Among postmenopausal women with a normal body mass index (BMI) and no history of cardiovascular disease (CVD), maintaining a healthy lifestyle based on diet, physical activity, and other modifiable behavioral risk factors was significantly associated with a lower risk of a first CVD event. over a 20-year follow-up period, according to new research published in Journal of the American Heart Association.

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The study, based on a cohort of more than 40,000 women in the Women’s Health Initiative (WHI; 1993-1998), suggests that adherence to recommended lifestyle guidelines provides significant CV benefits beyond body weight, where a “healthy” weight is generally understood to be essential to reduce the risk of CVD-related morbidity and mortality.

“Several studies have shown that a relatively high healthy lifestyle index, which reflects a high-quality diet, moderate to vigorous physical activity, low alcohol consumption, a relatively small waist circumference and no cigarette smoking, is associated with a lower risk of cardiovascular disease. Rita Peila, PhD, of the Department of Epidemiology and Population Health at Albert Einstein College of Medicine in New York, and colleagues wrote.

“Although previous studies have examined the association of individual behavioral factors, such as physical inactivity, with the risk of cardiovascular disease among women with a normal BMI, none have examined whether the combination of these factors, as reflected in a higher healthy lifestyle index, is associated with a lower risk of cardiovascular disease among individuals with a normal BMI.

To carry out the assessment, Peila and her team created a Healthy Lifestyle Index (HLI) based on 5 lifestyle-related factors: waist circumference, cigarette smoking, alcohol consumption, diet quality and leisure time exercise. A score (0–4) was assigned to the individual categories of each lifestyle component, with higher scores reflecting healthier behaviors. The scores for each factor were summed to form a composite HLI score (0–20), again with higher scores indicating healthy coping.

Participant data were extracted from the WHI with the final cohort for analysis consisting of 40 118 women aged 40-59 years with a BMI between 18.5 and 25.0 kg/m2 and without a history of CVD. Participants were then stratified according to quintiles of calculated HLI scores.

The primary outcome was the first event of cardiovascular events including stroke, angina, angina requiring hospitalization, and coronary angioplasty, as defined in the WHI.


Peila et al. reported that during a median follow-up of 20.1 years, there were 3821 documented cases of a first CVD event. They found that women in the higher quintiles of HLI scores compared with those in the lowest quintiles had a lower overall risk of cerebrovascular events with hazard ratios (HRs) as follows: quintile 2, HR 0.74; 95% CI, 0.67-0.81; quintile 3, HR 0.66; 95% CI, 0.6-0.72; quintile 4, HR 0.57; 95% CI, 0.51-0.63; quintile 5, HR 0.48; 95% CI, 0.43-0.54 (P for trends <.001).

They also reported an inverse relationship between HLI and risk of CVD events—stroke, CHD, MI, angina, and coronary revascularization. Furthermore, the inverse association between HLI score and CVD risk remained significant in subgroup analyses, stratified by age (≤63 years vs. >63 years), BMI (/≥ 22.0 kg/m).2), and general health status, eg absence/presence of hypertension, diabetes or lipid-lowering drug use.

In separate analyses, where 1 HLI component at a time is excluded from the total HLI score, the researchers reported no change in the association between healthy lifestyle and cardiovascular disease, “suggesting that no specific behavioral habit alone was responsible for relationship observed,” they wrote.

As the prevalence of overweight and obesity steadily increases worldwide, public health recommendations emphasize lifestyle changes aimed at weight loss or weight maintenance in a “healthy” range. Recognizing this need, Peila and colleagues point to their findings suggesting that lifestyle changes to reduce CVD risk may be important even when BMI is normal.

“In fact, we found that compared to those with the lowest levels of HLI, even those with moderate HLI levels, due to different correlates of different lifestyle behaviors, have a lower risk of CVD,” said Peira et al. “This trend was present in various subgroups of postmenopausal women, regardless of their BMI, age, or health status, despite differences in baseline risk in the reference categories, as reported by incidence.”

As a major limitation of the study, the researchers note the lack of information on changes in the participants’ lifestyles during the 2 decades of follow-up that could have influenced the observed associations.

Reference: Peila R, Xue X, Qi Q, et al. Healthy lifestyle and risk of cardiovascular disease among postmenopausal women with normal body mass index. J Am Heart Assoc. 2023; 12. Published online June 12, 2023. doi: 10.1161/JAHA.122.029111

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