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Combined lifestyle factors, all-cause mortality and cardiovascular disease: a systematic review and meta-analysis of prospective cohort studies
  1. Yan-Bo Zhang1,
  2. Xiong-Fei Pan1,2,
  3. Junxiang Chen1,
  4. Anlan Cao1,
  5. Lu Xia1,
  6. Yuge Zhang1,
  7. Jing Wang3,
  8. Huiqi Li1,
  9. Gang Liu4,
  10. An Pan1
  1. 1 Department of Epidemiology and Biostatistics, Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  2. 2 Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  3. 3 Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  4. 4 Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  1. Correspondence to An Pan, Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; panan{at}


Introduction Unhealthy lifestyles caused a huge disease burden. Adopting healthy lifestyles is the most cost-effective strategy for preventing non-communicable diseases. The aim was to perform a systematic review and meta-analysis to quantify the relationship of combined lifestyle factors (eg, cigarette smoking, alcohol consumption, physical activity, diet and overweight/obesity) with the risk of all-cause mortality, cardiovascular mortality and incident cardiovascular disease (CVD).

Methods PubMed and EMBASE were searched from inception to April 2019. Cohort studies investigating the association between the combination of at least three lifestyle factors and all-cause mortality, cardiovascular mortality or incidence of CVD were filtered by consensus among reviewers. Pairs of reviewers independently extracted data and evaluated study quality. Random-effects models were used to pool HRs. Heterogeneity and publication bias were tested.

Results In total, 142 studies were included. Compared with the participants with the least-healthy lifestyles, those with the healthiest lifestyles had lower risks of all-cause mortality (HR=0.45, 95% CI 0.41 to 0.48, 74 studies with 2 584 766 participants), cardiovascular mortality (HR=0.42, 95% CI 0.37 to 0.46, 41 studies with 1 743 530 participants), incident CVD (HR=0.38, 95% CI 0.29 to 0.51, 22 studies with 754 894 participants) and multiple subtypes of CVDs (HRs ranging from 0.29 to 0.45). The associations were largely significant and consistent among individuals from different continents, racial groups and socioeconomic backgrounds.

Conclusions Given the great health benefits, comprehensively tackling multiple lifestyle risk factors should be the cornerstone for reducing the global disease burden.

  • Cardiovascular disease
  • lifestyle
  • mortality
  • prevention
  • systematic reviews

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  • Contributors Y-BZ, X-FP and AP designed the study question. Y-BZ, JC, AC, LX, YZ, JW and HL conducted the literature screening, extracted the data and assessed the risk of bias of included studies. Y-BZ and JC conducted the analyses. Y-BZ wrote the first draft of the paper. AP took responsibility for the contents of the article. Y-BZ, GL and AP interpreted the data. All authors critically reviewed the manuscript and approved submission of the final manuscript.

  • Funding This work was supported by the National Key Research and Development Program of China (2017YFC0907504), National Nature Science Foundation of China (81930124), Hubei Province Science Fund for Distinguished Young Scholars (2018CFA033), China Postdoctoral Science Foundation (176596) and International Postdoctoral Exchange Fellowship of the China Postdoctoral Council (20180062).

  • Disclaimer The study sponsors had no role in study design; collection, analysis and interpretation of data; writing the report and the decision to submit the report for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.