May 29, 2024

Following evaluation of 5 factors related to lifestyle and their impact on heart failure–related outcomes—smoking status, alcohol consumption, diet quality, physical activity, and weight status—the authors of a new study in European Journal of Epidemiology have determined that living a healthy lifestyle has a positive impact on both overall life expectancy and years free of heart failure.

Noting that previous studies have investigated the independent association each of the above factors has in relation to heart failure risk and mortality outcomes, the authors wrote, “these lifestyle factors are interrelated and their effect should therefore be considered in conjunction. Our main goal, therefore was to address the etiological question whether overall lifestyle influences the average number of years lived with and without heart failure.”

The lifestyle score created from the 5 factors mentioned above was stratified into 3 levels: unhealthy (reference; 0-3), moderate (4-6), and healthy (7-10).

Data for the factors were collected from 1995 through 2008 on 6113 individuals (mean [SD] age, 65.8 [9.7] years; women, n = 3598; men, n = 2515). Most were classified as overweight (41.6%, women; 54.5%, men), followed by normal weight (33.5% and 30.3%, respectively) or obese (25.0% and 15.2%). More women than men had no smoking history (44.2% vs 16.5%), and more men than women were current smokers (22.6% vs 17.2%).

Reduced risks for incident heart failure were seen among those who had healthy lifestyle vs unhealthy lifestyle scores. For men, their risk of heart failure was reduced by 53% and for women, 30%. In addition, every 1-point increase in lifestyle score correlated with overall 11% and 9% risk reductions, respectively. Mortality risks were lowered, too, but not by much: 11% in men, and 13% in women.

In the study participants without heart failure, living a healthy vs unhealthy lifestyle correlated with a 45% reduced risk of an early death among men and 39% among women. Transitioning from no heart failure to first event was most strongly influenced by weight vs the other lifestyle factors, and from heart failure to death, smoking status exerted the most influence.

Overall longer life expectancies were seen in both the women and men, as well as those free of heart failure, upon comparison of the healthy and moderate lifestyle categories with the unhealthy lifestyle category, respectively at the ages of 45, 65, and 85 years.

The following increases in total life expectancy were seen from having moderate and lifestyle category scores, respectively, vs unhealthy category scores:

  • 45-year-old men: 2.1 and 4.4 years
  • 45-year-old women: 2.3 and 3.4 years
  • 65-year-old men: 1.7 and 4.0 years
  • 65-year-old women: 2.0 and 3.1 years
  • 85-year-old men: 0.8 and 2.0 years
  • 85-year-old women: 1.0 and 1.6 years

Corresponding heart failure–free life-years gained are 2.1 and 4.8, 1.8 and 4.4, and 0.9 and 2.3 years among the men and 2.3 and 3.4, 2.0 and 3.1, and 1.1 and 1.7 among the women.

The final year of study follow-up was 2016, and the average follow-up was 11.3 years. Heart failure events totaled 699 (women, n = 379; men, n = 320), and 35% (women, n = 1149; men, n = 997) of the entire study cohort died. This study was a subanalysis of 3 subcohorts of the Rotterdam Study, from the Netherlands. Physical activity levels, smoking status, alcohol use, and diet quality were self-reported; weight status was determined by research center staff; and heart failure was diagnosed according to European Society of Cardiology criteria.

The authors did not find that one lifestyle factor exerted more influence over all 5 vs the others, and they attribute this to the fact that all of the lifestyle factors they evaluated are important influences. “Indeed several mechanisms have been proposed to contribute to the association between individual lifestyle factors and heart failure,” they wrote.

Several examples include that poor diet and little physical activity can lead to higher body mass index and inflammation, which itself can lead to hypertension and diabetes; heavy alcohol use can damage the heart muscle; and smoking can lead to hypertension and coronary artery diseases. All of these are major causes of heart failure, the authors noted, adding that their findings also echo previous studies.

“We add to the literature that an overall healthy lifestyle may not only improve total life expectancy but also life expectancy without heart failure, and that there is not one major driving factor,” they concluded. “Focusing on healthy lifestyle in the prevention and treatment of heart failure is of major importance and should also be addressed in the older population. Hereby the focus should be on overall lifestyle and not only on a single aspect.”


Limpens MAM, Asllanaj E, Dommershuijsen LJ, et al. Healthy lifestyle in older adults and life expectancy with and without heart failure. Eur J Epidemiol. Published online January 27, 2022. doi:10.1007/s10654-022-00841-0