The combined effects of healthy lifestyle behaviors on all cause mortality: A systematic review and meta-analysis

doi:10.1016/j.ypmed.2012.06.017

Preventive Medicine

Volume 55, Issue 3, September 2012, Pages 163-170

https://doi.org/10.1016/j.ypmed.2012.06.017 Get rights and content

Abstract

Objective

Lifestyle factors are related to mortality. Although much is known about the impact of single factors, the current evidence about the combined effects of lifestyle behaviors on mortality has not yet been systematically compiled.

Method

We searched Medline, Embase, Global Health, and Somed up to February 2012. Prospective studies were selected if they reported the combined effects of at least three of five lifestyle factors (obesity, alcohol consumption, smoking, diet, and physical activity). The mean effect sizes that certain numbers of combined lifestyle factors have on mortality were compared to the group with the least number of healthy lifestyle factors by meta-analysis. Sensitivity analyses were conducted to explore the robustness of the results.

Results

21 studies (18 cohorts) met the inclusion criteria of which 15 were included in the meta-analysis that comprised 531,804 people with a mean follow-up of 13.24 years. The relative risks decreased proportionate to a higher number of healthy lifestyle factors for all cause mortality. A combination of at least four healthy lifestyle factors is associated with a reduction of the all cause mortality risk by 66% (95% confidence interval 58%–73%).

Conclusion

Adherence to a healthy lifestyle is associated with a lower risk of mortality.

Highlights

► We conducted a meta-analysis on the association of a healthy lifestyle and mortality. ► A healthy lifestyle was the combination of at least three healthy behaviors. ► The included factors were smoking, obesity, exercise, diet, and drinking alcohol. ► 4 healthy factors compared to 0 leads to a reduced mortality risk by 66%.

Introduction

The risk of developing a major non-communicable disease, the leading cause of death in the world, is decisively affected by lifestyle choices (WHO, 2011a). Smoking, physical inactivity, unhealthy diet, obesity and other lifestyle behaviors are associated with the development of diseases such as cancer, heart disease, stroke, and diabetes (Lopez et al., 2006).

In the United States, adherence to a healthy behavior in relation to the above factors decreased between 1988 and 2006: obesity in adults has increased from 28% to 36%, smoking rates have not changed, the consumption of five or more portions of fruit and vegetables a day has dropped from 42% to 26%, and the adherence to all five healthy habits decreased from 15% to 8% (King et al., 2009). The societal and monetary costs of the negative effects of these modifiable behaviors are huge (Scarborough et al., 2011). While many studies have investigated the effects of single lifestyle behaviors on health (Adams et al., 2006, Doll et al., 2000, Hung et al., 2004, Warburton et al., 2006), the minimization of the individual risk of disease might only be achieved by a combination of these behaviors. In the last decade, several cohorts have been examined for the combined effects of lifestyle factors on various outcomes.

Therefore we conducted a systematic review and a meta-analysis of prospective studies in order to quantitatively assess the association between the number of lifestyle habits (smoking, diet, physical activity, alcohol consumption, body mass index (BMI)) and all cause mortality.

Section snippets

Data Sources and Searches

We searched the following databases, from their onset up to February 2012, for studies that reported on the effects of single and combined health behaviors on morbidity or mortality: Embase, Global Health, Medline, and Somed. Three search themes were combined for this purpose. The themes covered the terms (1) combined effects, combined*, combination, integrated*, joint effects, merged effects and (2) lifestyle, health factor, healthy lifestyle, healthy behaviors, low risk, protective factors,

Statistical analyses

Studies were included in the meta-analysis if they provided effect sizes and confidence intervals for at least three lifestyle factors (in addition to the reference value). We standardized the data by calculating the effect sizes for varying numbers of healthy behaviors (dichotomously coded as “present” or “absent”) as average of all available factor combinations, in comparison to the group with the minimum number of healthy behaviors.

The minimum number of healthy behaviors was 0 healthy

Results

Twenty one studies (18 cohorts) met the inclusion criteria (Byun et al., 2010, Chakravarty et al., 2012, Ford et al., 2009, Ford et al., 2011, Gopinath et al., 2010, Hamer et al., 2011, Haveman-Nies et al., 2002, Iversen et al., 2010, Khaw et al., 2008, King et al., 2007, King et al., 2011, Knoops et al., 2004, Kvaavik et al., 2010, Matheson et al., 2012, McCullough et al., 2011, Nechuta et al., 2010, Rhee et al., 2012, Tamakoshi et al., 2009, Tsubono et al., 2004, van Dam et al., 2008, van den

Discussion

This meta-analysis has quantitatively shown that the number of healthy lifestyle behaviors, which people adopt, is inversely related to the risk of all cause mortality. Compared with individuals who have an unhealthy lifestyle (smoking, no or excessive alcohol consumption, no physical exercise, unhealthy diet, obese), those with four or more healthy behaviors have an overall risk of mortality that is lower by 66%.

The present study is robust due to the very large sample sizes and long follow-ups

Acknowledgments

This study was supported by the Samueli Institute and the Hans Gottschalk-Stiftung. The authors are grateful to Majella Horan for proofreading and for repeating the literature search and selection process. M. L. conducted the literature search, performed the analysis and drafted the manuscript. H. W. assisted with the analysis of critical information, contributed to the drafting of the manuscript and to the interpretation of data.

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ReviewThe combined effects of healthy lifestyle behaviors on all cause mortality: A systematic review and meta-analysis

Abstract

Objective

Method

Results

Conclusion

Highlights

Introduction

Section snippets

Data Sources and Searches

Statistical analyses

Results

Discussion

Acknowledgments

Am. J. Med.

Am. J. Med.

Am. J. Med.

Lancet

J. Clin. Epidemiol.

Prev. Med.

Am. J. Clin. Nutr.

Der Capability-Ansatz in der Gesundheitsförderung: Ansatzpunkte für eine Neuausrichtung der Ungleichheitsforschung

Osterr. Z. Soziol.

Overweight, Obesity, and Mortality in a Large Prospective Cohort of Persons 50 to 71 Years Old

New Engl. J. Med.

Effect of positive health factors and all-cause mortality in men

Med. Sci. Sports Exerc.

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Circulation

Primary prevention of stroke by healthy lifestyle

Circulation

Smoking and dementia in male British doctors prospective study

BMJ

Multiple risk factor interventions for primary prevention of coronary heart disease

Cochrane Database Syst. Rev.

Bias in meta-analysis detected by a simple, graphical test

BMJ

Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study

Arch. Intern. Med.

Low-Risk Lifestyle Behaviors and All-Cause Mortality: Findings From the National Health and Nutrition Examination Survey III Mortality Study

Am. J. Public Health

Lifestyle and the Risk of Dementia in Japanese-American Men

J. Am. Geriatr. Soc.

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Arch. Intern. Med.

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J. Am. Geriatr. Soc.

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Am. J. Epidemiol.

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Stat. Med.

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New Engl. J. Med.

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J. Natl. Cancer Inst.

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Review
The combined effects of healthy lifestyle behaviors on all cause mortality: A systematic review and meta-analysis