Lifestyle, cardiometabolic disease, and multimorbidity in a prospective Chinese study

Abstract

Aims: The potential difference in the impacts of lifestyle factors (LFs) on progression from healthy to first cardiometabolic disease (FCMD), subsequently to cardiometabolic multimorbidity (CMM), and further to death is unclear.

Methods and results: We used data from the China Kadoorie Biobank of 461 047 adults aged 30-79 free of heart disease, stroke, and diabetes at baseline. Cardiometabolic multimorbidity was defined as the coexistence of two or three CMDs, including ischaemic heart disease (IHD), stroke, and type 2 diabetes (T2D). We used multi-state model to analyse the impacts of high-risk LFs (current smoking or quitting because of illness, current excessive alcohol drinking or quitting, poor diet, physical inactivity, and unhealthy body shape) on the progression of CMD. During a median follow-up of 11.2 years, 87 687 participants developed at least one CMD, 14 164 developed CMM, and 17 541 died afterwards. Five high-risk LFs played crucial but different roles in all transitions from healthy to FCMD, to CMM, and then to death. The hazard ratios (95% confidence intervals) per one-factor increase were 1.20 (1.19, 1.21) and 1.14 (1.11, 1.16) for transitions from healthy to FCMD, and from FCMD to CMM, and 1.21 (1.19, 1.23), 1.12 (1.10, 1.15), and 1.10 (1.06, 1.15) for mortality risk from healthy, FCMD, and CMM, respectively. When we further divided FCMDs into IHD, ischaemic stroke, haemorrhagic stroke, and T2D, we found that LFs played different roles in disease-specific transitions even within the same transition stage.

Conclusion: Assuming causality exists, our findings emphasize the significance of integrating comprehensive lifestyle interventions into both health management and CMD management.

Keywords: Cardiometabolic disease; Lifestyle; Multimorbidity; Progression; Prospective cohort study.

High-risk lifestyle factors are associated with all disease transition stages from healthy to first cardiometabolic disease, to cardiometabolic multimorbidity, and then to death, but to different extents.

Figure 1

Numbers (percentages) of participants in transition pattern A from baseline to first cardiometabolic disease (FCMD), cardiometabolic multimorbidity (CMM), and death. Cardiometabolic diseases include ischaemic heart disease, stroke, and type 2 diabetes. Cardiometabolic multimorbidity is defined as the occurrence of at least two of the above-mentioned diseases.

Figure 2

Numbers (percentages) of participants in transition pattern B from baseline to one of IHD, IS, HS, and T2D, then to cardiometabolic multimorbidity (CMM), and subsequently to death. Cardiometabolic diseases include ischaemic heart disease (IHD), ischaemic stroke (IS), haemorrhagic stroke (HS), and type 2 diabetes (T2D). Cardiometabolic multimorbidity is defined as the occurrence of at least two of the above-mentioned diseases.

Figure 3

Hazard ratios (95% CIs) for transition pattern A by lifestyle factors among 461 047 participants. CI, confidence interval; CMM, cardiometabolic multimorbidity; FCMD, first cardiometabolic disease; HR, hazard ratio. Cardiometabolic diseases include ischaemic heart disease, stroke, and type 2 diabetes. Cardiometabolic multimorbidity is defined as the occurrence of at least two of the above-mentioned diseases. Number of cases refers to number of cases in each transition with the corresponding exposure. Multivariable models were stratified by age in the 5-year interval, study area, and adjusted for sex, education, marital status, and parental family history of cardiometabolic multimorbidity. For analyses of dichotomous lifestyle factors, five lifestyle factors were mutually adjusted. High-risk lifestyle factors were defined as follows: current smoking or having stopped because of illness; daily drinking ≥30 g/day of pure alcohol or having stopped drinking habit; non-daily eating of vegetables, fruits, and eggs, and eating red meat daily or less than weekly; engaging in a sex- and age-specific lower half of total physical activity; having BMI <18.5 or ≥28.0 kg/m² or having waist circumference ≥90 cm (men)/85 cm (women).

Figure 4

Hazard ratios (95% CIs) for transition pattern A by number of high-risk lifestyle factors among 461 047 participants. CI, confidence interval; CMM, cardiometabolic multimorbidity; FCMD, first cardiometabolic disease; HR, hazard ratio. Cardiometabolic diseases include ischaemic heart disease, stroke, and type 2 diabetes. Cardiometabolic multimorbidity is defined as the occurrence of at least two of the above-mentioned diseases. Number of cases refers to number of cases in each transition with the corresponding exposure. Multivariable models were stratified by age in the 5-year interval, study area, and adjusted for sex, education, marital status, parental family history of cardiometabolic multimorbidity. When the number of lifestyle factors was included as a categorical variable, the reference group was those having 0–1 lifestyle factors. High-risk lifestyle factors were defined as follows: current smoking or having stopped because of illness; daily drinking ≥30 g/day of pure alcohol or having stopped drinking habit; non-daily eating of vegetables, fruits, and eggs, and eating red meat daily or less than weekly; engaging in a sex- and age-specific lower half of total physical activity; having BMI <18.5 or ≥28.0 kg/m² or having waist circumference ≥90 cm (men)/85 cm (women).