The Scientific World Journal
Volume 2012, Article ID 379752, 14 pages
doi:10.1100/2012/379752
The cientificWorldJOURNAL
Research Article
eVITAL: A Preliminary Taxonomy and Electronic Toolkit of
Health-Related Habits and Lifestyle
Luis Salvador-Carulla,1, 2 Carolyn Olson Walsh,3 Federico Alonso,1, 2 Rafael Gómez,1
Carlos de Teresa,1 José Ricardo Cabo-Soler,1 Antonio Cano,1 and Mencı́a Ruiz2
1 Asociación Española para el Estudio Cientı́fico del Envejecimiento Saludable (AECES), Calle Infante Don Fernando 17,
Málaga, 29200 Antequera, Spain
2 Asociación Cientı́fica PSICOST, Plaza de San Marcos 6, 11403 Jerez, Spain
3 Harvard Medical School, c/o Peabody Society, 260 Longwood Avenue, Boston, MA 02115, USA
Correspondence should be addressed to Luis Salvador-Carulla,
Received 14 October 2011; Accepted 28 November 2011
Academic Editor: Javier Garcia Campayo
Copyright © 2012 Luis Salvador-Carulla et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Objectives. To create a preliminary taxonomy and related toolkit of health-related habits (HrH) following a person-centered
approach with a focus on primary care. Methods. From 2003–2009, a working group (n = 6 physicians) defined the knowledge base,
created a framing document, and selected evaluation tools using an iterative process. Multidisciplinary focus groups (n = 29 health
professionals) revised the document and evaluation protocol and participated in a feasibility study and review of the model based
on a demonstration study with 11 adult volunteers in Antequera, Spain. Results. The preliminary taxonomy contains 6 domains
of HrH and 1 domain of additional health descriptors, 3 subdomains, 43 dimensions, and 141 subdimensions. The evaluation
tool was completed by the 11 volunteers. The eVITAL toolkit contains history and examination items for 4 levels of engagement:
self-assessment, basic primary care, extended primary care, and specialty care. There was positive feedback from the volunteers
and experts, but concern about the length of the evaluation. Conclusions. We present the first taxonomy of HrH, which may aid the
development of the new models of care such as the personal contextual factors of the International Classification of Functioning
(ICF) and the positive and negative components of the multilevel person-centered integrative diagnosis model.
1. Introduction in investigative or clinical intervention in multiple behavior
change are unknown [7].
Noncommunicable diseases cause 6 out of 10 deaths, and The developing field of longevity medicine takes a
cardiovascular disease alone causes 31.5% of deaths in female holistic view of health that calls for integrative evaluation of
and 26.8% in males [1]. Many of the leading causes of death health-related habits (HrHs), both those that increase and
have evidence-based modifiable risk factors [2–4], but this decrease risk of disease and those related to general health
does not always translate to healthy behavior by individuals. and well-being, considering the endpoint of years lived
Several studies have shown that risk of mortality or disease without disability and taking into account a person-centered
decreases stepwise based on the number of healthy habits approach [8]. Taxonomies are particularly important in
practiced by an individual [5, 6]. In spite of the fact that developing fields of study in that they standardize terminol-
major chronic diseases are caused by multiple risks, which ogy and allow for common understanding of research results;
when combined are associated with health outcomes, the recently proposed examples include the fields of adverse drug
science of multiple health behavior change and assessment is reactions [9] and patient-initiated medical errors [10]. In
at an early stage, and factors that facilitate or impede success the current study, we present a preliminary taxonomy for
, 2 The Scientific World Journal
Table 1: Metabolic classification based on body mass index and 3. Results
physical activity (eVITAL).
