Dynamic cross-lagged effects between healthy lifestyles and multimorbidity among middle-aged and older adults in China


  • Halpin HA, Morales-Suárez-Varela MM, Martin-Moreno JM. Chronic disease prevention and the new public health. Public Health Rev. 2010;32(1):120–54.

    Article 

    Google Scholar 

  • Zhou M, Wang H, Zeng X, Yin P, Zhu J, Chen W, et al. Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2019;394(10204):1145–58.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zhao Y, Atun R, Oldenburg B, et al. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in china: an analysis of Population-Based panel Data-All databases. Lancet Global Health. 2020;8(6):e840–9.

    Article 
    PubMed 

    Google Scholar 

  • Hu Y, Wang Z, He H, Pan L, Tu J, Shan G. Prevalence and patterns of multimorbidity in China during 2002-2022: A systematic review and meta-analysis. Ageing Research Reviews. 2024;93:102165–80.

  • The Academy of Medical Sciences. Multimorbidity: a priority for global health research. London: Academy Of Medical Sciences; 2018.

    Google Scholar 

  • Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of Multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37–43.

    Article 
    PubMed 

    Google Scholar 

  • Skou ST, Mair FS, Fortin M, et al. Multimorbidity Nat Rev Dis Primers. 2022;8(1):48.

    Article 
    PubMed 

    Google Scholar 

  • The State Council Information Office of China. China implements gradual retirement age increase to address population aging. http://english.scio.gov.cn/chinavoices/2025-01/02/content_117641102.html. (17 January 2025, data last accessed).

  • Zhang X, Dupre ME, Qiu L, et al. Urban-rural differences in the association between access to healthcare and health outcomes among older adults in China. BMC Geriatr. 2017;17:151.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Xue L, Cai M, Liu Q, et al. Trends and regional variations in chronic diseases and their risk factors in china: an observational study based on National health service surveys. Int J Equity Health. 2023;22:120.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • World Health Organization. Major NCDs and their risk factors. https://www.who.int/ncds/introduction/en/. (7 January 2025, data last accessed).

  • Steel N, Ford JA, Newton JN, et al. Changes in health in the countries of the UK and 150 english local authority areas 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2018;392(10158):1647–61.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Pinto J, Bradbury K, Newell D, et al. Lifestyle and health behaviour change support in traditional acupuncture: a mixed method survey study of reported practice (UK). BMC Complement Med Ther. 2022;22(1):1–12.

    Article 

    Google Scholar 

  • Li Y, Schoufour J, Wang DD, Dhana K, Pan A, Liu X, et al. Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study. BMJ. 2020;368:l6669–79.

  • Ye X, Liang M, Chen Z, Jiang X, Xie M, Xie X, et al. Association between healthy lifestyle on life course and Multimorbidity in adults: results from two National prospective cohort studies. BMC Public Health. 2024;24(1):2942.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zhong J, Chen L, Li C, Li J, Niu Y, Bai X, et al. Association of lifestyles and Multimorbidity with mortality among individuals aged 60 years or older: two prospective cohort studies. SSM Popul Health. 2024;26:101673.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Hu Y, Yang Y, Gao Y, et al. The impact of chronic diseases on the health-related quality of life of middle-aged and older adults: the role of physical activity and degree of digitization. BMC Public Health. 2024;24(1):2335.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • LeMasters K, Renson A, Zalla L, Martin CL, Edwards JK. Understanding the accumulation of Health-Related inequities over the life course using the mean cumulative count. Am J Epidemiol. 2023;192(9):1425–31.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Li Q, Yang Z, Zhu M, et al. Prevalence and risk factors of osteoporotic fracture among the elderly population in china: a multicenter cross-sectional study. Int Orthop (SICOT). 2024;48(5):1323–30.

    Article 

    Google Scholar 

  • LV K, Liu Y, Zhang X, et al. Prevalence of chronic kidney disease in a City of Northwestern china: a cross-sectional study. Int Urol Nephrol. 2023;55(8):2035–45.

    Article 
    PubMed 

    Google Scholar 

  • Freisling H, Viallon V, Lennon H, et al. Lifestyle factors and risk of Multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study. BMC Med. 2020;18:5.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Nguyen H, Chua KC, Dregan A, et al. Factors associated with Multimorbidity patterns in older adults in england: findings from the english longitudinal study of aging (ELSA). J Aging Health. 2020;32(9):1120–32.

    Article 
    PubMed 

    Google Scholar 

  • Wister A, Cosco T, Mitchell B, Fyffe I. Health behaviors and Multimorbidity resilience among older adults using the Canadian longitudinal study on aging. Int Psychogeriatr. 2020;32(1):119–33.

