Associations Between Healthy Lifestyle Trajectories and the Incidence of Cardiovascular Disease With All-Cause Mortality: A Large, Prospective, Chinese Cohort Study

Effect of healthy lifestyle score trajectory on all-cause mortality in the late middle-aged and older population: Finding from 17-year retrospective cohort study

PURPOSE

Recently, the World Health Organization has emphasized the importance of a healthy lifestyle in reducing severe illnesses and premature mortality. To evaluate this, the Healthy Lifestyle Score (HLS), which focuses on health protecting behaviors (e.g., smoking, alcohol consumption, physical activity, body mass index), is widely used. However, as HLS may fluctuate over time, there is increasing focus on monitoring HLS trends. Accordingly, this study aims to track HLS trajectories (HLST) and examine their association with mortality among middle-aged and older Koreans.

METHODS

After excluding missing values, data from 6249 participants were analyzed using the group-based trajectory model (GBTM) to classify HLST, based on the first to fourth waves of the Korean Longitudinal Study of Aging (KLoSA). The chi-square test and Cox proportional hazards model were employed to examine the association between HLST and all-cause mortality over a 10-year follow-up period (December 31, 2012, to December 31, 2022; 3650 days).

RESULTS

Three HLST groups were identified in the GBTM analysis. These were the Poor HLST (17.8 %), Average HLST (42.9 %), and Good HLST (39.4 %) groups. Compared to the good HLST, the poor HLST had higher mortality at 1 year (hazard ratio [HR]: 1.98, p: 0.029), 3 years (HR: 1.78, p: 0.001), 5 years (HR: 1.52, p: 0.002), 7 years (HR: 1.39, p: 0.002), and 10 years (HR: 1.40, p: 0.000). Furthermore, stratified analysis by sex, age, marital status and residential region showed that male, ≥65 years, single and urban area groups had a strong association between HLST and all-cause mortality.

CONCLUSION

The findings of this study underscore the necessity of policies and institutional measures grounded in community networks to mitigate the risk of all-cause mortality among vulnerable groups with persistently poor HLST.

Dual-trajectory of TyG levels and lifestyle scores and their associations with ischemic stroke in a non-diabetic population: a cohort study

BACKGROUND

The Triglyceride-glucose (TyG) index, a surrogate marker of insulin resistance, has been implicated in the risk of ischemic stroke. However, the interplay between TyG levels, lifestyle factors, and their collective impact on stroke risk in non-diabetic populations remains inadequately explored. This study aims to evaluate the association of ischemic stroke with the joint development of the TyG index and lifestyle in the non-diabetic population.

METHODS

In this prospective cohort study, data was collected across three consecutive biennial surveys of the Kailuan Study from 2006 to 2011. The dual-trajectory model was used to determine the temporal development of TyG levels and lifestyle scores. Statistical analysis involved Cox regression models to evaluate the association between TyG-lifestyle trajectories and ischemic stroke risk, adjusting for potential confounders.

RESULTS

A total of 44,403 participants were included, with five distinct TyG levels and lifestyle scores trajectory subtypes identified. In the multivariable-adjusted analyses, significant differences in ischemic stroke risk among the trajectory subtypes. Group 5, characterized by the highest TyG levels and moderate lifestyle scores, exhibited the greatest ischemic stroke risk (HR = 1.81, 95% CI: 1.51-2.18), while group 4, with moderate TyG levels and higher lifestyle scores, demonstrated the lowest risk (HR = 1.19, 95% CI: 1.04-1.37), compared with group 3. Participants with elevated TyG levels were at an increased risk of ischemic stroke in cases of pronounced insulin resistance, even with a healthy lifestyle.

CONCLUSIONS

This study reveals the significant associations between the identified TyG and lifestyle trajectories and the stratification of ischemic stroke risk among non-diabetics. The TyG index is a valuable indicator for assessing insulin resistance. However, the potential benefits of lifestyle changes for those with significantly high TyG levels need to be clarified by more research to develop more effective stroke prevention strategies.

