Journal of Epidemiology xxx (2017) 1e9

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Journal of Epidemiology
journal homepage: http://www.journals.elsevier.com/journal-of-epidemiology/

Original Article

The association between changes in lifestyle behaviors and the
incidence of chronic kidney disease (CKD) in middle-aged and
older men
Ryoma Michishita a, b, *, Takuro Matsuda b, c, Shotaro Kawakami d, Satoshi Tanaka d,
Akira Kiyonaga b, Hiroaki Tanaka b, d, Natsumi Morito e, f, Yasuki Higaki b, d
a
Department of Health Development, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
b
The Fukuoka University Institute for Physical Activity, Fukuoka, Japan
c
Department of Rehabilitation, Fukuoka University Hospital, Fukuoka, Japan
d
Laboratory of Exercise Physiology, Faculty of Health and Sports Science, Fukuoka University, Fukuoka, Japan
e
Fukuoka University Health Care Center, Fukuoka, Japan
f
Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan

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

Article history: Background: This study was designed to evaluate whether changes in lifestyle behaviors are correlated
Received 21 April 2016 with the incidence of chronic kidney disease (CKD).
Accepted 28 August 2016 Methods: The subjects consisted of 316 men without a history of cardiovascular disease, stroke, or renal
Available online xxx
dysfunction or dialysis treatment. The following lifestyle behaviors were evaluated using a standardized
self-administered questionnaire: habitual moderate exercise, daily physical activity, walking speed,
Keywords:
eating speed, late-night dinner, bedtime snacking, skipping breakfast, and drinking and smoking habits.
Incidence of CKD
The subjects were divided into four categories according to the change in each lifestyle behavior from
The changes in lifestyle behaviors
Habitual moderate exercise
baseline to the end of follow-up (healthyehealthy, unhealthyehealthy, healthyeunhealthy and un-
Late-night dinner healthyeunhealthy).
Bedtime snacking Results: A multivariate analysis showed that, with respect to habitual moderate exercise and late-night
dinner, maintaining an unhealthy lifestyle resulted in a significantly higher odds ratio (OR) for the
incidence of CKD than maintaining a lifestyle (OR 8.94; 95% confidence interval [CI], 1.10e15.40 for
habitual moderate exercise and OR 4.00; 95% CI, 1.38e11.57 for late-night dinner). In addition, with
respect to bedtime snacking, the change from a healthy to an unhealthy lifestyle and maintaining an
unhealthy lifestyle resulted in significantly higher OR for incidence of CKD than maintaining a healthy
lifestyle (OR 4.44; 95% CI, 1.05e13.93 for healthyeunhealthy group and OR 11.02; 95% CI, 2.83e26.69 for
unhealthyeunhealthy group).
Conclusions: The results of the present study suggest that the lack of habitual moderate exercise, late-
night dinner, and bedtime snacking may increase the risk of CKD.
© 2017 The Authors. Publishing services by Elsevier B.V. on behalf of The Japan Epidemiological
Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction patients at present is believed to be associated with the increase in
number of patients with CKD. It is well known that aging, hyper-
The number of patients with end-stage renal disease (ESRD) in tension, diabetes mellitus, and metabolic syndrome are risk factors
Japan is continuously increasing.1 Chronic kidney disease (CKD) has for CKD.4e6
been related to the development of ESRD and cardiovascular dis- In addition to the above factors, the incidence of CKD is also
ease (CVD) morbidity and mortality.2,3 The large number of ESRD closely related to unhealthy lifestyle behaviors, such as smoking,
heavy alcohol intake, obesity, lack of exercise habit, and unhealthy
eating styles.7e12 In our previous cross-sectional and longitudinal
* Corresponding author. 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, studies,13,14 we observed that reduced incidence of CKD correlated
Japan. with an increase in the number of healthy lifestyle behaviors.
E-mail address: rmichishita@med.uoeh-u.ac.jp (R. Michishita). Adherence to healthy lifestyle behaviors is therefore thought to be
Peer review under responsibility of the Japan Epidemiological Association.

http://dx.doi.org/10.1016/j.je.2016.08.013
0917-5040/© 2017 The Authors. Publishing services by Elsevier B.V. on behalf of The Japan Epidemiological Association. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Michishita R, et al., The association between changes in lifestyle behaviors and the incidence of chronic kidney
disease (CKD) in middle-aged and older men, Journal of Epidemiology (2017), http://dx.doi.org/10.1016/j.je.2016.08.013

6. eGFR. Please cite this article in press as: Michishita R.6%). 141  (Cr/ informed consent.08. or cardiovascular events and is more useful for this purpose than proteinuria. at baseline16 was as follows: G1 (eGFR  90 mL/min/1. The association between changes in lifestyle behaviors and the incidence of chronic kidney disease (CKD) in middle-aged and older men. walking speed. cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL- tively investigated the influence of changes in lifestyle behaviors on C) levels were measured using the direct method. were also serum Cr. The subjects' drinking and smoking Fig. and mean eGFR: 81. renal dysfunction (estimated glomerular filtration who have mild renal impairment despite having normal or nearly rate [eGFR] using the Japanese coefficient-modified CKD-Epide. CVD. described in a previous study. 30 min at a time and 2 times per week (yes or no). The study conforms to the Declaration of Helsinki and was The purpose of lifestyle modification in improving CKD is not approved by the Ethics Committee of Fukuoka University (No. 3 times per week (yes or no).. mean body mass index [BMI]: sults were classified as (). 0.doi. Michishita et al.84 [SD. normal Cr levels. equal to walking at least 1 h per day (yes or no). However. 178 women were excluded to remove the in. “yes” or “no” responses): drinking habit (not drinking everyday). 11- only to increase renal function. or (3þ). level was measured using the enzyme method. the eGFR is a strong predictor of miology Collaboration [EPI] equation <60 mL/min/1. Journal of Epidemiology (2017). HbA1c is presented as the National Glyco- Subjects hemoglobin Standardization Program (NGSP) value. of ESRD and CVD. after agreeing with the purpose.14 The subjects' lifestyle behaviors regarding physical activity. or both). 3 times per week (yes or no). 3 times per week (yes or no). Blood pressure was measured in the right arm with the subject sitting in a chair. proteinuria positive [1þ missing information during the follow-up were deemed eligible for or greater].9)0. 1. / Journal of Epidemiology xxx (2017) 1e9 important to prevent the incidence of CKD.209  0.4%). 2.73 m2) ¼ Cr  0.73 m2).02  JDS value (%) þ 0. and drinking and smoking habits were eval- uated using the standardized self-administered questionnaire of the National Health Promotion Program. but also to prevent the development 08-01). late-night dinner.16 in 2008.org/10. and G2 (eGFR 60e89 mL/min/1. 23.13.5 hematuria were performed using a dipstick. A flow-chart of the participants included in the study. blood pressure. physical activity.3 [SD.993age  0. estimated glomerular filtration rate.25%. sure of the renal function than serum Cr18 and identifies patients stroke (n ¼ 2). n ¼ 21 (6.9 mg/dL. exercise. Subjects with a previous history of CVD (n ¼ 4).13.2 R.73 m2). no study has All of the subjects gave their informed consent for participation that evaluated the effect of lifestyle behaviors changes on pre. methods.21 In this study. eating style. Assessment of lifestyle behaviors The subjects' lifestyle behaviors regarding exercise.20 A urinalysis for assessment of the proteinuria and excluded from the analysis. n ¼ 295 (93. The height and body weight were measured. riodic health check-up at a health care center in Fukuoka University %) ¼ 1. (1þ). high-density lipoprotein prevention of the development of CKD.7] years. the Japan Diabetes Society (JDS): HbA1c (NGSP value.. physical activity. after more than 5 min of rest.1016/j.73 m2) with no Nephrology (eGFR < 60 mL/min/1.14 Of the 434 subjects who provided 141  (Cr/0.19.013 . Furthermore. We therefore hypothesized that Blood samples were collected early in the morning via veni- maintaining or improving healthy lifestyle behaviors may help puncture from an antecubital vein after at least 12 h of fasting. mean serum creatinine [Cr]: 0.813. as the accumulation of healthy blood samples were analyzed by Special Reference Laboratories lifestyle behaviors has been demonstrated to be associated with (SRL Inc.9 mg/dL. The serum Cr.7] kg/m2.17 The eGFR is a more accurate mea- fluence of gender. and significance of the venting the onset of CKD through long-term follow-up. The method for this health check-up has already been by a Japanese coefficient: eGFR (mL/min/1.813. The waist circumference was measured at the level of the umbilicus. (±). The plasma glucose level was measured using an ultraviolet/hexokinase method and Methods hemoglobin A1c (HbA1c) was measured via high-performance liquid chromatography.73 m2. eating style. The reduce the development of CKD. (2þ). eating speed. and drinking and smoking habits were determined based on their responses to the following questionnaire items: habitual moderate exercise. compared with others (fast or slow). http://dx. The triglyceride the incidence of CKD in middle-aged and older men. bedtime snacking.411  0. Tokyo.15 The breakdown of subjects' CKD grade the present study.je.22. or both15).14 This study retrospec.73 m2.1] mL/min/1. and skipping breakfast.23 The contents for this questionnaire were described in a previous study. and/or dialysis treatment (n ¼ 45). and the BMI was calculated as the ratio of body weight (kg) to height squared (m2).9)1. 0.09] CKD was defined according to definition of the Japanese Society of mg/dL. 1. et al.2016. study. and the urine test re- [standard deviation {SD}. and was expressed as an average of duplicate measurements. compared with people of the same sex and age group (fast or slow). 6.2 [SD. Cr > 0. which was calculated using the conversion equation for HbA1c derived from A total of 773 middle-aged and older adults received their pe. The flow of participants through the study is shown in The eGFR was calculated using the CKD-EPI equations modified Fig. and anthropometry measurements contribute to understanding the importance of lifestyle modifica- tion in CVD and ESRD prevention. Japan). A total of 316 men (mean age: 52. Clarification of the association between the changes in lifestyle behaviors and the incidence of CKD may Blood sampling.993age  0. cardiovascular habits were assessed using the following questionnaire items (with disease.

