Lifestyle risk score and mortality in Korean adults: a population-based cohort study

Abstract

Individual lifestyle risk factors have been associated with an increased risk of mortality. However, limited evidence is available on the combined association of lifestyle risk factors with mortality in non-Western populations. The analysis included 37,472 participants (aged ≥19 years) in the Korea National Health and Nutrition Examination Surveys (2007-2014) for whom the data were linked to death certificates/medical records through December 2016. A lifestyle risk score was created using five unhealthy behaviors: current smoking, high-risk alcohol drinking, unhealthy weight, physical inactivity, and insufficient/prolonged sleep. Cox proportional hazards models were used to estimate hazard ratio (HR) and 95% confidence interval (CI). During up to 9 years of follow-up, we documented 1,057 total deaths. Compared to individuals with zero lifestyle risk factor, those with 4-5 lifestyle risk factors had 2.01 times (HR = 2.01, 95% CI = 1.43-2.82) and 2.59 times (HR = 2.59, 95% CI = 1.24-5.40) higher risk of all-cause and cardiovascular mortality, respectively. However, higher lifestyle risk score was not significantly associated with cancer mortality (p-trend >0.05). In stratified analyses, the positive associations tended to be stronger in adults aged <65 years, unemployed, and those with lower levels of education. In conclusion, combined unhealthy lifestyle behaviors were associated with substantially increased risk of total and cardiovascular mortality in Korean adults. Individual lifestyle risk factors such as obesity, physical inactivity, smoking, heavy alcohol use and poor diet have been associated with increased risk of various chronic diseases and premature death 1-4. More recently, insufficient or prolonged sleep has been identified as a predictor of adverse health outcomes 5,6. Generally, lifestyle behaviors have complex relationships and they tend to cluster in specific combinations within populations 7,8. Moreover, having multiple lifestyle risk factors can have synergistic effects on diseases. Thus, it is important to evaluate the combined effects of lifestyle factors on health outcomes to quantify disease burden and provide valuable public health messages for disease prevention. A number of epidemiological studies have examined the combined association of major lifestyle factors including obesity, smoking, alcohol, and physical activity in relation to mortality. A systematic review and meta-analysis of 15 cohort studies showed that adherence to at least four healthy lifestyle behaviors was associated with a 66% reduced risk of all-cause mortality, although high heterogeneity (I 2 = 94%) was observed between study populations 9. Subsequent studies consistently suggested the importance of healthy lifestyle behaviors for the prevention of diseases 10-18. However, majority of the studies were conducted in Western populations (e.g., US and Europe). Limited data are available for non-Caucasians, especially Asians 16,19-21 including Koreans 10,12,18 whose lifestyle patterns are different from Western populations...

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