Healthy lifestyle change and all-cause and cancer mortality in the European Prospective Investigation into Cancer and Nutrition cohort

BACKGROUND

Healthy lifestyles are inversely associated with the risk of noncommunicable diseases, which are leading causes of death. However, few studies have used longitudinal data to assess the impact of changing lifestyle behaviours on all-cause and cancer mortality.

METHODS

Within the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, lifestyle profiles of 308,497 cancer-free adults (71% female) aged 35-70 years at recruitment across nine countries were assessed with baseline and follow-up questionnaires administered on average of 7 years apart. A healthy lifestyle index (HLI), assessed at two time points, combined information on smoking status, alcohol intake, body mass index, and physical activity, and ranged from 0 to 16 units. A change score was calculated as the difference between HLI at baseline and follow-up. Associations between HLI change and all-cause and cancer mortality were modelled with Cox regression, and the impact of changing HLI on accelerating mortality rate was estimated by rate advancement periods (RAP, in years).

RESULTS

After the follow-up questionnaire, participants were followed for an average of 9.9 years, with 21,696 deaths (8407 cancer deaths) documented. Compared to participants whose HLIs remained stable (within one unit), improving HLI by more than one unit was inversely associated with all-cause and cancer mortality (hazard ratio [HR]: 0.84; 95% confidence interval [CI]: 0.81, 0.88; and HR: 0.87; 95% CI: 0.82, 0.92; respectively), while worsening HLI by more than one unit was associated with an increase in mortality (all-cause mortality HR: 1.26; 95% CI: 1.20, 1.33; cancer mortality HR: 1.19; 95% CI: 1.09, 1.29). Participants who worsened HLI by more than one advanced their risk of death by 1.62 (1.44, 1.96) years, while participants who improved HLI by the same amount delayed their risk of death by 1.19 (0.65, 2.32) years, compared to those with stable HLI.

CONCLUSIONS

Making healthier lifestyle changes during adulthood was inversely associated with all-cause and cancer mortality and delayed risk of death. Conversely, making unhealthier lifestyle changes was positively associated with mortality and an accelerated risk of death.

Epidemiology and current management of cerebrovascular disease in China

The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China. In connection with the previous section, this fifth section of the report continues the dissection on the management of cardiovascular diseases (CVD). Cerebrovascular disease is the leading cause of death and loss of healthy life among Chinese residents. Based on the results of GBD 2019, from 1990 to 2019, the years of life lost due to premature death caused by stroke showed a decreasing trend, while the years lived with disability still increased continuously. At present, national mortality surveillance system can provide national and provincial representative annual death data on cerebrovascular disease, but the national representative data on some other important epidemiological indicators (such as incidence, prevalence, disability rate, and case fatality rate) are scarce in China. With the construction of large cohort population and extension of follow-up time, research on stroke-related risk factors is increasing, providing a basis for the prevention and control of risk factors. Due to limited large-scale population-based intervention studies, there is a lack of epidemiological evidence to transform into feasible intervention strategies and measures. In recent years, great progress in endovascular treatment for basilar-artery occlusion has been achieved in China, but there is still much room for improvement of guideline-based anticoagulant treatment and lipid-lowering treatment, as well as standardized diagnosis and treatment among patients with ischemic stroke.

Life's essential 8 and risk of all-cause mortality in individuals with cardiovascular diseases: A prospective community-based study

BACKGROUND

Although risk factors for mortality in individuals with cardiovascular diseases (CVD) have been reported, little is known regarding the association between the comprehensive cardiovascular health (CVH) index assessed by life's essential 8 (LE8) and the risk of mortality.

HYPOTHESIS

The aim of this study was to evaluate the CVH assessed by LE8 and risk of mortality in individuals with CVD.