3.1. Domains and Dimensions. The working group and
Body mass index (BMI) Physical activity experts revised 7 proposed domains (physical activity,
(a) Underweight (BMI <18.5) (i) Sedentary diet, cognition, sleep, stress, psychosocial vitality, and risk
(ii) Daily activity, no behaviors) into the final 6 HrH domains by combining
(b) Normal weight (BMI 18.5–25)
purposeful exercise vitality and stress into a single domain combining physical
(c) Overweight (BMI 25–30) (iii) Regular exercise activity and diet into one domain, and dividing “other risk
(d) Obese (BMI >30) (iv) Very active behaviors” into the two domains of substance use and other
risk habits (Table 2); the domains of cognition and sleep
were unchanged. After discussion regarding the placement
HrH, as well as the Spanish version of the eVITAL toolkit for of sexuality within the hierarchy, it was decided that, while
clinical evaluation of the lifestyle and related determinants of important for quality of life, sexuality does not meet all
longevity of an individual. of the criteria for domains in terms of contributing to
years lived without disability; it was therefore included as a
subdimension within the vitality and stress domain. Despite
2. Methods the initial intention to only include evaluation of HrH, the
Methods and ethics are described in detail elsewhere [11]. working group decided that the clinical utility of the toolkit
In short, the taxonomy and the related eVITAL toolkit were would be increased by including an assessment of other
created using a nominal group technique involving a core determinants and conditions of health specifically related to
group of 6 physicians with expertise in various aspects of each basic HrH.
longevity medicine and 29 health professionals, including The panel suggested creating an overarching “health
physicians, nurses, and psychologists, in a series of four lifestyle profile,” with 6 subprofiles related to the 6 basic
multidisciplinary focus groups. The model used in the HrHs. A seventh domain, “Health descriptors,” includes
creation of the taxonomy was adapted from the International generic descriptors of health related to longevity, such as
Classification of Functioning, Disability and Health (ICF) social and medical determinants of health and current status
[12] and other documents by the World Health Organization of health.
(WHO) [13–15], as well as the multilevel person-centered The complete taxonomy developed through this process
integrative diagnosis model [16], and the transtheoretical is shown in Table 3. The preliminary taxonomy includes
model of stages of change [17] and related model of 6 domains or classes (with diet/exercise further divided
multibehavior change [18]. According to the ICF a “domain” into three subdomains: generic, diet, and exercise), 43
is “a practical and meaningful set of related physiological dimensions or subclasses, and 141 subdimensions. Once
functions, anatomical structures, actions, tasks, or areas of the preliminary taxonomy was defined, codes were assigned
life” [12]. “Dimensions” are the identifiable components of to each entity and subentity following a hierarchical tree
every domain. In some cases mutually exclusive domains structure. Letters code the main branches or domains:
could not be categorized and subdomains had to be defined cognition (c), vitality/stress (v), sleep (s), diet/exercise (de),
(see below). substance use (s), and other risk habits (r). Each letter is
Entities were organized hierarchically into constructs, followed by a number for the branches, or dimensions,
domains, subdomains, dimensions, subdimensions, and in- except for the Prochaska stage of change which is coded
dividual items, and codes were assigned using a hierarchical within each domain by the letter “s” (see Table 3). The
tree. In this conceptual model, health behaviors are part of complete evaluation schema is shown in Table 4; the toolkit
HrH, complex behavioral patterns which are closely related is available online at http://www.longevidad.org/.
to other determinants of health as well as to specific health Regarding cognition, the working group and expert pan-
conditions. HrH are in turn part of the health lifestyle, which els included evaluation tools related to intellectual reserve
is a key component of the “personal factors” defined in the or to a higher vulnerability to problems with memory or
ICF. These personal factors “are the particular background other higher cognitive functions. Tools were selected for
of an individual’s life and living,” and these factors comprise, the vitality and stress domain to evaluate psychological and
among others, “fitness, lifestyle, habits . . . overall behaviour social characteristics that are associated with longevity or an
pattern and character style, individual psychological assets improved response to stress and illness. The group decided
and other characteristics, all or any of which may play a role to include a biologic dimension to this domain due to the
