( pinteraction > 0.05 ) ( online table  4 ) , although the aha 2020 diet pattern was associated with a trend toward lower hf risk in african americans ( pinteraction  = 0.07 ) and those without baseline chd ( pinteraction  = 0.06 ; hr : 0.86 ; 95% ci 0.70 to 1.06 ) .
after bonferroni correction , there was also little evidence for heterogeneity by age , sex , baseline chd , treated hypertension , and diabetes for the association of nondietary lifestyle factors with hf ( figure  2 ) . in the secondary analyses that evaluated individual dietary components , including fruits , vegetables , whole grains , fish , polyunsaturated to saturated fat  ratio , nuts , red meat , processed meat , sugar - sweetened beverages , and transfat , no component was significantly associated with incident hf ( online table  5 ) . after adjusting for demographic and lifestyle variables , sodium was associated with a 19% increased risk of incident hf in the highest versus lowest quintile of intake . when potential mediators were added to the model , the association was slightly attenuated ( highest quintile hr : 1.15 ; 95% ci 0.96 to 1.36 ; ptrend  = 0.05 ) , with diagnosed diabetes having the largest influence on mitigating the sodium  hf association .
all results were similar if we excluded participants with prevalent chd , except for a stronger positive association between dietary sodium and incident chd ( ptrend  = 0.014 ) ( online tables  6 to 8) .
in additional sensitivity analysis restricted to adults with self - perceived excellent , very good , or good health , associations were not materially altered ( online tables  9 and 10 ) .
in contrast , inverse associations of  walking pace and leisure activity were attenuated  in  self - perceived healthier participants ( online table  10 ) .
b - type natriuretic peptide had minimal influence on associations for diet patterns , walking pace , smoking , and alcohol intake ( online table  11 ) .
in this large , prospective cohort of older u.s . adults , lifestyle factors , including moderate alcohol use , physical activity , not smoking , and avoiding obesity late in life , were each independently associated with a lower risk of incident hf .
participants with  4 of these healthy lifestyle factors , compared with none , had a 45% lower risk of developing hf . among different physical activity measures , walking pace and leisure activity , but not exercise intensity , were each independently associated with lower risk .
if associations were causal , our results suggested that moderate physical activity ( > 845 kcal / week in leisure activity ) and higher walking speed ( > 3 mph ) , rather than high - intensity exercise , might be most useful in older adults for hf prevention . a second
important , and unexpected , finding , was that overall dietary patterns were not associated with hf .
however , higher sodium intake was associated with trends toward increased risk in the overall cohort , and significantly increased risk among those without chd at baseline .
our work provided an assessment of the relative importance and burden of major lifestyle factors in the development of hf in older adults , the fastest growing segment of the u.s .
the association of physical activity with lower hf is mechanistically plausible because of the benefits on endothelial function , autonomic function , nitric oxide bioavailability , and progenitor cell mobilization ( 17,18 ) .
benefits may be mediated through prevention of hypertension , left ventricular hypertrophy , obesity , chd , and type 2 diabetes , which are all major risk factors for hf ( 17 ) .
our findings that moderate energy expenditure through leisure activity is associated with a lower hf risk , as well as the lack of independent association for exercise intensity , are consistent with recent prospective analyses that showed little or no additional benefit accrued from vigorous over moderate activity for prevention of hypertension , chd , and diabetes ( 19,20 ) .
physical activity was no longer associated with hf in sensitivity analyses restricted to individuals with better self - perceived health .
alternatively , the attenuation could reflect over - adjustment ( adjustment for a major mediator of the effect ) , because physical activity increases self - perceived health in older adults , including benefits on mental well - being , physical well - being , quality of life ( 21 ) , and reduced hospitalizations among patients with hf ( 22 ) .
moderate alcohol use is associated with lower hf risk in most longitudinal analyses ( 23 ) .
although the upper limit of the low - risk alcohol intake category in our analysis was unconstrained , alcohol use in the chs was low , with only 25% of participants consuming > 1 drink / week , and 
heavy alcohol use induces alcoholic cardiomyopathy ( 24 ) and increases risk of hf , whereas modest use improves endothelial function and increases plasma atrial natriuretic peptide ( 25 ) . in the absence of large randomized trials of moderate alcohol use and incident hf , in addition to risk of abuse and other adverse health consequences , it would be premature  to recommend alcohol intake for public health prevention of hf .
the observed magnitude of association for smoking was similar to that observed in the coronary artery surgery study , in which smoking was associated with a 47% increased risk of hf ( 26 ) .
associations of obesity with incident hf may be mediated through hypertension , chd , type 2 diabetes , and sleep apnea ( 27 ) ; key postulated mechanisms include increases in atherogenic lipids , cardiac preload and afterload , and neurohormonal disruption ( 17 ) .
although robust evidence from longitudinal studies and randomized trials showed that healthful dietary patterns reduced major hf risk factors , such as high blood pressure and chd ( 13,14,28,29 ) , no known large trials and few observational studies directly linked dietary patterns and their components with incident hf ; these studies had mixed results .
our findings of no association of overall dietary patterns with hf differed from 2 swedish cohorts , in which adherence to dash was associated with a 22%  to 37% lower risk of hf in the highest quartiles ( 8,9 ) . the absolute incidence of hf in these cohorts was approximately 8-fold lower than in the chs , and these previous studies only captured hf events that  resulted in hospitalization or death . in the chs ,
incident hf was adjudicated by a centralized chs committee that used all available outpatient and inpatient data , which more completely captured hf , including those treated on an outpatient basis .
the  chs also included only elderly participants , compared with middle - aged participants in the swedish cohorts .
