Abstract

Holy Qur’an recommends physical activity, eating healthy, and avoiding
addictive substances. All these recommendations are part of what is known as low-risk
lifestyle behaviors in modern medicine and have been associated with reduced risk of

cardiovascular mortality in individual studies. We conducted a systematic review and meta-
analysis to quantify the association of all-cause mortality with adherence to multiple low-risk

lifestyle behaviors.
METHODS: Searches in Medline, EMBASE, and Cochrane (through June 14, 2017) were
conducted. Prospective cohort studies reporting association between multiple-lifestyle
behaviors (at least three low-risk lifestyle behaviors including healthy diet) with risk of all-cause mortality were included. Low-risk lifestyle behaviors were defined as healthy body
weight (minimum BMI <25kg/m2), healthy diet (minimum daily intake of vegetables), regular
physical activity (minimum ≥20min/day, 3 times/week), smoking cessation
(minimum >12months), and moderate alcohol consumption (up to 30g/day). Two
independent reviewers extracted the data and assessed study quality (Newcastle-Ottawa
Scale). Risk estimates of extreme comparisons were pooled using inverse variance random
effects models. Inter-study heterogeneity was assessed (Cochran Q statistic) and quantified
(I2 statistic). The overall certainty of evidence was assessed using the Grading of
Recommendations, Assessment, Development, and Evaluation (GRADE) approach.
RESULTS: 21 cohort comparisons (696,476 participants, 69,679 all-cause mortality cases)
were eligible. Adherence to all possible low-risk lifestyle behaviors compared to none was
associated with a 55% lower incidence of cardiovascular disease (risk ratio, 0.45 [95%
confidence interval, 0.37 to 0.55]). The overall certainty of the evidence was graded as
“high” using the GRADE system owing to upgrades for a large magnitude of effect and
significant dose-response gradient in the absence of any downgrades.