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. 2024 Jul 15;14(1):16330.
doi: 10.1038/s41598-024-66772-w.

On the use of the healthy lifestyle index to investigate specific disease outcomes

Vivian Viallon  1 , Heinz Freisling  2 , Komodo Matta  2 , Anne Østergaard Nannsen  3 , Christina C Dahm  3 , Anne Tjønneland  4   5 , Anne Kirstine Eriksen  4 , Rudolf Kaaks  6 , Verena A Katzke  6 , Matthias B Schulze  7   8   9 , Giovanna Masala  10 , Giovanna Tagliabue  11 , Vittorio Simeon  12 , Rosario Tumino  13 , Lorenzo Milani  14 , Jeroen W G Derksen  15 , Yvonne T van der Schouw  15 , Therese Haugdahl Nøst  16   17 , Kristin Benjaminsen Borch  17 , Torkjel M Sandanger  17 , J Ramón Quirós  18 , Miguel Rodriguez-Barranco  19   20   21 , Catalina Bonet  22   23 , Amaia Aizpurua-Atxega  24   25 , Lluís Cirera  21   26 , Marcela Guevara  21   27   28 , Björn Sundström  29 , Anna Winkvist  30   31 , Alicia K Heath  32 , Marc J Gunter  32 , Elisabete Weiderpass  2 , Mattias Johansson  2 , Pietro Ferrari  2
Affiliations

On the use of the healthy lifestyle index to investigate specific disease outcomes

Vivian Viallon et al. Sci Rep. .

Abstract

The healthy lifestyle index (HLI), defined as the unweighted sum of individual lifestyle components, was used to investigate the combined role of lifestyle factors on health-related outcomes. We introduced weighted outcome-specific versions of the HLI, where individual lifestyle components were weighted according to their associations with disease outcomes. Within the European Prospective Investigation into Cancer and Nutrition (EPIC), we examined the association between the standard and the outcome-specific HLIs and the risk of T2D, CVD, cancer, and all-cause premature mortality. Estimates of the hazard ratios (HRs), the Harrell's C-index and the population attributable fractions (PAFs) were compared. For T2D, the HR for 1-SD increase of the standard and T2D-specific HLI were 0.66 (95% CI: 0.64, 0.67) and 0.43 (0.42, 0.44), respectively, and the C-index were 0.63 (0.62, 0.64) and 0.72 (0.72, 0.73). Similar, yet less pronounced differences in HR and C-index were observed for standard and outcome-specific estimates for cancer, CVD and all-cause mortality. PAF estimates for mortality before age 80 were 57% (55%, 58%) and 33% (32%, 34%) for standard and mortality-specific HLI, respectively. The use of outcome-specific HLI could improve the assessment of the role of lifestyle factors on disease outcomes, thus enhancing the definition of public health recommendations.

Keywords: Cancer; Cardiovascular diseases; Composite score; Healthy lifestyle index; Lifestyle factors; Mortality; Type 2 diabetes.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1
Figure 1
Flowchart summarizing the exclusion criteria that led to the final EPIC study population used in our analyses.
Figure 2
Figure 2
Premature mortlity, T2D, CVD and cancer hazard ratios in relation to the 32 possible lifestyle profiles defined by combining the 5 binary lifestyle scores. The “unhealthiest” profile, corresponding to all five summary variables equal to 0, was set as the reference. The heatmap describes each profile in terms of the 5 lifestyle scores, with purple and green entries corresponding to value 0 (unhealthy behavior) and value 1 (healthy behavior), respectively. Profiles were grouped according to their standard HLI value. Cox models used age as the main time scale, were stratified on study center, sex, and age at recruitment, and were adjusted for education level, height, and energy intake from non-alcoholic sources, and, for women, menopausal status and use of postmenopausal hormones.
Figure 3
Figure 3
Estimated PAF of unhealthy lifestyle for death, T2D, CVD and Cancer, as a function of age. Estimations were derived from models based on the standard (red) and outcome-specific (cyan) HLIs, using binary scores for each lifestyle component.
Figure 4
Figure 4
Estimated PAF of unhealthy lifestyle for death, T2D, CVD and cancer, as a function of age. Estimations were derived from models based on the standard (red) and outcome-specific (cyan) HLIs, using categorical scores for each lifestyle component.
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