The Association of the Healthy Lifestyle Index (Hli) and Hli Trajectories With Risk of All-Cause and Cause-Specific Mortality: A Grade-Assessed Dose-Response Systematic Review and Meta-Analysis Publisher Pubmed



Hasanrashedi M ; Norouzzadeh M ; Gohari Dezfuli Z ; Jamshidi S ; Mehdipoor F ; Ghoreishy S M ; Teymoori F ; Shidfar F ; Eskandari R
Source: BMJ Open Published:2026

Abstract

Background: The Healthy Lifestyle Index (HLI) integrates key behaviours to assess their cumulative impact on health. While higher HLI adherence is linked to lower disease and mortality risk, its long-term trajectory association remains understudied. This study aims to examine the dose-response relationship and long-term association of HLI on mortality risks. Design: Systematic review and dose-response meta-analysis using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. Data sources: PubMed, Scopus and Web of Science were searched until June 2024. Eligibility criteria for selecting studies: We included observational cohort studies that assessed the relationship of HLI or its trajectories with all-cause, cardiovascular disease (CVD)-cause or cancer-cause of mortality. Result: Analysis of 13.7 million participants demonstrated that higher adherence to the HLI is linked to lower risk of all-cause (HR: 0.48; 95% CI 0.46 to 0.53; GRADE: moderate), CVD-cause (HR: 0.49; 95% CI 0.44 to 0.51; GRADE: moderate) and cancer-cause mortality (HR: 0.55; 95% CI 0.49 to 0.61; GRADE: low). These associations were further confirmed in a dose-response manner. Moreover, compared with maintaining an unhealthy lifestyle, a decline in HLI adherence was associated with a 14% higher risk of all-cause and a 19% higher risk of cancer-related mortality. In contrast, an improvement in HLI adherence was linked to a 20% lower risk of all-cause and a 13% lower risk of cancer-related mortality. Conclusion: Adherence to HLI and its long-term patterns are associated with lower mortality risk. These findings emphasise the importance of lifestyle-based prevention and intervention strategies in reducing mortality. PROSPERO registration number: CRD42024500538. © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/.