these differences could account for the varied findings ; our results highlighted the need for further study of dietary factors , including sodium , and incident hf .
demographic characteristics , lifestyle factors , and hf events were prospectively recorded with little loss to follow - up over 21.5 years .
multiple dietary patterns were investigated , including 2 established patterns associated with reduced hypertension and chd ( dash and ahei ) and 2 additional biologically derived patterns ( biologic and aha 2020 ) .
the lack of association observed across all patterns for incident hf implied that our dietary findings were robust .
we restricted our sensitivity analyses to those without prevalent chd , which reduced confounding by indication and corroborated our main findings .
a large number of validated hf cases provided sufficient power to detect associations , including across multiple risk categories .
communities , which provided a population - based sample of older adults and increased generalizability .
although we adjusted for major demographics and lifestyle factors , residual confounding by unknown or unmeasured factors might be present .
associations of dietary patterns and physical activity might be mediated through adiposity , hypertension , and prevalent chd ; therefore , analyses adjusted for these factors might underestimate the impact of lifestyle on hf .
however , we performed stratified analyses and tests for interactions for diet and lifestyle factors by these potential mediating factors .
some misclassification of lifestyle factors was inevitable , especially in those that were assessed via self - report , as well as in those analyzed in categories or dichotomously , which would likely attenuate findings toward the null and underestimate the true magnitude of associations .
we also highlight the need to better understand and integrate the determinants and relative contribution of lifestyle and other risk factors for hf beyond the scope of this work , including congenital defects , cardiomyopathies , drugs and/or toxins , renal dysfunction , and genetic risk predictors .
although we adjusted for major demographics and lifestyle factors , residual confounding by unknown or unmeasured factors might be present .
associations of dietary patterns and physical activity might be mediated through adiposity , hypertension , and prevalent chd ; therefore , analyses adjusted for these factors might underestimate the impact of lifestyle on hf .
however , we performed stratified analyses and tests for interactions for diet and lifestyle factors by these potential mediating factors .
some misclassification of lifestyle factors was inevitable , especially in those that were assessed via self - report , as well as in those analyzed in categories or dichotomously , which would likely attenuate findings toward the null and underestimate the true magnitude of associations .
we also highlight the need to better understand and integrate the determinants and relative contribution of lifestyle and other risk factors for hf beyond the scope of this work , including congenital defects , cardiomyopathies , drugs and/or toxins , renal dysfunction , and genetic risk predictors .
our findings suggested that adherence to a few modifiable risk factors , including physical activity , moderate alcohol use , not smoking , and avoiding obesity , halved the risk of incident hf later in life .
although overall dietary patterns were not associated with lower hf risk in this cohort , adherence to a healthy diet remains crucial for prevention of other cardiometabolic diseases , including hypertension , type 2 diabetes , and chd .
our results also underscored the importance of further investigating specific dietary determinants , such as sodium , and physical activity type , duration , and frequency in future studies and trials for hf prevention among older adults.perspectivescompetency in medical knowledge : in older adults , the risk of developing hf can be cut in half by adherence to key protective lifestyle factors , including modest physical activity , in addition to not smoking and maintaining a healthy weight.translational outlook : randomized trials investigating physical activity type , duration , and frequency in more detail for the prevention of hf in older adults are needed . competency in medical knowledge : in older adults , the risk of developing hf can be cut in half by adherence to key protective lifestyle factors , including modest physical activity , in addition to not smoking and maintaining a healthy weight .
translational outlook : randomized trials investigating physical activity type , duration , and frequency in more detail for the prevention of hf in older adults are needed .
 objectivesthe goal of this study was to determine the relative contribution of major lifestyle factors on the development of heart failure ( hf ) in older adults.backgroundhf incurs high morbidity , mortality , and health care costs among adults  65 years of age , which is the most rapidly growing segment of the u.s . 
 population.methodswe prospectively investigated separate and combined associations of lifestyle risk factors with incident hf ( 1,380 cases ) over 21.5 years among 4,490 men and women in the cardiovascular health study , which is a community - based cohort of older adults . 
 lifestyle factors included 4 dietary patterns ( alternative healthy eating index , dietary approaches to stop hypertension , an american heart association 2020 dietary goals score , and a biologic pattern , which was constructed using previous knowledge of cardiovascular disease dietary risk factors ) , 4 physical activity metrics ( exercise intensity , walking pace , energy expended in leisure activity , and walking distance ) , alcohol intake , smoking , and obesity.resultsno dietary pattern was associated with developing hf ( p > 0.05 ) . walking pace and leisure activity were associated with a 26% and 22% lower risk of hf , respectively ( pace > 3 mph vs.  < 2 mph ; hazard ratio [ hr ] : 0.74 ; 95% confidence interval [ ci ] : 0.63 to 0.86 ; leisure activity  845 kcal / week vs.  < 845 kcal / week ; hr : 0.78 ; 95% ci : 0.69 to 0.87 ) . modest alcohol intake , maintaining a body mass index  < 30 kg / m2 , and not smoking were also independently associated with a lower risk of hf . 
 participants with  4 healthy lifestyle factors had a 45% ( hr : 0.55 ; 95% ci : 0.42 to 0.74 ) lower risk of hf . 
 heterogeneity by age , sex , cardiovascular disease , hypertension medication use , and diabetes was not observed.conclusionsamong older u.s . 
 adults , physical activity , modest alcohol intake , avoiding obesity , and not smoking , but not dietary patterns , were associated with a lower risk of hf . 
Methods
Design and population
Assessment of lifestyle
Ascertainment of incident heart failure
Statistical analysis
Results
Discussion
Study limitations
Conclusions
Appendix