    Article 
    PubMed 

    Google Scholar 

  • Dong, Zhao. Key roles of five lifestyle risk factors in the harmful transition from a healthy condition to Multimorbidity in the Chinese population. Eur Heart J. 2021;42(34):7.

    Google Scholar 

  • Ni W, Yuan X, Zhang Y, et al. Sociodemographic and lifestyle determinants of Multimorbidity among community-dwelling older adults: findings from 346,760 SHARE participants. BMC Geriatr. 2023;1:419.

    Article 

    Google Scholar 

  • Xing X, Yang X, Chen J, et al. Multimorbidity, healthy lifestyle, and the risk of cognitive impairment in Chinese older adults: a longitudinal cohort study. BMC Public Health. 2024;24:46.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Ho IS, Azcoaga-Lorenzo A, Akbari A, et al. Examining variation in the measurement of Multimorbidity in research: a systematic review of 566 studies. Lancet Public Health. 2021;6(8):e587–97.

    Article 
    PubMed 

    Google Scholar 

  • Lin YW, Hu YD, Guo JH, Chen MJ, Xu XY, Wen YY, et al. Association between sleep and Multimorbidity in Chinese elderly: results from the Chinese longitudinal healthy longevity survey (CLHLS). Sleep Med. 2022;98:1–8.

    Article 
    PubMed 

    Google Scholar 

  • Lim SS, Vos T,,Flaxman DA, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2013;380(9859):2224–60.

    Article 

    Google Scholar 

  • Hurst JR, Agarwal G, van Boven JFM, Daivadanam M, Gould GS, Huang EWC, et al. Critical review of Multimorbidity outcome measures suitable for low-income and middle-income country settings: perspectives from the global alliance for chronic diseases (GACD) researchers. BMJ Open. 2020;10(9):e037079.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Li BJ, Fan YJ, Bz A, Zhao BB, Yang LH, Yang J, et al. Later bedtime is associated with angina pectoris in middle-aged and older adults: results from the sleep heart health study. Sleep Med. 2021;79:1–5.

    Article 
    PubMed 

    Google Scholar 

  • World Health Organization. Guidelines on physical activity and sedentary behaviour. https://www.who.int/publications/i/item/9789240015128. (7 April 2025, data last accessed).

  • General Administration of Sport of China. China issues national fitness plan for 2021–2025. http://www.china.org.cn/china/2021-08/08/content_77680600.htm. (7 April 2025, data last accessed).

  • National Health Commission of the People’s Republic of China. Notice of the General Office of the National Health Commission of the People’s Republic of China on the issuance of nutrition and exercise guidelines for chronic diseases such as hypertension (2024 edition). https://www.gov.cn/zhengce/zhengceku/202407/content_6960475.htm. (7 April 2025, data last accessed).

  • National Health Commission of the People’s Republic of China. Notice of the General Office of the National Health Commission on Issuing the Guiding Principles for Weight Management. (2024 Edition).http://www.nhc.gov.cn/ylyjs/s3573d/202412/4cf1905d32304c15ac3bc4446ddb83f1.shtml. (7 April 2025, data last accessed).

  • Fisher K, Griffith LE, Gruneir A, Kanters D, Markle-Reid M, Ploeg J. Functional limitations in people with Multimorbidity and the association with mental health conditions: baseline data from the Canadian longitudinal study on aging (CLSA). PLoS ONE. 2021;16(8):e0255907.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Mulder JD, Hamaker EL. Three extensions of the random intercept Cross-Lagged panel model. Struct Equation Modeling: Multidisciplinary J. 2020;28(4):638–48.

    Article 

    Google Scholar 

  • Constandt B, Thibaut E, De Bosscher V, Scheerder J, Ricour M, Willem A. Exercising in times of lockdown: an analysis of the impact of COVID-19 on levels and patterns of exercise among adults in Belgium. Int J Environ Res Public Health. 2020;17(11):4144.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Faulkner J, O’Brien WJ, McGrane B, Wadsworth D, Batten J, Askew CD, et al. Physical activity, mental health and well-being of adults during initial COVID-19 containment strategies: A multi-country cross-sectional analysis. J Sci Med Sport. 2021;24(4):320–6.

    Article 
    PubMed 

    Google Scholar 

  • Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, et al. Impact of social isolation due to COVID-19 on health in older people: mental and physical effects and recommendations. J Nutr Health Aging. 2020;24(9):938–47.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zheng Z, Peng F, Xu B, Zhao J, Liu H, Peng J, et al. Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis. J Infect. 2020;81(2):e16–25.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Hirko KA, Kerver JM, Ford S, Szafranski C, Beckett J, Kitchen C, et al. Telehealth in response to the COVID-19 pandemic: implications for rural health disparities. J Am Med Inf Assoc. 2020;27(11):1816–8.