METHODS

A total of 1391 participants with CVD diagnosed before 2014 from the Kailuan cohort were included in the analysis. The CVH score ranged from 0 to 100 was assessed using the LE8 metrics (diet quality, physical activity, sleep health, cigarette smoking, body mass index, lipids, blood glucose, and blood pressure). Cox regression model was used to estimate the association between the CVH score and risk of all-cause mortality.

RESULTS

During a mean follow-up of 6.1 ± 1.5 years, 229 deaths occurred. The hazard ratio for all-cause mortality was 0.57 (95% confidence interval [CI]: 0.38, 0.84) in the highest quartiles compared with the lowest quartiles of CVH scores and 0.85 (95% CI: 0.75, 0.95) for each 10 points increment in CVH scores (ptrend  = .009), after adjustment for age, sex, CVD duration, social-economic status, alcohol consumption, inflammation, medicine use, and kidney function. We did not observe significant interactions between the CVH scores and age, sex, and duration of CVD diagnosis (pinteraction  > .05 for all).

CONCLUSIONS

The CVH assessed by the LE8 metrics was associated with a lower risk of all-cause mortality in individuals with CVD.

Multi-trajectories of triglyceride-glucose index and lifestyle with Cardiovascular Disease: a cohort study

BACKGROUND

Previous studies using trajectory models focused on examining the longitudinal changes in triglyceride-glucose (TyG) levels and lifestyle scores separately, without exploring the joint evolution of these two factors. This study aimed to identify the multi-trajectories of TyG levels and lifestyle scores and assess their association with the risk of cardiovascular disease (CVD).

METHODS

The study enrolled 47,384 participants from three health surveys of the Kailuan Study. The TyG index was computed as Ln [fasting triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2], and the lifestyle scores were derived from five factors, including smoking, alcohol consumption, physical activity, sedentary behaviors, and salt intake. A group-based multi-trajectory model was adopted to identify multi-trajectories of TyG levels and lifestyle scores. The association of identified multi-trajectories with incident CVD was examined using Cox proportional hazard model.

RESULTS

Five distinct multi-trajectories of TyG levels and lifestyle scores were identified. During a median follow-up period of 10.98 years, 3042 participants developed CVD events (2481 strokes, 616 myocardial infarctions, and 55 co-current stroke and myocardial infarctions). In comparison to group 3 with the lowest TyG levels and the best lifestyle scores, the highest CVD risk was observed in group 5 characterized by the highest TyG levels and moderate lifestyle scores (HR = 1.76, 95% CI: 1.50-2.05). Group 2 with higher TyG levels and the poorest lifestyle scores had a 1.45-fold (95% CI 1.26-1.66) risk of CVD, and group 1 with lower TyG levels and poorer lifestyle scores had a 1.33-fold (95% CI 1.17-1.50) risk of CVD. Group 4, with moderate TyG levels and better lifestyle scores, exhibited the lowest CVD risk (HR = 1.32, 95% CI: 1.18-1.47).

CONCLUSIONS

Distinct multi-trajectories of TyG levels and lifestyle scores corresponded to differing CVD risks. The CVD risk caused by a high level TyG trajectory remained increased despite adopting healthier lifestyles. These findings underscored the significance of evaluating the combined TyG and lifestyle patterns longitudinally, and implementing early interventions to reduce CVD risk by lowering TyG levels.

Lifestyle improvement and the reduced risk of cardiovascular disease: the China-PAR project

BACKGROUND

The benefits of healthy lifestyles are well recognized. However, the extent to which improving unhealthy lifestyles reduces cardiovascular disease (CVD) risk needs to be discussed. We evaluated the impact of lifestyle improvement on CVD incidence using data from the China-PAR project (Prediction for Atherosclerotic Cardiovascular Disease Risk in China).

METHODS

A total of 12,588 participants free of CVD were followed up for three visits after the baseline examination. Changes in four lifestyle factors (LFs) (smoking, diet, physical activity, and alcohol consumption) were assessed through questionnaires from the baseline to the first follow-up visit. Cox proportional hazard models were used to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). The risk advancement periods (RAPs: the age difference between exposed and unexposed participants reaching the same incident CVD risk) and population-attributable risk percentage (PAR%) were also calculated.

