title: Which modifiable health risk behaviours are related? A systematic review of the clustering of Smoking, Nutrition, Alcohol and Physical activity ('SNAP') health risk factors.
abstract: OBJECTIVE
  There is a growing body of literature examining the clustering of health risk behaviours, but little consensus about which risk factors can be expected to cluster for which sub groups of people. This systematic review aimed to examine the international literature on the clustering of smoking, poor nutrition, excess alcohol and physical inactivity (SNAP) health behaviours among adults, including associated socio-demographic variables.
  
  
  METHODS
  A literature search was conducted in May 2014. Studies examining at least two SNAP risk factors, and using a cluster or factor analysis technique, or comparing observed to expected prevalence of risk factor combinations, were included.
  
  
  RESULTS
  Fifty-six relevant studies were identified. A majority of studies (81%) reported a 'healthy' cluster characterised by the absence of any SNAP risk factors. More than half of the studies reported a clustering of alcohol with smoking, and half reported clustering of all four SNAP risk factors. The methodological quality of included studies was generally weak to moderate. Males and those with greater social disadvantage showed riskier patterns of behaviours; younger age was less clearly associated with riskier behaviours.
  
  
  CONCLUSIONS
  Clustering patterns reported here reinforce the need for health promotion interventions to target multiple behaviours, and for such efforts to be specifically designed and accessible for males and those who are socially disadvantaged.
authors.affiliation: Priority Research Centre for Health Behaviour, University of Newcastle, Newcastle, NSW, Australia. Electronic address: Natasha.Noble@newcastle.edu.au.
authors.forename: Natasha
authors.initials: N
authors.lastname: Noble
authors.affiliation: Priority Research Centre for Health Behaviour, University of Newcastle, Newcastle, NSW, Australia.
authors.forename: Christine
authors.initials: C
authors.lastname: Paul
authors.affiliation: Priority Research Centre for Health Behaviour, University of Newcastle, Newcastle, NSW, Australia.
authors.forename: Heidi
authors.initials: H
authors.lastname: Turon
authors.affiliation: Hunter Medical Research Institute and Faculty of Health, University of Newcastle, Newcastle, NSW, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Oldmeadow
mesh_terms: D000428:Alcohol Drinking / Q000453:epidemiology*; D016000:Cluster Analysis; D004032:Diet; D015444:Exercise; D005260:Female; D015438:Health Behavior; D006801:Humans; D008019:Life Style; D008297:Male; D012307:Risk Factors; D012737:Sex Factors; D012907:Smoking / Q000453:epidemiology*; D012959:Socioeconomic Factors
keywords: Cluster analysis; Clustering; Health behaviours; Multiple risk factors; SNAP risk factors