NGSP %.795 Waist circumference.3 (18.5) 0. walking Comparisons of the data at the baseline and after the follow-up speed. In this anthropometry measurements and assessment of lifestyle behav.3 (2.024). eating speed. 69. In this study.83 (0.1) 125. The association between changes in lifestyle behaviors and the incidence of chronic kidney disease (CKD) in middle-aged and older men. waist circumference. high-density lipoprotein cholesterol. No significant differences between these groups were performed using the StatView 5.4) 5. cm 83.020 DBP. late-night dinner (more multiple logistic regression analysis.7 (29. R. G2. estimated-glomerular filtration rate. including daily physical activity equal to walking. while that after the follow-up was as follows: G1.8) 0. mean (SD) 5.doi.114 Fasting glucose.3) 133. and no bedtime snack- eGFR and other coronary risk factors at baseline and after follow-up ing (61.6) 57. Because no subjects stared smoking again After the follow-up.7) 58. and eGFR levels at baseline were entered as week).73 m2).7 (78. n ¼ 286 (90.3%).05 was considered to be defined as unhealthy lifestyle behaviors. 90. No significant differences among these groups Table 1 The baseline characteristics in subjects with and without the development of CKD.686 Triglyceride. mg/dL 58. n (%) 10 (3. including 2 with proteinuria year of CKD.4) 0. eGFR 60e89 mL/min/1.6) 0.8 (77.6 (27.2) 9 (3. diastolic blood pressure.0) <0. mg/dL 99. the subjects' lifestyle behaviors were factors. chronic kidney disease.5%). mL/min/1. n (%) 26 (8.8)/23 (76.7) 21 (100) 275 (93.6) 5.73 m2. mg/dL 114. mg/dL 118.1)/286 (96.6 (0.1) 23.0) 0. The classifications of CKD grade was defined according to definition of the Japanese Society of Nephrology.1) 0.3) 0.3 (2. BMI. n (%) 296 (93. The rates of healthy lifestyle behaviors of were performed using Welch's t-test for continuous variables and habitual moderate exercise (14.1) 85. n ¼ 21 (6. systolic blood pressure.9) 0.062 Hypoglycemic drugs.84 (0.3) 0 (0) 20 (6.045 Anti-hypertensive drugs. p ¼ 0.09) 0.15 Please cite this article in press as: Michishita R. http://dx.0 (6.001) were significantly lower in the CKD among the changes in lifestyle behaviors were determined using a group than in the non-CKD group. mg/dL 0.0001 Age. Michishita et al.8) 0. Table 1 com- iors were conducted at baseline (2008) and the end-point year pares the baseline characteristics in subject who did and did not (maximal 5 years [until 2013]).5 (126.1) 5 (23.9 (16.9 (14. n ¼ 20 (6. noted in the classifications of CKD grade and other coronary risk Cary.8) 4 (19.0%. A probability value <0. the subjects' end-point of follow-up was the onset 45e59 mL/min/1. The data were cantly lower (p ¼ 0. in other coronary risk factors.8) 1 (4. n (%) 44 (13.4 (9.2 (6.0001 Classifications of CKD grade G1.0) 138. no significant differ- two-way repeated-measures analysis of variance and TukeyeK. Journal of Epidemiology (2017).5 (8.8%. bedtime snacking (more than 3 times per SBP. and skipping breakfast.6% vs.7%). age.1 (26. eGFR  90 mL/min/1.org/10.0 (10. NGSP. Tables 3 and 4 shows the differences in the changes in the uous variables.0 (12. DBP.2)/306 (96.1 (13. body mass index.5 (6. study.4) 99. eGFR.8) 0.2) 39 (13.9% vs. Statistical analyses were group.8%).873 HbA1c. yes/no. HbA1c. systolic blood pressure.2 (13.372 SBP. were performed using a Wilcoxon signed-ranks test for contin.4) 52.0) 22 (7. hematuria (1þ or greater) was not observed. The serum Cr. yes/no. The subjects were divided statistically significant.2) Serum creatinine.1) 0.1016/j. 0.09) <0.6 (0.9) 82.4 (7. changes in lifestyle behaviors and the incidence of CKD. subjects by CKD grade15 at baseline was as follows: G1 (eGFR  90 mL/min/1. All (n ¼ 316) Developed CKD (n ¼ 21) Did not develop CKD (n ¼ 295) p value 2 eGFR. mm Hg 126. years 52.8 (0..6%). while other coronary risk factors Table 2 compares the lifestyle behaviors in subjects who did and were shown as continuous variables.8) 81.3) 99.035).0001) in the CKD group than in the non-CKD expressed as the mean value with the SD.8)/20 (95. and and 2 with microalbuminuria [urinary proteinuria (±)]).2016.1) 83.8 (8.226 HDL-C. HbA1c. The breakdown of the unhealthyeunhealthy.013 . unhealthyehealthy.73 m2 after they quit smoking.je. n ¼ 296 (93. mm Hg 82.828 BMI. However. and the biochemical analysis.7) 23. low-density lipoprotein cholesterol.05) and eGFR was signifi- check-up at baseline and the end-point year. The mean only three categories: healthyehealthy. p ¼ 0. no late- the chi-square test for categorical variables. SBP.08. blood pressure.73 m2).741 Body weight.9) 0.73 m2. LDL-C. LDL-C. subjects' smoking habit was classified into and/or proteinuria) was observed in 21 subjects (6. slow-walking was performed to investigate the relationships between the speed (compared with people of the same sex and age group).08) 0. G2 (eGFR 60e89 mL/ Statistical analysis min/1. / Journal of Epidemiology xxx (2017) 1e9 3 and smoking habit (recently not smoking).5 (3.6) 0. national glycohemoglobin standardization program.73m 81.0) 111.2%. expressed as categorical variables. and HbA1c analyzed data from subjects who had undergone a periodic health level were significantly higher (all p < 0. In this high eating speed (compared with others). USA). The differences in the night dinner (47. and unhealthyeunhealthy. as follows: Results healthyehealthy.9) 67.4 (9. yes/no. the present study only develop CKD.2)/290 (91. unhealthyehealthy.6 (6. the lack of determine the associations of the change in eGFR with the changes exercise habit (less than 30 min at a time and 2 times per week).4) 84. and follow-up period was 4.665 CKD.5) 0. A multiple logistic regression analysis low-physical activity level (less than 1 h per day). n (%) 20 (6.0)/17 (80.9)/272 (86.2) 67.1 (5. In this study.0 (10.6) years.2)/255 (86.3 (7.9 (SD. kg 67.6%.0) 119. BMI. hemoglobin A1c. ences were noted between these groups in the other lifestyle be- ramer method for the follow-up and groups  time interactions. incident CKD (eGFR < 60 mL/min/1. haviors.5)/273 (92. and G3a (eGFR In this study. et al. HDL-C.7) 52.218 G2. than 3 times per week).92 (0.176 Anti-hyperlipidemic agents. p ¼ 0. healthyeunhealthy.7) 0. into four categories according to the change in each of the above lifestyle behaviors from baseline to end-point year.73 m2). NC. Data are expressed as mean (standard deviation) or number of subjects (%). The inter-group comparisons did not develop CKD. As a result.1) 76.9 (16.3% vs. kg/m2 23.2 (10. 39. and skipping breakfast (more than 3 times per week) were adjusted factors.0 software package (SAS Institute.2) 116.4 (9.4 (14.5 (6. DBP. n ¼ 9 (2.125 LDL-C. Pearson's simple regression and the stepwise coronary risk factors among the four categories of changes in life- multivariate regression analyses were performed in order to style behaviors.