RESULTS

A total of 909 incident CVD cases occurred over a median follow-up of 11.14 years. Compared with maintaining 0-1 healthy LFs, maintaining 3-4 healthy LFs was associated with a 40% risk reduction of incident CVD (HR = 0.60, 95% CI: 0.45-0.79) and delayed CVD risk by 6.31 years (RAP: -6.31 [-9.92, -2.70] years). The PAR% of maintaining 3-4 unhealthy LFs was 22.0% compared to maintaining 0-1 unhealthy LFs. Besides, compared with maintaining two healthy LFs, improving healthy LFs from 2 to 3-4 was associated with a 23% lower risk of CVD (HR = 0.77, 95% CI: 0.60-0.98).

CONCLUSIONS

Long-term sustenance of healthy lifestyles or improving unhealthy lifestyles can reduce and delay CVD risk.

Adherence to a modified nordic diet and the risk of cardiovascular events in a non-nordic population: a prospective cohort study

BACKGROUND

Even though studies have demonstrated that the Nordic diet is beneficial for cardiovascular disease (CVD) risk factors, it is unknown if this diet is associated with actual CVD cases. So, the aim of this study was to investigate the association between a modified Nordic diet and the risk of CVD in non-Nordic adults.

METHODS

In this cohort study, 2918 people who participated in the third phase of the Tehran Lipid and Glucose Study (TLGS) were examined. All participants had no CVD at the beginning of the study, which was monitored until 2018. The Nordic score was calculated using a validated food frequency questionnaire (FFQ). Patients' medical records were examined for cardiovascular events such as coronary heart disease (CHD), stroke, and mortality from CVD. The Cox proportional hazards model was used to assess the relationship between the Nordic score and the risk of CVD.

RESULTS

During a median follow-up of 10.6 years, 203 subjects experienced cardiovascular events. The third and fourth quartiles of the Nordic score were associated with a 35% (HR: 0.65; 95% CI: 0.45, 0.95) and 60% (HR: 0.40; 95% CI: 0.27 to 0.65) reduced risk of CVD compared to the lowest quartile. Subgroup analyses revealed that a high Nordic score was inversely associated with a lower risk of CVD in adults older than 45 years of age, both sexes, and all BMI categories. Each 1-score increase in cereal consumption was associated with a 24% (HR: 0.76; 95% CI: 0.67 to 0.87) lower risk of CVD; low-fat milk with a 23% (HR: 0.77; 95% CI: 0.68 to 0.87); and fish with a 22% (HR: 0.78; 95% CI: 0.69 to 0.89) lower risk of CVD.

CONCLUSION

We found that high Nordic score adherence may prevent cardiovascular events in non-Nordic populations. Cereals, fish, and low-fat milk were the primary components of the Nordic diet that indicated an inverse relationship with CVD.

Association of cardiovascular health score trajectory and risk of subsequent cardiovascular disease in non-diabetic population: a cohort study

BACKGROUND

Diabetes is an important risk factor for cardiovascular disease (CVD), but in the non-diabetic population, high glucose values within the normal range are also positively associated with CVD risk. There is a lack of concern for people without diabetes and evidence is lacking regarding the association between changes in cardiovascular health score (CVHS) and CVD risk in the non-diabetic population.

METHODS

The current study included 37,970 non-diabetic participants free of CVD events in or before 2010 from the Kailuan Study and calculated CVHS according to the overall status of 7 cardiovascular health metrics between the 2006 and 2010 waves. Latent mixture models were used to explore the subgroups with different development trends included in the context of the Kailuan non-diabetic population and to identify the trajectory of each subgroup. The outcomes of the current study were CVD events, including myocardial infarction and stroke. CVHS trajectory was developed to predict subsequent CVD risk from 2010 to 2020. The Cox proportional hazard model was established to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of CVD across different trajectory patterns.