in disability at any level” [12]. evidence linking stress to these components of allostatic
A demonstration study was performed with 11 adult load [55]. It was decided that, while diet and exercise have
volunteers who completed the evaluation package followed traditionally been considered separate domains, there is
by an open-ended feedback questionnaire. The assessment sufficient overlap in evaluation, clinical consequences, and
package was then revised and computerized, the experts intervention strategies that they should be combined. For
involved in the focus groups evaluated the feasibility of the example, both diet and exercise affect body mass index,
online toolkit using the criteria of applicability, acceptability, which can be combined with activity level to form 16
and practicality [54], and responses were used to further metabolic types (Table 1). For substance use, the group
refine eVITAL. considered 3 categories: substances that are always harmful
Volume 2012, Article ID 379752, 14 pages
doi:10.1100/2012/379752
The cientificWorldJOURNAL
Research Article
eVITAL: A Preliminary Taxonomy and Electronic Toolkit of
Health-Related Habits and Lifestyle
Luis Salvador-Carulla,1, 2 Carolyn Olson Walsh,3 Federico Alonso,1, 2 Rafael Gómez,1
Carlos de Teresa,1 José Ricardo Cabo-Soler,1 Antonio Cano,1 and Mencı́a Ruiz2
1 Asociación Española para el Estudio Cientı́fico del Envejecimiento Saludable (AECES), Calle Infante Don Fernando 17,
Málaga, 29200 Antequera, Spain
2 Asociación Cientı́fica PSICOST, Plaza de San Marcos 6, 11403 Jerez, Spain
3 Harvard Medical School, c/o Peabody Society, 260 Longwood Avenue, Boston, MA 02115, USA
Correspondence should be addressed to Luis Salvador-Carulla,
Received 14 October 2011; Accepted 28 November 2011
Academic Editor: Javier Garcia Campayo
Copyright © 2012 Luis Salvador-Carulla et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Objectives. To create a preliminary taxonomy and related toolkit of health-related habits (HrH) following a person-centered
approach with a focus on primary care. Methods. From 2003–2009, a working group (n = 6 physicians) defined the knowledge base,
created a framing document, and selected evaluation tools using an iterative process. Multidisciplinary focus groups (n = 29 health
professionals) revised the document and evaluation protocol and participated in a feasibility study and review of the model based
on a demonstration study with 11 adult volunteers in Antequera, Spain. Results. The preliminary taxonomy contains 6 domains
of HrH and 1 domain of additional health descriptors, 3 subdomains, 43 dimensions, and 141 subdimensions. The evaluation
tool was completed by the 11 volunteers. The eVITAL toolkit contains history and examination items for 4 levels of engagement:
self-assessment, basic primary care, extended primary care, and specialty care. There was positive feedback from the volunteers
and experts, but concern about the length of the evaluation. Conclusions. We present the first taxonomy of HrH, which may aid the
development of the new models of care such as the personal contextual factors of the International Classification of Functioning
(ICF) and the positive and negative components of the multilevel person-centered integrative diagnosis model.
1. Introduction in investigative or clinical intervention in multiple behavior
change are unknown [7].
Noncommunicable diseases cause 6 out of 10 deaths, and The developing field of longevity medicine takes a
cardiovascular disease alone causes 31.5% of deaths in female holistic view of health that calls for integrative evaluation of
and 26.8% in males [1]. Many of the leading causes of death health-related habits (HrHs), both those that increase and
have evidence-based modifiable risk factors [2–4], but this decrease risk of disease and those related to general health
does not always translate to healthy behavior by individuals. and well-being, considering the endpoint of years lived
Several studies have shown that risk of mortality or disease without disability and taking into account a person-centered
decreases stepwise based on the number of healthy habits approach [8]. Taxonomies are particularly important in
practiced by an individual [5, 6]. In spite of the fact that developing fields of study in that they standardize terminol-
major chronic diseases are caused by multiple risks, which ogy and allow for common understanding of research results;
when combined are associated with health outcomes, the recently proposed examples include the fields of adverse drug
science of multiple health behavior change and assessment is reactions [9] and patient-initiated medical errors [10]. In
at an early stage, and factors that facilitate or impede success the current study, we present a preliminary taxonomy for
, 2 The Scientific World Journal
Table 1: Metabolic classification based on body mass index and 3. Results
physical activity (eVITAL).
