Abstract
We examined the effect of education level on the association between healthy lifestyle behaviors and cardiovascular mortality in the Japanese population. A total of 42,647 community-based men and women aged 40–79 years were enrolled at baseline (1988–1990), followed through 2009. The components of the healthy lifestyle score included the intake of fruits, fish, and milk; body mass index; exercise; avoidance of smoking; moderate alcohol intake; and moderate sleep duration. During the 19.3 years of follow-up, 8,314 all-cause and 2,377 total cardiovascular mortality cases were noted. Inverse associations were observed between healthy lifestyle scores and total cardiovascular disease (CVD) for both the lower and higher education level groups. Multivariable hazard ratios (95% confidence interval) for CVD mortality from the highest to the lowest healthy lifestyle scores, and the population attributable fraction (95% CIs) without healthy lifestyle scores of 7–8 were 0.51 (0.33–0.52) and 42% (24–58%), and 0.38 (0.27–0.47) and 55% (36–69%) for the higher and lower education levels, respectively. Our findings suggest that the association between higher CVD mortality and lower education level can be explained by the individuals’ lower adherence to a healthy lifestyle; hence, lifestyle modification would be beneficial for the prevention of cardiovascular mortality, irrespective of the education level.
Highlights
We examined the effect of education level on the association between healthy lifestyle behaviors and cardiovascular mortality in the Japanese population
In the present study, we aimed to assess the effects of education level on the association between lifestyle behaviors and cardiovascular or all-cause mortality, by examining the extent of impact of lifestyle behaviors on cardiovascular disease (CVD) and all-cause mortality according to the education stratum, and by evaluating the effect modification of education on the association between lifestyle behaviors and CVD or all-cause mortality among Japanese men and women
We estimated the multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for total CVD and all-cause mortality with modified lifestyle scores, including sleep duration of 5.5–8.4 hours considered as a healthy lifestyle with reference scores of 0–3, as well as another sensitivity analysis with the binominal diet score in addition to the modified sleep score considered as a healthy lifestyle with reference scores of 0–1, stratified by education level, using Cox proportional hazard models
Summary
This is a large-scale, population-based cohort study of several lifestyle variables and multiple potential confounding variables. Thereafter, we estimated the multivariable-adjusted HRs and 95% CIs for mortality from stroke, CHD, total CVD, and all-cause in those with higher healthy lifestyle score categories, compared to those with the lowest lifestyle score categories (0–3) during the follow-up period, stratified by education level, by using Cox proportional hazard models. We estimated the multivariable-adjusted HRs and 95% CIs for total CVD and all-cause mortality with modified lifestyle scores, including sleep duration of 5.5–8.4 hours considered as a healthy lifestyle with reference scores of 0–3, as well as another sensitivity analysis with the binominal diet score (with vegetable and bean intake in addition to fruit, fish, and milk intake) in addition to the modified sleep score considered as a healthy lifestyle with reference scores of 0–1, stratified by education level, using Cox proportional hazard models. All the probability values for the statistical tests were two-tailed, and P values of < 0.05 were regarded as statistically significant
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