404 Drinking habit. LDL-C. daily physical activity equal to walking. a significant interaction effect for group  time 11.0)/65 (22. unhealth. were noted in age. The association between changes in lifestyle behaviors and the incidence of chronic kidney disease (CKD) in middle-aged and older men.032).233 CKD. atherosclerotic events.96 and OR p < 0.261. fast/slow. diastolic blood pressure (DBP).83e26. OR 4.133 1 h/day.org/10.9) 29 (9.05).8) 14 (66. The change from a healthy to an un.08. However. 1.60. trols for preventing the development of CKD. pertension. 95% CI.4)/10 (47.0) 0. 1.83e26.3) 230 (78.001 Skipping breakfast: 3 times/week. n (%) 28 (8. type 2 diabetes.16. Furthermore.1016/j. respectively). fast/slow. and eGFR levels at baseline were entered as adjusted reduced with increasing healthy lifestyle scores.6)/184 (62. n (%) 122 (38.5) 26 (8. changing from a follow-up. p ¼ 0.6)/194 (61. In this multiple logistic regression analysis. daily resulted in a significantly higher ORs for incidence of CKD than physical activity equal to walking. and maintaining a healthy significantly higher OR for incidence of CKD than maintaining a lifestyle or improving an unhealthy one therefore plays an impor- healthy lifestyle behavior (OR 6. maintaining a reasonable ORs for incidence of CKD than maintaining a healthy lifestyle (OR body weight. and enjoying a healthy eating style) on 6.7) 65 (22. In addition. In multivariate analysis.95.8) 5 (23. and HbA1c levels Discussion among all four lifestyle groups with respect to habitual moderate exercise.3)/18 (85.013 . determined using a simple regression analysis.45e12.4)/10 (47. was observed in the waist circumference.188. BMI. than maintaining a healthy lifestyle behavior (OR 8.89. yes/no. our current findings suggest that an increasing in Table 7 shows the differences in the odds ratio (OR) for the SBP and HbA1c level were associated with the reduction in renal incidence of CKD among the four categories of changes in lifestyle function. DBP. promising findings. Similarly. and late-night dinner resulted in a behaviors and reduced risk of CKD. daily physical anism underlies the relationship between healthy lifestyle activity equal to walking. the association between any changes in life- 1.120. age.2) 0. 2. p < 0.44.035 Bedtime snacking: 3 times/week. All (n ¼ 316) Developed CKD (n ¼ 21) Did not develop CKD (n ¼ 295) p value Habitual moderate exercise: 30 min/session 118 (37. despite our 1.4) 11 (52.69. systolic blood pressure (SBP). the incidence of CKD progression.0)/230 (78. p ¼ 0.4 R. LDL-C style.0001). may be Please cite this article in press as: Michishita R.7)/7 (33.121. n (%) 68 (21.912 Smoking habit. yes/no. SBP.8)/266 (90. eGFR.6) 111 (37. 1. 95% confidence interval [CI].8) 0.1) 2 (9.191 the same sex and age group. 95% CI.94.0) 0. and dyslipidemia.0001) (Table 6). a stepwise multiple regression analysis (r ¼ 0. and HbA1c levels (r ¼ 0.6) 89 (30. increased the incidence of CKD versus maintaining a healthy life- SBP (r ¼ 0.05.3)/198 (62. atherosclerotic events. the eGFR level decreased in all groups.0) 0.3)/176 (59. tant role in the preventing these diseases. n (%) 244 (77. 95% CI. n (%) Eating speed: compared with others. yes/no. DBP. yehealthy. 95% CI. p < 0. and we consider that early lifestyle intervention is behaviors.1)/13 (61.7) 0.05).9)/288 (91. p ¼ 0.024 and 2 times/week.4) 11 (52. HbA1c. changing from a healthy to an unhealthy lifestyle and main- eGFR level between maintaining a healthy lifestyle and maintaining taining an unhealthy lifestyle with respect to bedtime snacking also a healthy lifestyle with respect to habitual moderate exercise. DBP (r ¼ 0. hy- variable.006).8)/269 (91. yes/no.5)/248 (78. Michishita et al. the category required. It is well known was entered as a dependent variable. waist circumference (r ¼ 0.155. yes/no. n (%) 100 (31.0001). 95% CI. that elevations of blood pressure and blood glucose levels are the waist circumference. Journal of Epidemiology (2017). 2. p < 0.5)/19 (90. After adjusting for these factors.69.02.2) 119 (40.10e15.doi. Our recent cross- factors.64. In the univariate analysis. / Journal of Epidemiology xxx (2017) 1e9 Table 2 The differences in the lifestyle behaviors in subjects with and without CKD.6)/11 (52. 95% CI. http://dx.0) 0. and all-cause mortality was significantly LDL-C.3)/18 (85.14 also found that the accu- lifestyle with respect to habitual moderate exercise and late-night mulation of healthy lifestyle behaviors.16e13.02.27 and OR 11. et al.0)/112 (38. and other coronary risk factors at baseline.7) 3 (14. not smoking.2) 0.. respectively). The major finding of the present study was that maintaining an and bedtime snacking (all p < 0. The change in eGFR level was function.0008).0)/180 (61. yes/no.4) 0. unhealthy lifestyle with respect to habitual moderate exercise and Table 5 shows that the association between the change in eGFR late-night dinner significantly increased the incidence of CKD level and the changes in other coronary risk factors from baseline to versus maintaining a healthy lifestyle. yes/no.033). chronic kidney disease.00. waist circumference.7) 115 (39. Those authors showed that the incidence of CKD. diabetes. demonstrated that the change in eGFR level was dependently In a stepwise multiple regression analysis. and OR 5.je. while the changes in BMI. SBP. 95% CI. 1.8)/16 (76. and all- respectively). 2.7)/279 (88.6)/216 (68.38e11. especially those related to dinner resulted in a significantly higher OR for incidence of CKD habitual moderate exercise and no bedtime snacking. style behaviors and the prevention of CKD remains unclear at healthy lifestyle and maintaining an unhealthy lifestyle with present.05e13. respectively). 95% CI.57.2)/206 (69. walking speed. A sig.40 and OR 4. maintaining an unhealthy sectional and longitudinal studies13.5) 3 (14.08. the number of patients with ESRD in Japan independently associated with the changes in SBP and HbA1c level is continuously increasing according to an increase in the type 2 (r2 ¼ 0. n (%) 37 (11.27e30 We think that a similar mech- style with respect to habitual moderate exercise.24e26 Moreover.4) 183 (62. Ricardo et al31 evaluated the influence of four health life- respect to bedtime snacking also resulted in a significantly higher style factors (regular physical activity. and unhealthyeunhealthy) was a Adherence to a healthy lifestyle is well known to be related to a dependent variable. n (%) Physical activity equal to walking at least 124 (39.223.13e11. especially focusing on blood pressure and glycemic con- of changes in lifestyle behaviors (healthyehealthy.1)/123 (38. The healthy to an unhealthy lifestyle and maintaining an unhealthy change in eGFR level negatively correlated with the changes in BMI lifestyle with respect to bedtime snacking also significantly (r ¼ 0. p ¼ 0.2016. After the follow-up. maintaining an unhealthy life.1 Thus. cause mortality.9) 10 (47. In addi- nificant interaction effect for group  time was observed in the tion. n (%) Walking speed: compared with people of 193 (61.083.3) 8 (38. the change in eGFR level associated with changes in SBP and HbA1c level.2)/72 (22. healthyeunhealthy.180 Late-night dinners: 3 times/week.14e13. LDL-C. and HbA1c levels were important independent risk factors for development of renal dys- entered as independent variables. and bedtime snacking (all maintaining a healthy lifestyle (OR 4.2)/192 (60. and the incidence of CKD was an independent decreased incidence of metabolic syndrome.