RESULTS

Five distinct CVHS trajectory patterns were identified, including low-stable pattern (n = 2835), moderate-increasing pattern (n = 3492), moderate-decreasing pattern (n = 7526), high-stable I pattern (n = 17,135), and high-stable II pattern (n = 6982). Compared with the low-stable pattern, participants with the high-stable II pattern had a lower subsequent risk of CVD (HR = 0.22, 95%CI = 0.18-0.28); In stratification analysis, the lower risk for CVD was observed in females (HR = 0.10, 95%CI = 0.05-0.23, P for interaction < 0.05) and those aged < 60 years (HR = 0.16, 95%CI = 0.11 to 0.22, P for interaction < 0.05).

CONCLUSIONS

CVHS trajectory patterns were associated with an altered CVD risk in the non-diabetic population. When stratified by age and sex, the association was stronger in young adults and females.

Ideal cardiovascular health metrics and life expectancy free of cardiovascular diseases: a prospective cohort study

Objectives

Whether cardiovascular health (CVH) metrics impact longevity with and without cardiovascular diseases (CVDs) has not been well established. This study aimed to investigate the association between CVH metrics and life expectancy in participants free of CVD events. We hypothesized that ideal CVH status was associated with increased life expectancy and assessed the effect of CVH status as a prevention target of longevity in the framework of predictive, preventive, and personalized medicine (PPPM/3PM).

Methods

A total of 92,795 participants in the Kailuan study were examined and thereafter followed up until 2020. We considered three transitions (from non-CVD events to incident CVD events, from non-CVD events to mortality, and from CVD events to mortality). The multistate lifetable method was applied to estimate the life expectancy.

Results

During a median follow-up of 13 years, 12,541 (13.51%) deaths occurred. Compared with poor CVH, ideal CVH attenuated the risk of incident CVD events and mortality without CVD events by approximately 58% and 27%, respectively. Women with ideal CVH at age 35 had a 5.00 (3.23-6.77) year longer life expectancy free of CVD events than did women with poor CVH metrics. Among men, ideal CVH was associated with a 6.74 (5.55-7.93) year longer life expectancy free of CVD events.

Conclusion

An ideal CVH status is associated with a lower risk of premature mortality and a longer life expectancy, either in the general population or in CVD patients, which are cost-effective ways for personalized medicine of potential CVD patients. Our findings suggest that the promotion of a higher CVH score or ideal CVH status would result in reduced burdens of CVD events and extended disease-free life expectancy, which offered an accurate prediction for primary care following the concept of PPPM/3PM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-023-00322-8.

Lifestyle Trajectories Are Associated with Incidence of Cardiovascular Disease: Highlights from the ATTICA Epidemiological Cohort Study (2002-2022)

The study aimed to assess the trajectories of lifestyle characteristics and their association with 20-year cardiovascular disease (CVD) incidence. In 2002, 3042 Greek adults (aged: 45 (12) years) free of CVD were enrolled. In 2022, the 20-year follow-up was performed on 2169 participants; of those, 1988 had complete data for CVD. The 20-year CVD incidence was 3600 cases/10,000 individuals; the man-to-woman ratio was 1.25, with the peak difference in the 35-45 age group (i.e., 2.1); however, a reversal of the trend was observed in the age-groups 55-65 and 65-75, with a resumption of an almost equal incidence in those >75 years. In multi-adjusted analysis, age, sex, abnormal waist circumference, hypercholesterolemia, hypertension, and diabetes were positively associated with 20-year CVD risk, explaining 56% of the excess CVD risk, whereas an additional 30% was attributed to lifestyle trajectories; being physically active throughout life-course and being close to the Mediterranean diet were protective, while continuous smoking was detrimental against CVD risk. Mediterranean diet adherence protected against CVD development even if not sustained, while quitting smoking or engaging in physical activities during the 20-year observation did not offer any significant protection. A life-course personalized approach that is cost-effective and long-term sustained is needed to prevent CVD burden.

