Combined Impact of Lifestyle-Related Factors on Total and Cause-Specific Mortality among Chinese Women: Prospective Cohort Study

University of Cambridge, United Kingdom
PLoS Medicine (Impact Factor: 14.43). 09/2010; 7(9). DOI: 10.1371/journal.pmed.1000339
Source: PubMed


Although cigarette smoking, excessive alcohol drinking, obesity, and several other well-studied unhealthy lifestyle-related factors each have been linked to the risk of multiple chronic diseases and premature death, little is known about the combined impact on mortality outcomes, in particular among Chinese and other non-Western populations. The objective of this study was to quantify the overall impact of lifestyle-related factors beyond that of active cigarette smoking and alcohol consumption on all-cause and cause-specific mortality in Chinese women.
We used data from the Shanghai Women's Health Study, an ongoing population-based prospective cohort study in China. Participants included 71,243 women aged 40 to 70 years enrolled during 1996-2000 who never smoked or drank alcohol regularly. A healthy lifestyle score was created on the basis of five lifestyle-related factors shown to be independently associated with mortality outcomes (normal weight, lower waist-hip ratio, daily exercise, never exposed to spouse's smoking, higher daily fruit and vegetable intake). The score ranged from zero (least healthy) to five (most healthy) points. During an average follow-up of 9 years, 2,860 deaths occurred, including 775 from cardiovascular disease (CVD) and 1,351 from cancer. Adjusted hazard ratios for mortality decreased progressively with an increasing number of healthy lifestyle factors. Compared to women with a score of zero, hazard ratios (95% confidence intervals) for women with four to five factors were 0.57 (0.44-0.74) for total mortality, 0.29 (0.16-0.54) for CVD mortality, and 0.76 (0.54-1.06) for cancer mortality. The inverse association between the healthy lifestyle score and mortality was seen consistently regardless of chronic disease status at baseline. The population attributable risks for not having 4-5 healthy lifestyle factors were 33% for total deaths, 59% for CVD deaths, and 19% for cancer deaths.
In this first study, to our knowledge, to quantify the combined impact of lifestyle-related factors on mortality outcomes in Chinese women, a healthier lifestyle pattern-including being of normal weight, lower central adiposity, participation in physical activity, nonexposure to spousal smoking, and higher fruit and vegetable intake-was associated with reductions in total and cause-specific mortality among lifetime nonsmoking and nondrinking women, supporting the importance of overall lifestyle modification in disease prevention. Please see later in the article for the Editors' Summary.

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    • "Most commonly, researchers have created a combined health behavior index, where dichotomous measures of multiple behaviors are summed e.g., [4,6,10-23]. Others have attempted to account for the risks associated with various individual behaviors more precisely by defining multiple categories of risk for each behavior before creating a composite measure [24,25], or by assigning differential weights for each behavior prior to creating a summary score [26]. Findings from these types of studies generally show that mortality can be postponed by maximizing the number of healthy behaviors in one’s profile, and minimizing the number of unhealthy, or risky, behaviors. "
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    ABSTRACT: Background This study examines the mortality risk associated with distinct combinations of multiple risk behaviors in middle-aged and older adults, and assesses whether the mortality risks of certain health behaviors are moderated by the presence of other risk behaviors. Methods Data for this prospective cohort study are from the Health and Retirement Study (HRS), a nationwide sample of adults older than 50 years. Baseline data are from respondents (n = 19,662) to the 1998 wave of the HRS. Twelve distinct health behavior profiles were created, based on each respondent’s smoking, physical activity, and alcohol use status in 1998. Mortality risk was estimated through 2008 using Cox regression. Results Smoking was associated with elevated risk for mortality within all behavioral profiles, but risk was greatest when combined with heavy drinking, both for middle-aged (ages 51–65) and older (ages 66+) adults. Profiles that included physical inactivity were also associated with increased mortality risk in both age groups. However, the impact of inactivity was clearly evident only among non-smokers; among smokers, the risk of inactivity was less evident, and seemingly overshadowed by the risk of smoking. Moderate drinking was protective relative to abstinence among non-smokers, and relative to heavy drinking among smokers. Conclusions In both middle-aged and older adults, multiple unhealthy behaviors increase mortality risk. However, the level of risk varies across unique combinations of unhealthy behaviors. These findings highlight the role that lifestyle improvements could play in promoting healthy aging, and provide insight into which behavioral combinations should receive top priority for intervention.
    BMC Public Health 09/2012; 12(1):803. DOI:10.1186/1471-2458-12-803 · 2.26 Impact Factor
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    • "These studies have been conducted in specific populations of Caucasian origin [17-20], the elderly [19,21] or in women only [8,17,22]. Few studies have examined the relationship between combined lifestyle factors and mortality in East Asian countries [22,23]. "
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    ABSTRACT: Background Most studies that have evaluated the association between combined lifestyle factors and mortality outcomes have been conducted in populations of Caucasian origin. The objective of this study was to examine the association between combined lifestyle scores and the risk of mortality in Korean men and women. Methods The study population included 59,941 Koreans, 30–84 years of age, who had visited the Severance Health Promotion Center between 1994 and 2003. Cox regression models were fitted to establish the association between combined lifestyle factors (current smoker, heavy daily alcohol use, overweight or obese weight, physical inactivity, and unhealthy diet) and mortality outcomes. Results During 10.3 years of follow-up, there were 2,398 cases of death from any cause. Individual and combined lifestyle factors were found to be associated with the risk of mortality. Compared to those having none or only one risk factor, in men with a combination of four lifestyle factors, the relative risk for cancer mortality was 2.04-fold, for non-cancer mortality 1.92-fold, and for all-cause mortality 2.00-fold. In women, the relative risk was 2.00-fold for cancer mortality, 2.17-fold for non-cancer mortality, and 2.09-fold for all-cause mortality. The population attributable risks for all-cause mortality for the four risk factors combined was 44.5% for men and 26.5% for women. Conclusion This study suggests that having a high (unhealthy) lifestyle score, in contrast to a low (healthy) score, can substantially increase the risk of death by any cause, cancer, and non-cancer in Korean men and women.
    BMC Public Health 08/2012; 12(1):673. DOI:10.1186/1471-2458-12-673 · 2.26 Impact Factor
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    • "The contribution of these wrongly-called health services to reduce the risk of dying from various causes and what is spent in this reduction becomes such a waste that it should be fully disclosed to the population. In the USA, for example: To reduce mortality by 11% from all causes served by so-called health services 91% of total resources allocated to the health sector are spent; for reducing deaths from environmental causes by 19%, 1.5% of the total is spent; for reducing 27% of the biological causes of death 7% is spent, and for a 43% reduction in deaths from lifestyle causes barely 1.2% of the total resources allocated are spent 9 - 11 . "
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    ABSTRACT: What we know today as Health Services is a fiction, perhaps shaped involuntarily, but with deep health repercussions, more negative than positive. About 24 centuries ago, Asclepius, god of medicine, and Hygeia, goddess of hygiene and health, generated a dichotomy between disease and health that remains with us until today. The confusing substitution of Health Services with Medical Services began toward the end of the XIX century. But it was in 1948 when the so called English National Health Service became a landmark in the world with its model being adopted by many countries with resulting distortion of the true meaning of Health Services. The consequences of this fiction have been ominous. It is necessary to call things by their names and not deceive society. To correct the serious imbalance between Medical Services and Health Services, Hygeia and Asclepius must become a brother and sisterhood.
    06/2012; 43(2):185-188.
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