4) 82.3) 124.8) 83.5 (7.2) 79. kg/m2 Waist circumference.0 (7.6) 75.5 (13.1 (6.8) 84.5) Walking speed: compared with Healthyehealthy 52.4) 84.8) 77.0 (8.3) 84.4) 80.4 (5.8) 84.1 (9.9)* 125.6) 84.9 (6.3 (10.9 (6.5 (4.6) 80.6 (7.3 (16.4) 76.9 (19.9 (18.8)* 23.2 (9.8 (8.1) 129.2) 130.9) Unhealthyehealthy 49.5) 76.3)* 82.1 (3. mm Hg DBP.9 (7.3 (9.8 (17.0 (12.1) 135.0 (3.6 (8.b.3 (7.a. eGFR.0) 81.6) with others Unhealthyehealthy 52.1 (6.6 (9.2) 84.8) 23.a.a.8)* 126.2 (2.7) 78.9 (6.9 (11.6) 22.8 (5.7) 129.1) 76.1) 81.4 (12. group  time interaction.5) 23.2 (6.3 (7.5 (2.3 (12.0 (17. 5 .4) 85.5)* 23.1) 132.3)* 82.5 (6.4 (6.6 (10.4 (13.4 (8.9 (12.0 (8.4) 131.4) 80.9 (17.3) 68.3) 24.9 (7.3 (7.6) 23.4)* 82.1 (6.5) 83.6 (8.4 (2.2 (2.1 (13.7 (11.3 (7.4) 84.2) 132.7 (2.8) 23.2) 75.7 (2.a.8 (9.5)* 23.0 (9.1 (13.3 (8.1 (12.8 (9.8)*.y 126.8) 81.8) Unhealthyeunhealthy 52. a p < 0.2 (2.7 (8.4 (6.2 (13.5 (2.3 (3.4 (2.0 (15.0 (5.6) Drinking habit Healthyehealthy 52.6 (14.0 (7.4 (10.6) Unhealthyehealthy 51.4 (2.8 (7.7 (7.8 (12.y Skipping breakfast: 3 times/week Healthyehealthy 52.4 (8.4)* Healthyeunhealthy 52.9)* 83.9) 131.0 (6.5)* Unhealthyehealthy 52.8 (7.5 (8.7) 23.3) 84.8 (13.2 (10.0)* 82.9 (2.1 (5.7) 23.a.9 (7.3 (3.73 m2 BMI.6) 82.6 (6.8) 83.6 (10.2) 82.6 (12.8 (6.7) 83.0) 79.3 (9.3 (2.7) 129.3 (8.7 (6.5 (2.y 125. b p < 0.0) 78.9) 126.5 (14.2) Physical activity equal to Healthyehealthy 53.7 (3.2) 82.5)* 125.3) 82.7) 75.9 (8.0 (2.5) Healthyeunhealthy 52.0) 75.6) 125.3) 125.2) 82.2) 84.4) 80.3) 79.7 (12.4 (8.1 (6.8) 82.1 (13.5)* 23.4 (6.0 (7.7) 81.5) 131.4 (7.05.0 (12.5 (9.8) 83.6) 81.4 (9.7) Bedtime snacking: 3 times/week Healthyehealthy 52.1 (9.5) 85.5 (12.9 (7.5) 72.2 (6.7) 23.4 (6.disease (CKD) in middle-aged and older men. mL/min/1.3 (14. Age at baseline.9) 79.0 (2.6)* 82.1 (2.0) 131.1) 85.6) 84.4 (6.9)*.1 (13.3) 125.7 (19.9 (10.9 (8.8 (9.1) 84.b 80.5 (8.4) 129.0) 79. et al.3) Late-night dinners: 3 times/week Healthyehealthy 52.3)* 23.9)* 23.5) 127.3 (2.0 (7.8) 81.7 (7.7) 125.9 (7.2 (8.5) 81. y p < 0.4 (2.6) Healthyeunhealthy 51.8 (6.6) 23.4) 83.org/10.4 (13.9 (18.0) 76.b.2 (8.9) 83.9) 81.b.2 (10.4 (6.0 (5.9 (11.4 (12.5 (18.5 (2.5) 129.2 (6.6)*.0) 74.0 (14.7)* 82.5 (12.0)* exercise: 30 min/session Unhealthyehealthy 51.4 (2.a 23.8) 74.1) 23.2 (15.2 (2.1016/j.1 (7.3 (5.5) Eating speed: compared Healthyehealthy 52.2 (2.7 (5.0 (5.9) 79.6 (12.3) 84.1) 23.9) 75.6 (5.2) 78. body mass index.8) 83.5 (6.4) 126.1 (6.7 (15.3) 23.3 (2.3 (7.1) 80.2 (3.3 (8.2 (12.5 (2.5)*.7) 22.4)* 84.5) 81.2 (6.0) 76.9) 78.1 (9. Journal of Epidemiology (2017).4) 76.6 (16.0)* 23.0 (8.8 (9.4 (9.9 (8.8) 81.6 (18.2 (7.2)* 22.y 23.5 (8.7) 86.1) 128.7) Unhealthyeunhealthy 52.5 (10.7 (7.5) 82.0) 126.6) 80.9 (10.4 (3.8) 81.1) 83.7 (18.2) 129.0 (6. eGFR.5) 79.5 (9.6) 132.3) 83.2) 79.8) 80.8) 83.6 (7.6 (3.4) 87.2) 23.1) 123.0 (7.8 (3.0) 85.4 (11.2 (2.9) 23.b Unhealthyeunhealthy 52.5) 23.0)* 84. systolic blood pressure.1 (6.6 (11.9 (8.4)* 84.1) 81.2 (7.6 (12.6) 23.0) Healthyeunhealthy 52.5) 80. *p < 0.1 (9.3) 77.2)* 124.0) 125.5 (8.7 (6.3 (14.6 (8.2) 82.9) Unhealthyeunhealthy 52.8)* 23.5 (6.6) 23.9 (2.8) 85.5 (6.9 (18.6 (13.4) 131.7) 131.4) 78.4 (8.2) 81.7 (11.0) 23.9) 74.b.2 (16.6) 130.9) 75.4 (11.6 (6.6 (7.7)* 23.6) 23.5) 86.7) 81.b.6) 83.2)* 23.0) 126.2 (2.1 (12.3 (14.3 (6. and blood pressure.0)* 82.3) 85.1) 82.5) 84.7 (10.9 (6.0) 79.4) 132.5 (2.5)* 81.7 (14.6)* 82.1 (6.2 (5. eGFR level.2)* 24.6) 80.3 (7.1 (2.5)* 83.1)* 23.0 (8.9) Unhealthyeunhealthy 52.9) 82.3) BMI. compared to the values at baseline in each group.0 (12.8 (9.8) Unhealthyeunhealthy 52.7 (14.4) 86.8 (15.0 (2.6) 124.1) 85.8)* 23.1 (7.3 (9.4 (17.8) 23.0) 82.9) 84.6) Healthyeunhealthy 52.5)* 82.4 (6.6 (8.9) 80.y 83.7) 75.4) 74.7)* 23.3)* 23.5)a.5 (7.1 (7.2 (2.2 (2.6)* 82.2) 126.4) 85.6)* 80.0) 133.7 (15.5 (5.3 (16.3)*.9 (7.6 (9.5) 80.doi.5 (18.013 Please cite this article in press as: Michishita R.7 (14.9 (6.1)* 82.0 (12.3 (6.5) 130.6 (17.1) 23.3) 84.0)a.6 (7.8 (8.0)* 23.2) 74.05.3)* 23.8) 81.6 (5.4) 78.0 (3.4 (18.7) 23.5 (2.5 (15.0 (14.4 (6.4 (15.1) 75.3 (2.0) 80.8) 23.1 (3.6 (6.2) 75.0 (6.3 (7.5)* 83.8)* 82.6) 75.1)*.7) 23.1 (7.7 (7.6)* Unhealthyehealthy 52.5)* 23.3) 76.0 (2.4 (2.4 (2.6 (17.05.5) 84.8) 83.2)* 23.8) 83.7)* 82.7 (8.9 (11.6 (14.3 (2.5) 81.1) 84.2) 127.9 (11.5 (6.4) 126.3) 80.2 (2.0 (18.3 (7.1)* 23.6) 81.9 (5.3) and 2 times/week Healthyeunhealthy 51.2 (2. Data are expressed as mean (standard deviation).5 (19.7 (4.05.9 (10. compared to the unhealthyehealthy group.4)* 82.9 (21.8 (8.7) 84.3) 23.0 (6.5 (2.y 83.3 (17.4 (6.4)* 23.8 (7.1 (6.9) 82.8 (20.2 (6.7) 84.1 (6.9)* 23.9 (14.7 (17.5) 80.1) 82.0 (6.5 (13. SBP. http://dx.5) 76.b 80.3 (9.3) 129.9) 83.2)* 24.4 (7.b.3 (7.4 (6.9 (6.6 (13.8) 81.4) 132.6 (3.4 (2. mm Hg years Baseline After Baseline After Baseline After Baseline After Baseline After Habitual moderate Healthyehealthy 53. estimated-glomerular filtration rate.1) 22.1 (6..1)* 23.3)* 23.7 (6.8)*.3 (2.5)* 82.3 (3.3) 24.3 (3.5 (9.7)* 81.8) 130.0 (7.3) Healthyeunhealthy 50.1 (5.5) 84.4) 81.a.5 (7.6 (9.8 (7.6 (7.5 (6.3 (2.7 (6.5 (9.1) 130.7) 80.8) 83.4) 83.8 (13.a.1) R.4 (12.7) Unhealthyeunhealthy 52.1)* 82.0) 81.3)* Unhealthyehealthy 51.1) Unhealthyeunhealthy 52.2)* age group Healthyeunhealthy 53.3)* 82. diastolic blood pressure.9) 82. compared to the healthyehealthy group.4) 81.0)* 23.7) 23.4 (6.7) 76.6) 79.4) 81.9) 80.9 (9.3)* 78. Michishita et al.6) 136.1)*.2) 81. anthropometric indices.5 (14.2 (12.1) 74.9 (6.9 (19.4) 76. The association between changes in lifestyle behaviors and the incidence of chronic kidney Table 3 The influence of the changes in lifestyle behaviors on age.2016.9 (14.9) 82.1) 84.0 (8.0 (8.9)* 23.9 (3.2 (19.2) 78.8) 80.2) 76.5)* 82.0)* 23.2) 84.7) Smoking habit Healthyehealthy 52.7 (7.0 (10.2 (12.4) 24.1) 83.0 (6.3)* 82.4) 133.je.4) 86.2 (3.8) 23.6 (12.5 (6.2) 79.1) 79.4) 82.3 (7.3) 127.5)a.0 (8.4) 76.9 (12.8) 83.9) 80.4) 80.5) 23.0)a. DBP.7) 23.3 (2.2) 84.0 (2.3 (3.5 (8.9 (2.1 (8.0) 126.2) 85.6 (7.9) 81.b 127.4) 81.3 (17.2 (8.2 (11.0 (10.5) 135.4 (13.1) 84.6 (8.1) 125.1 (10.6) 23.5 (7.5) 132.5 (2.6) 76.9) 81.2 (6.7)* 23.08.7 (11.2 (2.9 (9.8) 83.7) 81.0 (8.4 (4.8) 83.1) 132.1) 75.7 (5.9 (4.6) 124.5 (15.7) 131.2 (2.1) 126.3) 82.7)* 23.9) 81.9 (6.1) walking at least 1 h/day Unhealthyehealthy 52.9 (21.3 (7.3) 81.5)* 23.9 (7.6 (6.8 (3.5) 80.1) 131.7) 83.5) 75.0 (13.2 (6.5) Unhealthyeunhealthy 51.6) 127.4 (10.9 (11.7) 76.1) 75.6 (6.3 (1.0 (17.7 (2.4 (10. cm SBP. / Journal of Epidemiology xxx (2017) 1e9 people of the same sex and Unhealthyehealthy 52.4)* 82.y 23.8) 75.

