title: The Combined Effects of Healthy Lifestyle Behaviors on All-Cause Mortality: The Golestan Cohort Study.
abstract: BACKGROUND
  Most studies that have evaluated the association between combined lifestyle factors and mortality outcomes have been conducted in populations of developed countries.
  
  
  OBJECTIVE
  The aim of this study was to examine the association between combined lifestyle scores and risk of all-cause and cause-specific mortality for the first time among Iranian adults.
  
  
  METHODS
  The study population included 50,045 Iranians, 40 - 75 years of age, who were enrolled in the Golestan Cohort Study, between 2004 and 2008. The lifestyle risk factors used in this study included cigarette smoking, physical inactivity, and Alternative Healthy Eating Index. The lifestyle score ranged from zero (non-healthy) to 3 (most healthy) points. From the study baseline up to analysis, a total of 4691 mortality cases were recorded. Participants with chronic diseases at baseline, outlier reports of calorie intake, missing data, and body mass index of less than 18.5 were excluded from the analyses. Cox regression models were fitted to establish the association between combined lifestyle scores and mortality outcomes.
  
  
  RESULTS
  After implementing the exclusion criteria, data from 40,708 participants were included in analyses. During 8.08 years of follow-up, 3,039 cases of all-cause mortality were recorded. The adjusted hazard ratio of a healthy lifestyle score, compared with non-healthy lifestyle score, was 0.68 (95% CI: 0.54, 0.86) for all-cause mortality, 0.53 (95% CI: 0.37, 0.77) for cardiovascular mortality, and 0.82 (95% CI: 0.53, 1.26) for mortality due to cancer. When we excluded the first two years of follow up from the analysis, the protective association between healthy lifestyle score and cardiovascular death did not change much 0.55 (95% CI: 0.36, 0.84), but the inverse association with all-cause mortality became weaker 0.72 (95% CI: 0.55, 0.94), and the association with cancer mortality was non-significant 0.92 (95% CI: 0.58, 1.48). In the gender-stratified analysis, we found an inverse strong association between adherence to healthy lifestyle and mortality from all causes and cardiovascular disease in either gender, but no significant relationship was seen with mortality from cancer in men or women. Stratified analysis of BMI status revealed an inverse significant association between adherence to healthy lifestyle and mortality from all causes, cardiovascular disease and cancer among non-obese participants.
  
  
  CONCLUSIONS
  We found evidence indicating that adherence to a healthy lifestyle, compared to non-healthy lifestyle, was associated with decreased risk of all-cause mortality and mortality from cardiovascular diseases in Iranian adults.
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Akbar
authors.initials: A
authors.lastname: Fazel-Tabar Malekshah
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Marsa
authors.initials: M
authors.lastname: Zaroudi
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.
authors.forename: Arash
authors.initials: A
authors.lastname: Etemadi
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran, Surveillance and Health Services Research, American Cancer Society, Atlanta, USA.
authors.forename: Farhad
authors.initials: F
authors.lastname: Islami
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Sadaf
authors.initials: S
authors.lastname: Sepanlou
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Maryam
authors.initials: M
authors.lastname: Sharafkhah
authors.affiliation: Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Abbas-Ali
authors.initials: AA
authors.lastname: Keshtkar
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Hooman
authors.initials: H
authors.lastname: Khademi
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Hossein
authors.initials: H
authors.lastname: Poustchi
authors.affiliation: Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Azita
authors.initials: A
authors.lastname: Hekmatdoost
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Akram
authors.initials: A
authors.lastname: Pourshams
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Akbar
authors.initials: A
authors.lastname: Feiz Sani
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Elham
authors.initials: E
authors.lastname: Jafari
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran, Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, Maryland, USA.
authors.forename: Farin
authors.initials: F
authors.lastname: Kamangar
authors.affiliation: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.
authors.forename: Sanford M
authors.initials: SM
authors.lastname: Dawsey
authors.affiliation: Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.
authors.forename: Christian C
authors.initials: CC
authors.lastname: Abnet
authors.affiliation: Departments of Oncology and Public Health and Primary Care, University of Cambridge, UK.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Pharoah
authors.affiliation: International Prevention Research Institute, Lyon, France.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Berennan
authors.affiliation: The Tisch Cancer Institute and Institute for Translational Epidemiology, Mount Sinai School of Medicine, New York, USA.
authors.forename: Paolo
authors.initials: P
authors.lastname: Boffetta
authors.affiliation: Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran, Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran, Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Esmaillzadeh
authors.affiliation: Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Reza
authors.initials: R
authors.lastname: Malekzadeh
mesh_terms: D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000401:mortality*; D015331:Cohort Studies; D003906:Developing Countries; D015930:Diet Records; D005260:Female; D015438:Health Behavior; D000070497:Healthy Lifestyle; D006801:Humans; D007492:Iran / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009369:Neoplasms / Q000401:mortality*; D012307:Risk Factors; D012907:Smoking / Q000453:epidemiology; D011795:Surveys and Questionnaires