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Lifestyle risk factors and all-cause and cause-specific mortality: assessing the influence of reverse causation in a prospective cohort of 457,021 US adults

  • MORTALITY
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Abstract

Background

Lifestyle risk factors have been associated with increased all-cause and cause-specific mortality, but the influence of reverse causation has been underappreciated as a limitation in epidemiological studies.

Methods

Prospective cohort study including 457,021 US adults from the National Health Interview Survey 1997–2013 linked to the National Death Index records through December 31, 2015. Multivariable Cox models were performed to examine the association of lifestyle risk factors with all-cause and cause-specific mortality. Participants with prevalent diseases and the first 2, 5, 10, and 15 years of follow-up were excluded to account for reverse causation.

Results

During 4,441,609 person-years, we identified 60,323 total deaths. Heavy alcohol drinking (HR 1.12; 95% CI 1.08 to 1.16), smoking (HR 1.78; 95% CI 1.74 to 1.83) and lack of physical activity (HR 1.51; 95% CI 1.47 to 1.54) were associated with increased all-cause mortality. Overweight was associated with lower all-cause mortality (HR 0.88; 95% CI 0.86 to 0.90). After exclusion of participants with diseases and first 10 years of follow-up, associations changed to: heavy alcohol drinking (HR 1.31; 95% CI 1.20 to 1.43), smoking (HR 1.99; 95% CI 1.87 to 2.11), lack of physical activity (HR 1.21; 95% CI 1.15 to 1.27), and overweight (HR 1.05; 95% CI 1.00 to 1.10).

Conclusions

Methods to account for reverse causation suggest different effects of reverse causation on the associations between lifestyle risk factors and mortality. Exclusion of participants with diseases at baseline, and exclusion of 5–10 years of follow-up may be necessary to mitigate reverse causation.

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Availability of data and materials

The National Health Interview Survey data are available at www.cdc.gov/nchs/nhis/index.htm.

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Funding

None declared.

Author information

Authors and Affiliations

  1. Departamento de Medicina Preventiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil

    Leandro F. M. Rezende

  2. Universidad de Santiago de Chile (USACH), Escuela de Ciencias de la Actividad Física, el Deporte y la Salud, Santiago, Chile

    Gerson Ferrari

  3. Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Dong Hoon Lee & Edward Giovannucci

  4. Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK

    Dagfinn Aune

  5. Department of Nutrition, Bjørknes University College, Oslo, Norway

    Dagfinn Aune

  6. Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway

    Dagfinn Aune

  7. Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden

    Dagfinn Aune

  8. School of Nursing, Guangdong Pharmaceutical University, Haizhu District, Guangzhou, China

    Bing Liao & Wentao Huang

  9. Department of Sociology & Institute for Empirical Social Science Research, School of Humanities and Social Sciences, Xi’an Jiaotong University, 28 Xianning West Road, Xi’an, 710049, Shaanxi, China

    Jing Nie

  10. Department of Epidemiology and Biostatistics, School of Health Sciences, Wuhan University, Wuhan, China

    Yafeng Wang

  11. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Edward Giovannucci

Authors
  1. Leandro F. M. Rezende
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  2. Gerson Ferrari
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  3. Dong Hoon Lee
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  4. Dagfinn Aune
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  5. Bing Liao
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  7. Jing Nie
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  8. Yafeng Wang
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  9. Edward Giovannucci
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Contributions

L.F.M.R., D.H.L, G.F., J.N., and Y.W. designed and conceptualized study. L.F.M.R., B.L., W.H., J.N., and Y.W. had a major role in the acquisition, analysis, or interpretation of the data. L.F.M.R., wrote the first draft of the manuscript. All authors contributed to the interpretation of data and commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jing Nie.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The National Health Interview Survey data in this study are deidentified and do not include any protected health information. This study was based on secondary analyses of publicly available and deidentified NHIS data and no further institutional review board approval is needed for this study.

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Rezende, L.F.M., Ferrari, G., Lee, D.H. et al. Lifestyle risk factors and all-cause and cause-specific mortality: assessing the influence of reverse causation in a prospective cohort of 457,021 US adults. Eur J Epidemiol 37, 11–23 (2022). https://doi.org/10.1007/s10654-021-00829-2

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  • DOI: https://doi.org/10.1007/s10654-021-00829-2

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