Adherence to Healthy Lifestyle Prior to Infection and Risk of Post–COVID-19 Condition
Prospective analysis of 32,249 women from the Nurses’ Health Study II in the USA, showing lower risk of PASC with a healthy lifestyle, and in a dose-dependent manner. Participants with 5 or 6 healthy lifestyle factors had significantly lower COVID-19 hospitalization and PASC. BMI and sleep were independently associated with risk of PASC.
risk of PASC, 9.0% lower, RR 0.91, p = 0.43, higher quality diet 124 of 318 (39.0%), lower quality diet 218 of 480 (45.4%), NNT 16, adjusted per study, Q5 vs. Q1, multivariable, model 2.
risk of PASC, 49.0% lower, RR 0.51, p = 0.002, higher quality diet 188, lower quality diet 66, 5 or 6 healthy lifestyle factors vs. 0.
risk of hospitalization, 78.1% lower, RR 0.22, p = 0.006, higher quality diet 5 of 188 (2.7%), lower quality diet 8 of 66 (12.1%), NNT 11, 5 or 6 healthy lifestyle factors vs. 0.
Effect extraction follows pre-specified rules prioritizing more serious outcomes. Submit updates
Wang et al., 6 Feb 2023, prospective, USA, peer-reviewed, survey, mean age 64.7, 8 authors, study period April 2020 - November 2021.
JAMA Internal Medicine | Original Investigation
Adherence to Healthy Lifestyle Prior to Infection
and Risk of Post–COVID-19 Condition
Siwen Wang, MD; Yanping Li, PhD; Yiyang Yue, MS; Changzheng Yuan, ScD; Jae Hee Kang, ScD;
Jorge E. Chavarro, MD, ScD; Shilpa N. Bhupathiraju, PhD; Andrea L. Roberts, PhD
IMPORTANCE Few modifiable risk factors for post–COVID-19 condition (PCC) have been
OBJECTIVE To investigate the association between healthy lifestyle factors prior to
SARS-CoV-2 infection and risk of PCC.
DESIGN, SETTING, AND PARTICIPANTS In this prospective cohort study, 32 249 women in the
Nurses’ Health Study II cohort reported preinfection lifestyle habits in 2015 and 2017. Healthy
lifestyle factors included healthy body mass index (BMI, 18.5-24.9; calculated as weight in
kilograms divided by height in meters squared), never smoking, at least 150 minutes per
week of moderate to vigorous physical activity, moderate alcohol intake (5 to 15 g/d), high
diet quality (upper 40% of Alternate Healthy Eating Index–2010 score), and adequate sleep
(7 to 9 h/d).
MAIN OUTCOMES AND MEASURES SARS-CoV-2 infection (confirmed by test) and PCC (at least
4 weeks of symptoms) were self-reported on 7 periodic surveys administered from April
2020 to November 2021. Among participants with SARS-CoV-2 infection, the relative risk
(RR) of PCC in association with the number of healthy lifestyle factors (0 to 6) was estimated
using Poisson regression and adjusting for demographic factors and comorbidities.
RESULTS A total of 1981 women with a positive SARS-CoV-2 test over 19 months of follow-up
were documented. Among those participants, mean age was 64.7 years (SD, 4.6; range,
55-75); 97.4% (n = 1929) were White; and 42.8% (n = 848) were active health care workers.
Among these, 871 (44.0%) developed PCC. Healthy lifestyle was associated with lower risk
of PCC in a dose-dependent manner. Compared with women without any healthy lifestyle
factors, those with 5 to 6 had 49% lower risk (RR, 0.51; 95% CI, 0.33-0.78) of PCC. In a model
mutually adjusted for all lifestyle factors, BMI and sleep were independently associated with
risk of PCC (BMI, 18.5-24.9 vs others, RR, 0.85; 95% CI, 0.73-1.00, P = .046; sleep, 7-9 h/d vs
others, RR, 0.83; 95% CI, 0.72-0.95, P = .008). If these associations were causal, 36.0% of
PCC cases would have been prevented if all participants had 5 to 6 healthy lifestyle factors
(population attributable risk percentage, 36.0%; 95% CI, 14.1%-52.7%). Results were
comparable when PCC was defined as symptoms of at least 2-month duration or having
ongoing symptoms at the time of PCC assessment.
CONCLUSIONS AND RELEVANCE In this prospective cohort study, pre-infection healthy lifestyle
was associated with a substantially lower risk of PCC. Future research should investigate
whether lifestyle interventions may reduce risk of developing PCC or mitigate symptoms
among individuals with PCC or possibly other postinfection syndromes.
JAMA Intern Med. doi:10.1001/jamainternmed.2022.6555
Published online February 6, 2023.
Author Affiliations: Department of
Nutrition, Harvard T.H. Chan School
of Public Health, Boston,
Massachusetts (Wang, Li, Yue, Yuan,
Chavarro, Bhupathiraju); Zhejiang
University School of Public Health,
Hangzhou, China (Yuan); Channing
Division of Network Medicine,
Department of Medicine,
Brigham and Women’s Hospital
and Harvard Medical School, Boston,
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