Association between Lifestyle Modification and All-Cause, Cardiovascular, and Premature Mortality in Individuals with Non-Alcoholic Fatty Liver Disease

Abstract

Background: This study is designed to explore the correlation between multiple healthy lifestyles within the framework of "lifestyle medicine", and the mortality risk of nonalcoholic fatty liver disease (NAFLD).

Methods: The National Health and Nutrition Examination Survey (NHANES) database was employed. The analysis consisted of 5542 participants with baseline NAFLD and 5542 matched non-NAFLD participants from the database. Lifestyle information, including five low risk factors advocated by lifestyle medicine (healthy diet, vigorous physical activity, healthy sleep duration, avoiding smoking, and maintaining a non-depressed psychological status), was collected through a baseline questionnaire. Cox proportional hazards regression models and Kaplan-Meier survival curve were used to evaluate risk of mortality. In addition, subgroups were analyzed according to gender, age, body mass index and waist circumference.

Results: In total, 502 deaths (n = 181 deaths from cardiovascular disease (CVD)) were recorded among NAFLD participants after the median follow up duration of 6.5 years. In the multivariate-adjusted model, compared to participants with an unfavorable lifestyle (scoring 0-1), NAFLD participants with a favorable lifestyle (scoring 4-5) experienced a 56% reduction in all-cause mortality and a 66% reduction in CVD mortality. Maintaining an undepressed psychological state and adhering to vigorous exercise significantly reduced CVD mortality risk in NAFLD participants (HR, 0.64 [95% CI, 0.43-0.95]; HR, 0.54 [95% CI, 0.33-0.88]) while maintaining healthy sleep reduced premature mortality due to CVD by 31%.

Conclusions: Healthy lifestyle, characterized by maintaining an undepressed mental state and healthy sleep, significantly mitigates the risk of all-cause, CVD, and premature mortality risk among NAFLD patients, with a particularly pronounced effect observed in female and obese subpopulations.

Keywords: NAFLD; all-cause mortality; cardiovascular disease; healthy lifestyle; psychological status.

Figure 1

Cox regression analysis of the association between healthy lifestyle and all-cause and cardiovascular mortality. Adjusted for gender, age, marital status, ethnicity, education, and poverty status. p < 0.05 was considered significant.

Figure 2

Cox regression analysis of the association between healthy lifestyle and all-cause and cardiovascular mortality in men and women with NAFLD. Adjusted for gender, age, marital status, ethnicity, education, and poverty status. p < 0.05 was considered significant.

Figure 3

Kaplan–Meier survival curve for all-cause and cardiovascular mortality stratified on lifestyle category. (A) All-cause mortality for NAFLD by BMI; (B) cardiovascular mortality for NAFLD by BMI.

Figure 4

Kaplan–Meier survival curve for all-cause and cardiovascular mortality stratified on lifestyle category. (A) All-cause mortality for NAFLD by waist circumference; (B) cardiovascular mortality for NAFLD by waist circumference. p < 0.05 was considered significant.

Figure 5

Cox regression analysis of the association between healthy lifestyles and premature mortality in participants with NAFLD. Model 1 was adjusted for gender, age, marital status, ethnicity, education, and poverty status. Model 2 was adjusted for gender, age, marital status, ethnicity, education, and poverty status, BMI, cardiovascular disease, and cancer. p < 0.05 was considered significant. Abbreviation: PD, premature death.

Figure 6

Association between different combinations of healthy lifestyles and all-cause and cardiovascular mortality in NAFLD participants. Adjusted for gender, age, marital status, ethnicity, education, and poverty status. Abbreviation: SMK, smoking; SLP, sleeping; DEP, depression. (A) For participants from 5542 participants defined by the HSI; (B) for participants with NAFLD and obesity by BMI; (C) for participants with NAFLD and obesity by waist circumference.