6 (18.3) 117.6) Healthyeunhealthy 121.4 (0.6 (24.5) 59.4 (14.7) Unhealthyehealthy 115.9) 60.org/10.8) 108.1 (14.6 (0.2 (78. The association between changes in lifestyle behaviors and the incidence of chronic kidney Table 4 The influence of the changes in lifestyle behaviors on the blood lipid and glucose tolerance indices.2 (64.5) 5.5)* Unhealthyeunhealthy 119.5) 58.5 (76.1 (103.7) 101.7) 5.7 (0.9 (34.8 (11.8 (55.3 (26.8 (25.6 (14.3) 111.7 (23.1 (11.5) 101.1) 115.1 (9.6 (0.2 (13.2) 107.8 (22.7) 127.5 (0.9) 57.3) 97.9) 115.5) Healthyeunhealthy 118.5 (0.4 (12.3) 59.2 (19.9 (16.2 (10.4 (23.5) 5.2 (17.4 (26.3 (14.8 (69.6) 54.2) 63.5 (0.8) 58.5 (20.4) 101.6 (60.4) 121.1) 111.2) 99.0) 100.6 (28.1) 59.8) 127.9) 99.6) 5.8 (23.2) 5.5) 57.5) 61.5) Healthyeunhealthy 121.6)*.4) 59.8) 58. compared to the values at baseline in each group.9) 58.9 (16.1 (16.b Unhealthyeunhealthy 114.8) 102.1) 116.6) 5.1) 62.5) Healthyeunhealthy 123.7) 115.3 (60.4) 5.0 (13.4) 61.9) 113.1) 97.4 (0.3 (0.5 (0. mg/dL Triglyceride.5) 5.8) 133.7 (114.7) 120.1 (13.0 (15.3) 112.9) 5.2 (19.7 (0.2) 112.9) 5.3) 116.5 (15.5 (0.5) 117.5) 60.0 (27.4 (28.2 (15.2) 115. Data are expressed as mean (standard deviation).8 (13.7 (0.5 (26.6 (0. *p < 0.8 (16.6 (28.7) 55.4) 61.4 (27.5 (0.6 (0.0 (27.4 (0.0) 55.7 (0.2 (24.6 (0.9) Healthyeunhealthy 120.0 (25.1 (76.3) 56. low-density lipoprotein cholesterol.6 (24.3) 59.8 (12.4 (0.2 (125.3 (12.0 (120.0 (57.2 (27.6 (18.9 (19.9) 95.6) 5.6 (14.6) Smoking habit Healthyehealthy 119.5 (83.0 (20.1) 5.7 (74.6 (11.9 (14.3) 5.2) 118.7 (28.a.6) 54.7) 108.4 (16.9 (10.7) 5.9 (25.3) 5.6) 100.2 (17.6 (0.0) 98.6) 123.3) 123.0) 112.6) 120.7) 98.8 (30.4 (13.1) 98.2 (12.05.0 (14.3 (28.0 (11.5) 95.5) 100.4 (64.4 (15.6 (0.7) 125.7) 129.6 (11.2 (20.5) 59.4) 5.0) 122.4 (24.4 (23.3) 120.6 (25.4) 99.5 (0.3) 128.y Skipping breakfast: 3 times/week Healthyehealthy 118.y 53.6 (84.6 (11.0 (15.6 (0.5 (0.9 (54.doi. LDL-C.7 (12.3) 5.0 (28.0) 95.9) 133.7) 102.6) 5.a 55.7 (83.8 (9.8) 100.1 (30.0) 125.3 (14. et al.7) 101.3 (12.9 (29.8) 55.6 (16.6) 60.3) 57.8 (10.9 (105.6) 116.7) Unhealthyeunhealthy 114.2 (27.0) 115.0 (74.4 (13.3 (92.1 (86.6 (103.1) 5.5) 5.2 (23.6 (19. compared to the healthyehealthy group.7 (51.4) 5.8 (13.7 (13.5) 61.5) 5.6 (13.5 (0.3) 132.8) 95.2 (13.4 (77.5) Unhealthyeunhealthy 118.6) Unhealthyeunhealthy 115.4) 133.4) 58.2) 116.6) 5.7 (15.1 (12.2 (18.1 (18.9 (20.1 (10.5) 122.5) 5.0) 57.6) Drinking habit Healthyehealthy 118.5 (0.5 (102.3 (25.6) 55.je.5 (0.3) 114.2) 60.6 (27.1) 5.0) 57.7 (15.9) 56.6 (12.3) 99.0) 103.8 (16.7) 110.8) 57.3 (85.1 (17.6) 99.8) least 1 h/day Unhealthyehealthy 117.7 (93.5 (29.2) 101.7 (0.5) 5.8) 123.5 (0.5) 102.7) 5.9) 99.6 (0.6 (14.3) 131.9 (12.9) 123.2 (27.0 (18.8 (29.4) 5.8) 131.8 (15.7 (14.1) 58.3 (15.8) 98.6 (0.8) 109.7) 54.3) 58.6 (0.7 (27. high-density lipoprotein cholesterol.5) 5.6 (15.5 (21.4) 110.2) 113.5) 116.9) 114.1 (67.7 (76.5 (0. . LDL-C.4) 109.5) 5.9 (5.9 (21.7 (12.4) 119.7) Unhealthyeunhealthy 121.6 (106.4 (14.9 (25.7) 100.8 (17.3) 124.4 (16.0) 107.2 (17.5)* Healthyeunhealthy 119.8) 58.2 (34.5 (23.6 (0.8) 58.3 (27.6 (10.5) 5.6 (13.3) 5.0 (87.7) 121.3 (64.5 (56.a.5) 54. / Journal of Epidemiology xxx (2017) 1e9 the same sex and age group Unhealthyehealthy 114.3 (14.1 (54.6) 5.3 (125.6)*.9 (15.4) 5.5 (20.3 (78.0) 102.3 (19.b.0 (21..8 (68.7) Unhealthyehealthy 114.1) 59.4 (13. group  time interaction.7) 5.5 (16.2 (25.8) 52.6 (0. NGSP % Baseline After Baseline After Baseline After Baseline After Baseline After Habitual moderate exercise: 30 min/session Healthyehealthy 116.6 (0.3 (26. http://dx.7) 120.0) 98.8) 57.5 (123.6 (0. Michishita et al.0) 100.6 (0.3 (16.5 (14.3)*.5) 100.8) 101. Journal of Epidemiology (2017).3 (26.6 (0.2) 131.5 (24.7) R.a Unhealthyeunhealthy 119.4) 5.9 (75.0) 59.9) 111.0) 58.7) 5.1) 5. mg/dL Fasting glucose.6 (26.7) 100.7 (19.7)*.4 (0.1 (81.7 (31.0 (13.5) 96.3 (14.5 (0.3 (12.3) 97.4) 122.7) 96.b.5 (16.9) 97.5 (0.1 (10.7) 100. mg/dL HDL-C.2) 97.3 (10.4) 5.8) Unhealthyehealthy 120.2) 101.5) 101.2) 98.9) 126.4)* Unhealthyeunhealthy 119.4 (0.4) 99.3) 149.4 (27.7 (73.8) 111.6) 116.4 (0.4) 5. hemoglobin A1c.9 (85.1 (13.3) 56.3) 98.5 (0.7 (0.05.2 (12.3) 120.0) 104.7) 98.6 (19.3) 5.0) 56.6) 102.9 (17.6 (0.3) 126.1 (64.7) 5.0) 5.2 (26.2) 109.1016/j.9 (121.0 (28.0 (24.1 (77.4) 128.6 (84.6) 5.5 (89.8) and 2 times/week Unhealthyehealthy 120.3) 100.8) 58.9 (69.3 (65.0) 101.5) 114.5) 109.6 (0.5 (0.6) 97.05. mg/dL HbA1c.0) 5. a p < 0.3 (8.7 (22.1) 102.2 (15.5) 114.5) 113.5 (0.2) 99. national glycohemoglobin standardization program.6 (55.2 (12. NGSP.3) 102.7 (21.6 (80.1 (24.2) 124.4) 57.5) 5.1) 97.1) 99.8) 121.4) 117.4 (21.1) 57.9 (15.4 (58.4) 109.9) 55.7) 120.3 (59.6) Healthyeunhealthy 123.7 (17.9 (17.6) Bedtime snacking: 3 times/week Healthyehealthy 118.2 (62.7 (17.8 (81.7) Unhealthyehealthy 118.6) 56.2) 123.6 (26.0) 5.9 (11.6 (0.3)* 5.0 (95.8)a.5 (0.8) 113.2) 119.3 (66.3 (26.5) 5.4) 129.7 (20.6) 5.4) 139.3) 138.6) 118.2 (29.2 (23.4) 121.9 (19.1 (14.9) 5.4) 5.4 (89.9 (15.9) 113.5) 122.0) 124.7) 5.2 (20.8) Unhealthyehealthy 117.3 (25.9 (24.3) 5.8) 98.8 (27. 6 disease (CKD) in middle-aged and older men.5 (0.4 (76.2016.7) Healthyeunhealthy 115.9 (80.6) 5.4) 104.8 (0.5 (0.5 (0.4) 124.3 (20.6 (76.8 (14.1 (26.6) Late-night dinners: 3 times/week Healthyehealthy 120.6 (63.8 (26.6) 5.7 (0.4) 116.5) 119.7) 128.6) 59.5) 57.1) 101.3) 100.013 Please cite this article in press as: Michishita R.6 (64. y p < 0.5 (0.6 (0.3 (73.7) 5. b p < 0.6) 5.6) 5.2) 132.6) 5.8 (29.9) 5.3) 98.08.7 (0.0) 61.1) 120.0) 59.1 (25.7)* Unhealthyehealthy 123.8 (0.05.4) 5.9 (63.5) 5.5) 54.5) 124.4) 96.0) 56.4) 58.6 (0.5 (71.5) 119.0) 5.3) 107.3 (13.4) 124.7) HDL-C.6 (29.1 (14.4) 103.1) 59.7) 99.8 (14.8 (11.6 (0.2) 118.9 (16.3 (13.3 (13.0) 58.0 (12.4 (14.3) 123.y Walking speed: compared with people of Healthyehealthy 120.7 (27.8) 60.2) 119.4) 56.4) 60.4 (121.8 (32.2) 100. compared to the unhealthyehealthy group.1 (27.6 (16.8 (32.1 (13.6) 5.5) 54.8)a.5 (11.6) Unhealthyeunhealthy 115.5 (0.3) 115.2) 100.4 (10.3) 5.9 (21.3 (13.6) 98.7) 122.5) 5.5 (14.7) 5.2) 99.6 (0.6) 60.9) 120.7) Physical activity equal to walking at Healthyehealthy 115.7 (0.1) 99.6) Eating speed: compared with others Healthyehealthy 116.5) 5.6 (0.0) 100.5 (77.0 (15.5) 5. HbA1c.7 (65.5 (0.0) 56.3 (13.6 (0.

