A Healthy Lifestyle Has Substantial Benefit for Preventive Medication Users

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Aspirin, antihypertensives and lipid-lowering drugs are increasingly used by U.S. adults to prevent cardiovascular disease, and aspirin reduces the risk of certain cancers including colorectal cancer. Clinicians sometimes raise concerns about the "health certificate effect"—the notion by some patients that they don't need to make lifestyle changes because they're using preventive medication.

In a large cohort with a quarter-century of follow-up, Mingyang Song, MD, ScD, assistant professor in the Department of Medicine and researcher in the Division of Gastroenterology at Massachusetts General Hospital, and colleagues found a similar benefit of a healthy lifestyle among regular users and nonusers of common preventive medications. Their findings appear in the Journal of the American Heart Association.

Study Details

The data from this study were drawn from two ongoing U.S. epidemiologic studies: the Nurses' Health Study (NHS, 121,700 female registered nurses ages 30–55 when enrolled in 1976) and the Health Professionals Follow-up Study (HPFS, 51,529 male health professionals ages 40–75 in 1986). For the current analysis, the baselines were 1986 and 1988, respectively, when participants began to be asked about preventive medications.

The researchers defined a healthy lifestyle as:

• Body mass index ≥18.5 and <27.5 kg/m²
• Never smoking
• Moderate to vigorous physical activity for ≥30 minutes/day
• Light to moderate alcohol intake (>0 and <1 drink per day for women, <2 for men)
• Alternate Healthy Eating Index score within the upper 40th percentile for each cohort (assesses food choices associated with reduced chronic disease risk)

118,587 participants were followed for a median of 26 years (2,818,177 person-years). Overall, 72% of person-years in the NHS and 70% in the HPFS involved preventive use of aspirin, antihypertensives and/or lipid-lowering medications.

Lifestyle Factors and All-cause Mortality

Individually, all five lifestyle factors were significantly associated with all-cause mortality, and the associations were similar between medication users and nonusers.

When the five factors were analyzed collectively as a healthy lifestyle score (possible score 0–5), each increment in score was associated with an HR for all-cause mortality of 0.82 among medication users and 0.81 among medication nonusers (P for interaction = 0.54).

Risk of Premature Death

The researchers calculated hypothetical population-attributable risks (PARs) to estimate the proportion of premature deaths that could have been avoided if all participants in each cohort had adhered to the healthy lifestyle practices, assuming a causal relationship between lifestyle and mortality:

• For each lifestyle factor, similar PARs were observed among medication users and nonusers
• For all five lifestyle factors combined, the PAR was 38% among medication users and 40% among nonusers
• There was no substantial difference in PARs for users of aspirin, antihypertensives and lipid-lowering medications considered as separate groups

Counseling Patients

This study provides support for combining preventive pharmacologic therapy with lifestyle modification. A figure worth citing to patients is that even among individuals regularly using preventive medications, about 40% of premature deaths are potentially preventable through a healthy lifestyle. This benefit did not appear to vary according to the indication for the medication use.

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