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