7e12 Therefore.013 . the ables: the changes in BMI. / Journal of Epidemiology xxx (2017) 1e9 7 Table 5 unhealthy one with respect to habitual moderate exercise and The association of the change in eGFR level and the changes in other coronary risk healthy eating style may be important to prevent the incidence factors calculated using simple regression analysis. SBP. findings which are consistent lifestyle behaviors on the renal dysfunction. and bedtime snacking were D Waist circumference 0.doi. http://dx. estimated-glomerular this study. although the serum Cr and eating styles related to the development of renal dysfunction.19.0001 metabolic syndrome. late-night dinner and bedtime snacking. hemoglobin A1c. bedtime snacking. SBP. patients with ESRD. eating late-night dinner.34e36 The Framingham Heart Study37 findings. low-density lipoprotein cholesterol. level can be easily measured as part of a routine clinical evalua- For example. including subjects with other snacks beyond the three main meals (breakfast. Please cite this article in press as: Michishita R. These nisms underlying this association and the clinical implications of studies suggest that maintaining a healthy lifestyle or improving an long-term intervention. Given the present reduced renal function.261 <0. hemoglobin A1c. and dyslipi- D DBP 0. To fully clarify the influence of changes in maintaining an unhealthy lifestyle. practicing lifestyle intervention to prevent renal dysfunction. of CKD. styles. First. eGFR. As such. and dinner) complications. it has been et al33 demonstrated that high levels of physical activity and low observed that the development of CKD is also closely related to levels of sitting time are related to a lower prevalence of CKD.032 associated with mortality and the incidence/prevalence of CVD.20 On the basis of recent several studies. The change in eGFR was entered to women. LDL-C. Therefore.5% per year. and soft drinks has been reported to lead to prevent the development of CVD and ESRD. should be concurrently evaluated.120 0.org/10. HbA1c. low-density lipoprotein cholesterol. waist circumference. such as urinary protein excretion.121 0.223 0.155 0.2016. whether or not our results are generalizable Data are expressed as the coefficient of correlation. et al. our results suggest a clear link between muscular function. the assessed the eGFR as calculated using the CKD-EPI equations incidence of CKD was reduced among subjects who maintained a (modified by a Japanese coefficient17) and proteinuria as markers healthy lifestyle or improved an unhealthy one compared to of the renal function. body mass index. unable to measure any additional indices of renal function because ESRD. systolic blood pressure. current research was evaluated within the constraints of the In the present study. as well as the risk of introduction of D Fasting glucose 0. Data are expressed as the coefficient of correlation.39 Our results demonstrated that the lack of habitual D LDL-C 0. DBP. Therefore.0008 the evaluation of healthy lifestyle behaviors. Further tion. The following factors were entered as independent vari- tions remains unclear. and bedtime snacking D Triglyceride 0. in. or possibility that maintaining a healthy lifestyle or improving an cystatin C.279 dialysis in middle-aged and older men. Similarly. A few studies recently demonstrated that taining a healthy lifestyle or improving an unhealthy one can individual lifestyle behaviors relating to exercise. Second. improving an unhealthy one with respect to habitual moderate However.223 <0. who were D SBP 0. There are several limitations in this study. or subjects with other complica- as a dependent variable. and bedtime snacking was correlated first to elucidate the relationship with the changes in lifestyle with the incidence of CKD.je.006 D HDL-C 0. systolic blood pressure. Robinson-Cohen et al32 reported that each 60. with a particular focus BMI. HDL-C. as study subjects may have included more CKD subjects filtration rate. the present study is the exercise. unhealthy eating styles. diastolic blood pressure. and CVD. sodium. Thus. In our results. Additionally. is required to more precisely clarify the mecha- was related to an elevated risk of developing type 2 diabetes. obesity. LDL-C and HbA1c levels. maintaining a healthy lifestyle or health check-up. high-density lipoprotein cholesterol. Michishita et al. Coefficient of correlation p value Several prior studies have reported that lack of habitual mod- D BMI 0. we were unhealthy one is important to prevent the development of CKD.083 <0. Bharakhada Cr level. we predictive factors for the incidence of CKD. there is potential selection bias in BMI. the limited b r2 p value study population resulted in a small number of subjects. However. causality of proteinuria or microalbuminuria and the changes in other cardiovascular risk factors could not be clarified because the number of subjects with proteinuria was small. R.1016/j. However..031 0.36. We believe that our results support the notion that main- the development of CKD. tion. diastolic blood pressure. Journal of Epidemiology (2017). our current findings support the function. The association between changes in lifestyle behaviors and the incidence of chronic kidney disease (CKD) in middle-aged and older men. deterioration.136 health complications. hypertension.0001 demia. lunch. other markers of renal with those of prior research. DBP. cardiovascular function. with slowly declining renal function than CKD subjects with rapid SBP. such as smoking. such as avoiding no late-night dinner and no is associated with a decreased risk of incidence of renal dysfunc. body mass index. heavy alcohol dependent of other risk factors. walking capacity. microalbuminuria. unfortunately.061 0. estimated glomerular on regular exercise habit and healthy eating styles. and an unhealthy eating that aerobic exercise intervention can improve aerobic capacity. A previous meta-analysis10 showed intake. unhealthy lifestyles behaviors. the eGFR is a strong predictive factor of future incidence of min increase in weekly physical activity was associated with an CVD and ESRD and is more useful for this purpose than the serum annual eGFR reduction of 0.060 0. eGFR. the development of CKD and support the hypothesis that main- Furthermore. no significant associations behaviors and the incidence of CKD in a long-term follow-up were noted between the changes in other lifestyle behaviors and study.033 erate exercise. D SBP 0. Finally. type 2 diabetes. such as avoiding filtration rate.291 may increase the risk of CKD.188 0. prevent the incidence of CKD. Mekary et al38 demonstrated the consuming investigation in a larger population. we believe that D HbA1c 0. such as high intake of dietary taining a healthy lifestyle or improving an unhealthy one helps to animal fat. to reduce the development of CKD. we consider that lifestyle intervention should be pro- examined the association between lifestyle characteristics and vided.583 moderate exercise. eating late-night dinner.0001 predominantly middle-aged and older men and did not have any D HbA1c 0. in this study. are important when LDL-C. DBP. physical activity. late-night dinner.08. HbA1c. Table 6 Study limitations and clinical implications The association of the change in eGFR level and the changes in other coronary risk factors determined using stepwise multiple regression analysis. particularly with a focus on regular exercise habit and the incidence of renal dysfunction and found that better diet quality healthy eating styles. and maintaining a healthy lifestyle or improving an unhealthy one and health-related quality of life in patients with CKD and dialysis. Furthermore. lack of exercise habit. despite these limitations.