3.1. Domains and Dimensions. The working group and
Body mass index (BMI) Physical activity experts revised 7 proposed domains (physical activity,
(a) Underweight (BMI <18.5) (i) Sedentary diet, cognition, sleep, stress, psychosocial vitality, and risk
(ii) Daily activity, no behaviors) into the final 6 HrH domains by combining
(b) Normal weight (BMI 18.5–25)
purposeful exercise vitality and stress into a single domain combining physical
(c) Overweight (BMI 25–30) (iii) Regular exercise activity and diet into one domain, and dividing “other risk
(d) Obese (BMI >30) (iv) Very active behaviors” into the two domains of substance use and other
risk habits (Table 2); the domains of cognition and sleep
were unchanged. After discussion regarding the placement
HrH, as well as the Spanish version of the eVITAL toolkit for of sexuality within the hierarchy, it was decided that, while
clinical evaluation of the lifestyle and related determinants of important for quality of life, sexuality does not meet all
longevity of an individual. of the criteria for domains in terms of contributing to
years lived without disability; it was therefore included as a
subdimension within the vitality and stress domain. Despite
2. Methods the initial intention to only include evaluation of HrH, the
Methods and ethics are described in detail elsewhere [11]. working group decided that the clinical utility of the toolkit
In short, the taxonomy and the related eVITAL toolkit were would be increased by including an assessment of other
created using a nominal group technique involving a core determinants and conditions of health specifically related to
group of 6 physicians with expertise in various aspects of each basic HrH.
longevity medicine and 29 health professionals, including The panel suggested creating an overarching “health
physicians, nurses, and psychologists, in a series of four lifestyle profile,” with 6 subprofiles related to the 6 basic
multidisciplinary focus groups. The model used in the HrHs. A seventh domain, “Health descriptors,” includes
creation of the taxonomy was adapted from the International generic descriptors of health related to longevity, such as
Classification of Functioning, Disability and Health (ICF) social and medical determinants of health and current status
[12] and other documents by the World Health Organization of health.
(WHO) [13–15], as well as the multilevel person-centered The complete taxonomy developed through this process
integrative diagnosis model [16], and the transtheoretical is shown in Table 3. The preliminary taxonomy includes
model of stages of change [17] and related model of 6 domains or classes (with diet/exercise further divided
multibehavior change [18]. According to the ICF a “domain” into three subdomains: generic, diet, and exercise), 43
is “a practical and meaningful set of related physiological dimensions or subclasses, and 141 subdimensions. Once
functions, anatomical structures, actions, tasks, or areas of the preliminary taxonomy was defined, codes were assigned
life” [12]. “Dimensions” are the identifiable components of to each entity and subentity following a hierarchical tree
every domain. In some cases mutually exclusive domains structure. Letters code the main branches or domains:
could not be categorized and subdomains had to be defined cognition (c), vitality/stress (v), sleep (s), diet/exercise (de),
(see below). substance use (s), and other risk habits (r). Each letter is
Entities were organized hierarchically into constructs, followed by a number for the branches, or dimensions,
domains, subdomains, dimensions, subdimensions, and in- except for the Prochaska stage of change which is coded
dividual items, and codes were assigned using a hierarchical within each domain by the letter “s” (see Table 3). The
tree. In this conceptual model, health behaviors are part of complete evaluation schema is shown in Table 4; the toolkit
HrH, complex behavioral patterns which are closely related is available online at http://www.longevidad.org/.
to other determinants of health as well as to specific health Regarding cognition, the working group and expert pan-
conditions. HrH are in turn part of the health lifestyle, which els included evaluation tools related to intellectual reserve
is a key component of the “personal factors” defined in the or to a higher vulnerability to problems with memory or
ICF. These personal factors “are the particular background other higher cognitive functions. Tools were selected for
of an individual’s life and living,” and these factors comprise, the vitality and stress domain to evaluate psychological and
among others, “fitness, lifestyle, habits . . . overall behaviour social characteristics that are associated with longevity or an
pattern and character style, individual psychological assets improved response to stress and illness. The group decided
and other characteristics, all or any of which may play a role to include a biologic dimension to this domain due to the
in disability at any level” [12]. evidence linking stress to these components of allostatic
A demonstration study was performed with 11 adult load [55]. It was decided that, while diet and exercise have
volunteers who completed the evaluation package followed traditionally been considered separate domains, there is
by an open-ended feedback questionnaire. The assessment sufficient overlap in evaluation, clinical consequences, and
package was then revised and computerized, the experts intervention strategies that they should be combined. For
involved in the focus groups evaluated the feasibility of the example, both diet and exercise affect body mass index,
online toolkit using the criteria of applicability, acceptability, which can be combined with activity level to form 16
and practicality [54], and responses were used to further metabolic types (Table 1). For substance use, the group
refine eVITAL. considered 3 categories: substances that are always harmful
