Association of a Comprehensive Healthy Lifestyle Score with Risk of All-Cause, Cancer, and Cardiovascular Mortality:...

Comprehensive management of lifestyle factors is important for long-term survival. This study aims to examine whether a comprehensive healthy lifestyle score (HLS) incorporating overall diet assessment predicts all-cause, cancer, and cardiovascular mortality in Korean population.

This prospective cohort study was conducted among men and women (n = 111,633, 64.6% women) aged 40 to 85 years who participated in the Korean Genome and Epidemiology Study_Health Examinees (Mean age = 55.2, SD = 8.8). Participants completed a baseline questionnaire between 2004 and 2013 and were followed until December 2023. The HLS consisted of five components classified as healthy behaviors: never or former smoking; engaging in ≥30 min/day of moderate-to-vigorous physical activity on ≥5 days/week; alcohol intake ≤40 g/day for men and ≤20 g/day for women; a BMI of 18.5-24.9 kg/m²; and an unhealthful plant-based diet index (uPDI) in the bottom 40th percentile, which reflects overall diet quality and aligns with the traditional plant-rich dietary pattern of Koreans. Diet was assessed using data from baseline and the first follow-up, while the remaining components were measured at baseline only. Cox proportional hazards models were applied to evaluate multivariable-adjusted associations between the HLS and all-cause, cancer, and cardiovascular mortality.

During 1,538,490 person-years of follow-up, 5246 all-cause deaths, 2362 cancer deaths, and 815 cardiovascular deaths were documented. Compared with the lowest HLS category, men with the highest HLS had lower risks of all-cause (HR: 0.65, 95% CI: 0.53-0.80), cancer (HR: 0.62, 95% CI: 0.46-0.85), and cardiovascular mortality (HR: 0.34, 95% CI: 0.17-0.66). Among women, the corresponding HRs were 0.38 (95% CI: 0.26-0.55), 0.52 (95% CI: 0.29-0.90), and 0.30 (95% CI: 0.11-0.84), respectively. The inverse association was stronger in older adults (≥55 years) than in younger adults. All five individual lifestyle components, including diet (quintile 5 vs. quintile 1 of uPDI: HR 0.74, 95% CI: 0.66-0.83 in men; HR 0.67, 95% CI: 0.58-0.76 in women), were significantly associated with a lower risk of all-cause mortality. However, when smoking was excluded from the HLS, the inverse association was attenuated, particularly among men.

Greater adherence to a healthy lifestyle score was strongly associated with reduced risks of all-cause, cancer, and cardiovascular mortality. These findings underscore the importance of promoting integrated, multi-behavior lifestyle interventions, especially smoking cessation, to reduce premature mortality.