The impact of health behavior trajectories on all-cause and cause-specific mortality: an analysis using the National Health Insurance Service-National Health Screening Cohort in Korea.

Abstract

Objectives: Non-communicable diseases account for approximately 75% of global deaths and nearly 80% of deaths in Korea. Although the World Health Organization emphasizes the long-term management of multiple health behaviors (HBs), most studies have examined individual behaviors over short periods, thereby overlooking behavioral changes and their long-term effects. This study assessed how combined health behavior trajectories (HBTs) were associated with mortality risk, with consideration of sex-specific and age-specific differences.

Methods: Using the National Health Insurance Service-National Health Screening Cohort in Korea, we analyzed 167,343 Korean adults aged 40-79 years, including 95,226 male participants and 72,117 female participants. The mean follow-up duration was 10.34 years for male participants and 10.65 years for female participants. Group-based multi-trajectory modeling was used to identify trajectories of tobacco use, alcohol consumption, physical activity, and body mass index. Associations with all-cause, cancer, and cardiovascular disease (CVD) mortality were examined using time-dependent Cox proportional hazards models stratified by sex and age.

Results: Six distinct HBTs were identified in each sex, including a decreasing-risk trajectory that reflected improvements across multiple behaviors. Among male participants, the higher severe-risk group had markedly elevated all-cause mortality (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.63 to 2.51) and CVD mortality (HR, 3.17; 95% CI, 2.01 to 4.99). Among female participants, the severe-risk group had significantly higher risks of all-cause mortality (HR, 1.83; 95% CI, 1.43 to 2.34), cancer mortality (HR, 1.91; 95% CI, 1.20 to 3.05), and CVD mortality (HR, 2.68; 95% CI, 1.77 to 4.05). The decreasing-risk trajectory was associated with lower all-cause mortality in both sexes, particularly among individuals aged ≥65 years (male participants: HR, 0.87; 95% CI, 0.80 to 0.94; female participants: HR, 0.88; 95% CI, 0.79 to 0.98).

Conclusions: Distinct sex-specific HBTs were strongly associated with mortality. Sustained improvements across multiple HBs were associated with substantially lower long-term mortality. These findings support preventive health policies that target middle-aged and older populations.