    Article 

    Google Scholar 

  • Karaye IM, Horney JA. The impact of social vulnerability on COVID-19 in the U.S.: an analysis of spatially varying relationships. Am J Prev Med. 2020;59(3):317–25.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Hale T, Angrist N, Goldszmidt R, et al. A global panel database of pandemic policies (Oxford COVID-19 government response Tracker). Nat Hum Behav. 2021;5:529–38.

    Article 
    PubMed 

    Google Scholar 

  • Podsakoff PM, Organ DM. Self-reports in organizational research: problems and prospects. J Manag. 1986;12(4):531–44.

    Google Scholar 

  • Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879–903.

    Article 
    PubMed 

    Google Scholar 

  • Falkenström F, Solomonov N, Rubel JA. How to model and interpret cross-lagged effects in psychotherapy mechanisms of change research: A comparison of multilevel and structural equation models. J Consult Clin Psychol. 2022;90(5):446–58.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Griffin SC, Ravyts SG, Bourchtein E, Ulmer CS, Leggett MK, Dzierzewski JM, et al. Sleep disturbance and pain in U.S. Adults over 50: evidence for reciprocal, longitudinal effects. Sleep Med. 2021;86:32–9.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Keessen P, Kan KJ, Ter Riet G, Visser B, Jørstad HT, Latour CHM, et al. The longitudinal relationship between fear of movement and physical activity after cardiac hospitalization: A cross lagged panel model. PLoS ONE. 2024;19(4):e0297672.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Sun Q, Yu D, Fan J, Yu C, Guo Y, Pei P, et al. Healthy lifestyle and life expectancy at age 30 years in the Chinese population: an observational study. Lancet Public Health. 2022;7(12):e994–1004.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zhang YX, Zhou L, Liu SY, Qiao YN, Wu Y, Ke CF, Shen YP. Prevalence, correlates and outcomes of Multimorbidity among the middle-aged and elderly: findings from the China health and retirement longitudinal study.archives of gerontology and geriatrics: an international journal integrating experimental. Clin Social Stud Ageing. 2020;90(1):1–6.

  • Chakravarti D, LaBella KA, DePinho RA. Telomeres: history, health, and hallmarks of aging. Cell. 2021;184(2):306–22.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Keshavarz M, Xie K, Schaaf K, Bano D, Ehninger D. Targeting the hallmarks of aging to slow aging and treat age-related disease: fact or fiction? Mol Psychiatry. 2023;28(1):242–55.

    Article 
    PubMed 

    Google Scholar 

  • Liu Y, Wang J, Huang Z, Liang J, Xia Q, Xia Q, Liu X. Environmental pollutants exposure: A potential contributor for aging and age-related diseases. Environ Toxicol Pharmacol. 2021;83:103575.

    Article 
    CAS 
    PubMed 

    Google Scholar 

  • Nevalainen T, Kananen L, Marttila S, Jylhävä J, Mononen N, Kähönen M, Raitakari OT, Hervonen A, Jylhä M, Lehtimäki T, Hurme M. Obesity accelerates epigenetic aging in middle-aged but not in elderly individuals. Clin Epigenetics. 2017;9:20.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Johnson AA, Akman K, Calimport SR, Wuttke D, Stolzing A, de Magalhães JP. The role of DNA methylation in aging, rejuvenation, and age-related disease. Rejuvenation Res. 2012;15(5):483–94.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Sakib MN, Shooshtari S, St JP, Menec V. The prevalence of Multimorbidity and associations with lifestyle factors among middle-aged canadians: an analysis of Canadian longitudinal study on aging data. BMC Public Health. 2019;19(1):243.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Wu F. Intergenerational support and life satisfaction of older parents in china: A Rural–Urban divide. Soc Indic Res. 2022;160:1071–98.

    Article 

    Google Scholar 

  • Wu Y, Gong C, Pi L, Zheng M, Liu W, Wang Y. Interrelationships among individual factors, family factors, and quality of life in older Chinese adults: Cross-Sectional study using structural equation modeling. JMIR Aging. 2024;7:e59818.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Burnier M. The role of adherence in patients with chronic diseases. Eur J Intern Med. 2024;119:1–5.

    Article 
    CAS 
    PubMed 

    Google Scholar 

  • Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215.

    Article 
    CAS 
    PubMed 

    Google Scholar 

  • Chen J, Tian Y, Yin M, Lin W, Tuersun Y, Li L, Yang J, Wu F, Kan Y, Li X, Gan Y, Sun X, Wu Y, He F. Relationship between self-efficacy and adherence to self-management and medication among patients with chronic diseases in china: A multicentre cross-sectional study. J Psychosom Res. 2023;164:111105.

