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Combined impact of lifestyle factors on mortality: prospective cohort study in US women

BMJ 2008; 337 doi: (Published 16 September 2008) Cite this as: BMJ 2008;337:a1440
  1. Rob M van Dam, assistant professor of medicine12,
  2. Tricia Li, research fellow1,
  3. Donna Spiegelman, professor of epidemiology and biostatistics34,
  4. Oscar H Franco, researcher5,
  5. Frank B Hu, professor of nutrition and epidemiology123
  1. 1Department of Nutrition, Harvard School of Public Health, 665 Huntington Ave, Boston, MA 02115, USA
  2. 2Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston MA 02115
  3. 3Department of Epidemiology, Harvard School of Public Health
  4. 4Department of Biostatistics, Harvard School of Public Health
  5. 5Unilever Corporate Research, Sharnbrook, Bedfordshire MK44 1LQ
  1. Correspondence to: R van Dam rvandam{at}
  • Accepted 22 July 2008


Objective To evaluate the impact of combinations of lifestyle factors on mortality in middle aged women.

Design Prospective cohort study.

Setting Nurses’ health study, United States.

Participants 77 782 women aged 34 to 59 years and free from cardiovascular disease and cancer in 1980.

Main outcome measure Relative risk of mortality during 24 years of follow-up in relation to five lifestyle factors (cigarette smoking, being overweight, taking little moderate to vigorous physical activity, no light to moderate alcohol intake, and low diet quality score).

Results 8882 deaths were documented, including 1790 from cardiovascular disease and 4527 from cancer. Each lifestyle factor independently and significantly predicted mortality. Relative risks for five compared with zero lifestyle risk factors were 3.26 (95% confidence interval 2.45 to 4.34) for cancer mortality, 8.17 (4.96 to 13.47) for cardiovascular mortality, and 4.31 (3.51 to 5.31) for all cause mortality. A total of 28% (25% to 31%) of deaths during follow-up could be attributed to smoking and 55% (47% to 62%) to the combination of smoking, being overweight, lack of physical activity, and a low diet quality. Additionally considering alcohol intake did not substantially change this estimate.

Conclusions These results indicate that adherence to lifestyle guidelines is associated with markedly lower mortality in middle aged women. Both efforts to eradicate cigarette smoking and those to stimulate regular physical activity and a healthy diet should be intensified.


  • We thank the participants of the nurses’ health study for their continued participation, Ellen Hertzmark for expert programming help, and Walter Willett and Meir Stampfer for their valuable comments on the manuscript. The article adheres to the STROBE guidelines (

  • Contributors: RMvD and FBH had the idea for the study. TL did the data analysis. RMvD, TL, DS, and FBH provided statistical expertise. RMvD wrote the first draft of the paper. FBH obtained funding. All authors contributed to the interpretation of the results and critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. RMvD is the guarantor.

  • Funding: This research was supported by National Institutes of Health (NIH) grants CA87969 and HL60712. RMvD was partly supported by an unrestricted research grant from the Peanut Foundation. The funding sources had no role in the collection, management, analysis, or interpretation of the data and had no role in the preparation, review, or approval of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

  • Competing interests: None declared.

  • Ethical approval: The institutional review board at Brigham and Women’s Hospital approved this study.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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