Abstract

OBJECTIVES
Noncommunicable diseases account for approximately 75% of global deaths and nearly 80% of deaths in South Korea. Although the World Health Organization emphasizes the long-term management of multiple health behaviors (HBs), most studies have examined individual behaviors over short periods, thereby overlooking behavioral changes and their long-term effects. This study assessed how combined health behavior trajectories (HBTs) were associated with mortality risk, with consideration of sex- and age-specific differences.
METHODS
Using the National Health Insurance Service–Health Screening Cohort, we analyzed 167,343 Korean adults aged 40–79 years, including 95,226 male and 72,117 female participants. The mean follow-up duration was 10.34 years for male participants and 10.65 years for female participants. Group-based multi-trajectory modeling was used to identify trajectories of tobacco use, alcohol consumption, physical activity, and body mass index. Associations with all-cause, cancer, and cardiovascular disease (CVD) mortality were examined using time-dependent Cox proportional hazards models stratified by sex and age.
RESULTS
Six distinct HBTs were identified in each sex, including a decreasing-risk trajectory that reflected improvements across multiple behaviors. Among male participants, the higher severe-risk group had markedly elevated all-cause mortality (hazard ratio [HR]: 2.02, 95% confidence interval [CI]: 1.63–2.51) and CVD mortality (HR: 3.17, 95% CI: 2.01–4.99). Among female participants, the severe-risk group had significantly higher risks of all-cause mortality (HR: 1.83, 95% CI: 1.43–2.34), cancer mortality (HR: 1.91, 95% CI: 1.20–3.05), and CVD mortality (HR: 2.68, 95% CI: 1.77–4.05). The decreasing-risk trajectory was associated with lower all-cause mortality in both sexes, particularly among individuals aged ≥65 years (male participants: HR: 0.87, 95% CI: 0.80–0.94; female participants: HR: 0.88, 95% CI: 0.79–0.98).
CONCLUSIONS
Distinct sex-specific HBTs were strongly associated with mortality. Sustained improvements across multiple HBs were associated with substantially lower long-term mortality. These findings support preventive health policies that target middle-aged and older populations.

• Keywords: Health behavior trajectory; Mortality; Smoking; Alcohol consumption; Physical activity; Body mass index