Associations of Modified Healthy Aging Index With Major Adverse Cardiac Events, Major Coronary Events, and Ischemic Heart Disease

Background The Healthy Aging Index (HAI) has been regarded as useful in capturing the health status of multiple organ systems. However, to what extent the HAI is associated with major cardiovascular events remains largely unknown. The authors constructed a modified HAI (mHAI) to quantify the association of physiological aging with major vascular events and explored how the effects of a healthy lifestyle can modify this association. Methods and Results The participants with either missing values of any individual mHAI component or major illnesses such as heart attack, angina and stroke, and self-reported cancer at baseline were excluded. The mHAI components include systolic blood pressure, reaction time, forced vital capacity, serum cystatin c, and serum glucose. The authors used Cox proportional hazard models to quantify the association of mHAI with major adverse cardiac events, major coronary events, and ischemic heart disease. Cumulative incidence at 5 and 10 years was estimated, and joint analyses were stratified by age group and 4 mHAI categories. The mHAI was significantly correlated with major cardiovascular events, which is a better reflection of the aging level of the body than chronological age. An mHAI was calculated in 338 044 participants aged 38 to 73 years in the UK Biobank. Each point increase in the mHAI was associated with a 44% higher risk of major adverse cardiac events (adjusted hazard ratio [aHR], 1.44 [95% CI, 1.40-1.49]), 44% higher risk of major coronary events (aHR, 1.44 [95% CI, 1.40-1.48]), and 36% higher risk of ischemic heart disease (aHR, 1.36 [95% CI, 1.33-1.39]). The percentage of population-attribution risk was 51% (95% CI, 47-55) for major adverse cardiac events, 49% (95% CI, 45-53) for major coronary events, and 47% (95% CI, 44-50) for ischemic heart disease, which means that a substantial portion of these events could be prevented. Systolic blood pressure was the factor most significantly associated with major adverse cardiac events (aHR, 1.94 [95% CI, 1.82-2.08]; percentage of population-attribution risk, 36%), major coronary events (aHR, 2.01 [95% CI, 1.85-2.17]; percentage of population-attribution risk, 38%), and ischemic heart disease (aHR, 1.80 [95% CI, 1.71-1.89]; percentage of population-attribution risk, 32%). A healthy lifestyle significantly attenuated mHAI associations with incidence of vascular events. Conclusions Our findings indicate that higher mHAI is associated with increased major vascular events. A healthy lifestyle may attenuate these associations.

Association between exposure to earthquake in early life and diabetes mellitus incidence in adulthood with the modification of lifestyles: Results from the Kailuan study

BACKGROUND

Exposure to disasters in early life may induce lifetime health risk, but investigation on earthquake exposure and DM in later life is still limited. The aim of the current study is to evaluate the association between exposure to the Tangshan Earthquake in early life and diabetes mellitus (DM) incidence in adulthood, and explore the modification of lifestyles on DM development.

METHODS

Participants who were free of DM at baseline from the Kailuan Study were included in this study. All participants were divided into fetal-exposed, infant-exposed, early childhood-exposed and nonexposed group. The effect of earthquake exposure on DM and modification of lifestyles were examined by multivariable-adjusted Cox proportional hazard model.

RESULTS

The exposed group had a higher risk of DM than nonexposed group, especially in infant-exposed and early childhood-exposed group, with hazard ratio (HR) of 1.62 [95% confidence intervals (CI), 1.21-2.17] and 1.46 (95% CI, 1.06-1.99), respectively. After stratifying by lifestyles, a significant modification was observed in alcohol consumption.

CONCLUSION

Exposing to earthquake in early life could increase DM incidence in later life, and alcohol consumption might modify the effect of earthquake exposure on DM development. More attention should be paid on the preventions of DM among adults who exposed to earthquake in their early life.