994 0.96) 0.11) 0.0) 3.00 (Ref. Eiichi Yoshimura.9) 0.82e11.3) 0. eGFR.83 (0.97) 0.96) 0.77e9.52) 0.289 Unhealthyeunhealthy 160 15 (9. Clin Exp Nephrol.8) 1.16 (1.724 Unhealthyeunhealthy 12 1 (8.pdf. Gullion CM. so that they may reduce the 2015 [in Japanese].263 3.8) 2.) e walking at least 1 h/day Unhealthyehealthy 46 3 (6. eating late-night dinner. Horio M.49e9.532 2.jp/overview/pdf2014/p003.org/10. Imai E. http://docs.00 (Ref.5) 1.040 Physical activity equal to Healthyehealthy 82 2 (2. systolic blood pressure. et al. LDL-C. and hospitalization.45e8.002 4.190 0.94 (1.351:1296e1305. 2.15e2.00 (Ref.15e1. Conclusions the members of the Laboratory of Exercise Physiology and Health Care Center of Fukuoka University for their help with the data This retrospective study assessed the relationship between evaluation. Chronic kidney disease and the risks of death.45e13.96) 0.0001 11. Masaki Munekiyo.42) 0.4) 1.25) 0.06e6. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large None declared.0001 Skipping breakfast: 3 times/week Healthyehealthy 266 18 (6. Please cite this article in press as: Michishita R.40) 0.84) 0.13 (0.290 0.011 Bedtime snacking: 3 times/week Healthyehealthy 257 9 (3.69e12.07 (0.229 Unhealthyeunhealthy 146 13 (8.) e exercise: 30 min/session Unhealthyehealthy 39 2 (5.0) 1.53e9. We observed that maintaining an unhealthy Institute for Physical Activity via a Technology Scientific Research lifestyle with respect to habitual moderate exercise.00 (Ref.) e 1.75) 0.36:646e661.32) 0.48 (0. BMI.69 (0.) e Unhealthyehealthy 40 3 (7.117 3. Prevalence of chronic kidney disease (CKD) in the Japanese general population predicted by the NDRD equation modified by a Acknowledgments Japanese coefficient.264 1.60) 0.00 (Ref.15e10. CKD. Fan D.00 (Ref. et al.87) 0.14e4.69) 0.01e2. Preserving renal function in adults with hypertension and diabetes: a consensus approach.78) 0. Keith DS.13 (0.62 (0. managed care organization.521 Healthyeunhealthy 18 1 (5.00 (Ref.02 (2.2) 1. Brown JB. chronic kidney disease.89 (1.21e5.07e4.51 (0.13e11.9) 0.66 (0.) e Unhealthyehealthy 43 3 (7.888 Healthyeunhealthy 21 1 (4.) e 1. 2007.18) 0.05 (2.08 (1. and the incidence of CKD was an independent variable.03e4.89e8.00 (Ref.08.00 (Ref.17 (0.88 (0.05e13. Accessed 2 December night dinner or bedtime snacking.16e13.554 Unhealthyeunhealthy 41 3 (4. We are grateful to the participants of this study.21) 0.06e5.93 (2.74 (0.03) 0.doi.29) 0. and bedtime snacking may increase the risk of References CKD.74 (0. Dworkin L.80) 0.37 (0.54 (0.9) 1.310 and 2 times/week Healthyeunhealthy 34 3 (8.5) 0.43) 0.45 (0.) e 1. A19200049.164:659e663. Nichols GA.24e6.63e13.5) 1. and bedtime snacking resulted in significantly higher OR Infrastructure) from the Japanese Government's Ministry of Edu- of incident CKD compared to maintaining a healthy lifestyle.027 8.89e12.377 Healthyeunhealthy 33 3 (9.0) 0.190 3.14) 0.5) 2.52e8. age.114 Eating speed: compared with others Healthyehealthy 174 7 (4.5) 1.660 0. LDL-C. The Japanese Society for Dialysis Therapy.66) 0.91 (0. This changes in lifestyle behaviors and the incidence of CKD in middle.57) 0.99 (0. 4. HbA1c. body mass index. confidence interval. Smith DH.69) 0.8) 5. Conflicts of interest 3. late-night Budget Basic Research Grant (No.388 0.8) 0.397 4.66e11.) e 1. Kazunori Mine.69e12.11e6.43 (0.0) 6. HbA1c.) e Unhealthyehealthy 17 1 (5.05e4. 2004. Go AS.27) 0.56e11.1) 3.20) 0.323 1. low-density lipoprotein cholesterol.414 2.95) 0. Tatsuhiko Hypertension and Diabetes Executive Committees Working Group.236 2.2016.15e2. McCulloch CE..30e6. it is important for middle-aged and older Japanese men to engage in habitual moderate exercise and to avoid late.57 (0.1) 2. estimated-glomerular filtration rate.) e people of the same sex and age group Unhealthyehealthy 41 3 (7.38) 0.6) 0.540 1. 1.013 .10e15. Michishita et al.17 (0.28e9. the changes in lifestyle behaviors were dependent variables. waist circumference. and eGFR levels at baseline were entered as adjusted factors. et al.54) 0.) e 1.68) 0.03) 0. CI.02) 0.71) 0.0) 1.or.33e10.21e9.97 (0.00 (Ref. Journal of Epidemiology (2017). Total Developed CKD.60e9.4) 1.40) 0. http://dx.41e6.00 (Ref.2) 1.3) 13.66 (0.63) 0.34) 0.86 (0.45e12.8 R.51e9. Therefore.00 (Ref.) e 1.298 1.14e13.79) 0.00 (Ref. Strategic Research dinner.032 2.097 Late-night dinners: 3 times/week Healthyehealthy 182 7 (3.79e8. These cation.69 (0.83e26. n (%) Univariate model Multivariate model Odds ratio (95% CI) p value Odds ratio (95% CI) p value Habitual moderate Healthyehealthy 83 1 (1.25 (0.47 (0.179 2.006 4.96) 0. SBP.078 Walking speed: compared with Healthyehealthy 148 5 (3.09e5. 2004.833 Smoking habit Healthyehealthy 250 18 (7.15e1.04) 0.4) 6.) e 1.78) 0.00 (1.231 2. N Engl J Med.) e Unhealthyehealthy 17 1 (5.) e Unhealthyehealthy 46 3 (6.23) 0.3) 1. Arch Intern Med.10) 0.38e11.19 (0.jsdt. diastolic blood pressure.271 Healthyeunhealthy 42 3 (7.57) 0. Noriko Takeda. cardiovascular events. Sports.17e5.60 (0.44 (1.48 (0.00 (Ref.61e10. Science and Technology.51 (0.17 (0.00 (Ref. DBP.77 (0.00 (Ref.5) 2.1016/j.46 (0. Tomoe Horita and Dis.09 (0.8) 4. / Journal of Epidemiology xxx (2017) 1e9 Table 7 The influence of the changes in lifestyle behaviors on the incidence of CKD.116 BMI.97e23. In this analysis. 5. risk of dialysis therapy.) e 1. results suggest that the lack of habitual moderate exercise.33 (0.25) 0.003 Unhealthyeunhealthy 21 7 (33. Chertow GM. In the multivariate model.609 Healthyeunhealthy 21 4 (19. Current Status of Dialysis Therapy in Japan.1) 2.705 0. The association between changes in lifestyle behaviors and the incidence of chronic kidney disease (CKD) in middle-aged and older men.87) 0.476 Unhealthyeunhealthy 206 11 (5.19) 0.57 (0. SBP.47) 0.89) 0.29 (0.109 Unhealthyeunhealthy 82 8 (9.591 1.00 (Ref.45e7.50 (0.202 Unhealthyeunhealthy 58 8 (13.63 (0.094 Unhealthyeunhealthy 76 8 (10. work was performed with the support of the Fukuoka University aged and older men.46e7.78 (0.9) 4. Williams M.279 Healthyeunhealthy 45 5 (11.64) 0. National Kidney Foundation We thank Drs. Culture.474 Healthyeunhealthy 20 3 (15.je.00 (Ref.588 Drinking habit Healthyehealthy 52 6 (11. Am J Kidney Kawarabayashi.81 (0.11:156e163. 2000.764 0. Hsu CY.8) 1.52) 0.1) 3. hemoglobin A1c.3) 3.) e 1. Bakris GL. Iseki K. DBP.20 (0.92e12.) e Unhealthyehealthy 25 0 (4.

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