Healthy lifestyle partly mediates the association between self-rated health and risk of overall and cause-specific mortality

Self-rated health status is a subjective but important indicator of an individual's perception of overall health. However, it remains unclear whether lifestyle may mediate or modify the association of self-rated health status with overall and cause-specific mortality.
A prospective cohort analysis included 401,410 US adults from the National Institutes of Health-AARP Diet and Health Study. Self-rated health was categorised as "very good to excellent," "good," or "poor to fair." A healthy lifestyle was defined by a normal body mass index, never smoking, moderate alcohol consumption, adequate physical activity, and a higher diet quality score. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cause-specific mortality were estimated using multivariable-adjusted Cox models.
Over a median follow-up of 23.6 years, there were 181,776 deaths. Compared to individuals reporting "very good to excellent" health, those reporting "poor to fair" health faced a higher risk of overall mortality (HR = 1.90, 95% CI: 1.87-1.93), as well as deaths from cardiovascular disease (CVD), heart disease, stroke, cancer, respiratory disease, diabetes, infection, and injuries and accidents (risk increase ranged from 24% to 361%). Mediation analysis indicated that 5.1% to 33.6% of the observed associations were mediated by lifestyle factors. Self-rated health was more strongly linked to overall mortality than traditional risk factors, except for smoking. In comparison with individuals reporting "very good to excellent" health who maintained a healthier lifestyle, those reporting "poor to fair" health with a less healthy lifestyle showed a significantly higher risk of overall mortality and death from CVD, heart disease, cancer, and respiratory disease.
Poor self-rated health was significantly linked to a higher risk of overall and cause-specific mortality, with these links partly mediated by lifestyle. An additive positive interaction between self-rated health and lifestyle was observed for overall mortality and for deaths from CVD, heart disease, cancer, and respiratory disease. These findings highlight the clinical importance of self-rated health and imply that lifestyle changes may enhance health and lifespan, especially for those with low or moderate self-rated health.
Source: Miao, Y., Zhao, B., Yang, Y., et al. (2025). Healthy lifestyle partly mediates the association between self-rated health and risk of overall and cause-specific mortality. BMC Medicine, 23(1):574.