    Article 
    PubMed 

    Google Scholar 

  • María José Martos-Méndez. Self-efficacy and adherence to treatment: the mediating effects of social support. J Behav Health Social Issues. 2015;7(2):19–29.

    Article 

    Google Scholar 

  • Yin H, Knowlton B. The role of the basal ganglia in habit formation. Nat Rev Neurosci. 2006;7:464–76.

    Article 
    CAS 
    PubMed 

    Google Scholar 

  • Chen X, Ai C, Liu Z, et al. Neuroimaging studies of resting-state functional magnetic resonance imaging in eating disorders. BMC Med Imaging. 2024;24:265.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Wyatt Z. The neuroscience of habit formation. Neurol Neurosci. 2024;5(1):3.

    Article 

    Google Scholar 

  • Sum G, Lau LK, Jabbar KA, Lun P, George PP, Munro YL, Ding YY. The world health organization (WHO) integrated care for older people (ICOPE) framework: A narrative review on its adoption worldwide and lessons learnt. Int J Environ Res Public Health. 2022;20(1):154.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zhou Y, Zhou Y, Li L, Jin L. How to encourage consumers’ ongoing participation in physical exercise via feedback: evidence from a longitudinal field experiment. China Econ Rev. 2024;88:102268.

    Article 

    Google Scholar 

  • Blandford A, Wesson J, Amalberti R, AlHazme R, Allwihan R. Opportunities and challenges for telehealth within, and beyond, a pandemic. Lancet Glob Health. 2020;8(11):e1364–5.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Fan K, Zhao Y. Mobile health technology: a novel tool in chronic disease management. Intell Med. 2022;2(1):41–7.

    Article 

    Google Scholar 

  • Novara G, Checcucci E, Crestani A, et al. Telehealth in urology: A systematic review of the literature. How much can telemedicine be useful during and after the COVID-19 pandemic? Eur Urol. 2020;78(6):786–811.

    Article 
    CAS 
    PubMed 
    PubMed Central 

    Google Scholar 

  • World Health Organization. Atlas eHealth Country Profiles: Based on the Findings of the Second Global Survey on Ehealth. https://apps.who.int/iris/handle/10665/44502. (7 April 2025, data last accessed).

  • Wang Q, Zhang K, Zhang X, Fu J, Liu F, Gao Y, Lin R. WeChat mini-program, a preliminary applied study of the gestational blood glucose management model for pregnant women with gestational diabetes mellitus. Diabetes Res Clin Pract. 2025;219:111943.

    Article 
    PubMed 

    Google Scholar 

  • Ma X, Fan W, Zhang X, et al. The urban-rural disparities and factors associated with the utilization of public health services among diabetes patients in China. BMC Public Health. 2023;23:2290.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Tan XQ. The role of healthy lifestyles in preventing chronic disease among adults. Am J Med Sci. 2022;364(3):309–15.

    Article 
    PubMed 

    Google Scholar 

  • Tan MMC, Barbosa MG, Pinho PJMR, Assefa E, Keinert AÁM, Hanlon C, et al. Determinants of Multimorbidity in low- and middle-income countries: A systematic review of longitudinal studies and discovery of evidence gaps. Obes Rev. 2024;25(2):e13661.

    Article 
    PubMed 

    Google Scholar 

  • McCracken C, Raisi-Estabragh Z, Szabo L, Robson J, Raman B, Topiwala A, et al. NHS health check attendance is associated with reduced multiorgan disease risk: a matched cohort study in the UK biobank. BMC Med. 2024;22(1):1.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Berner K, Tawa N, Louw Q. Multimorbidity patterns and function among adults in low- and middle-income countries: a scoping review protocol. Syst Rev. 2022;11(1):139.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zhang X, Padhi A, Wei T, Xiong S, Yu J, Ye P, et al. Community prevalence and dyad disease pattern of Multimorbidity in China and india: a systematic review. BMJ Glob Health. 2022;7(9):e008880.

    Article 
    PubMed 
    PubMed Central 

    Google Scholar 

  • Zhang X, Liu T, Li Z, Yang J, Hou H, Hao T, et al. Using primary and routinely collected data to determine prevalence and patterns of Multimorbidity in rural china: a representative cross-sectional study of 6474 Chinese adults. Lancet Reg Health West Pac. 2024;54:101272.

    PubMed 
    PubMed Central 

    Google Scholar 

  • Krause AJ, Vallat R, Simon EB, Walker MP. Sleep loss influences the interconnected brain-body regulation of cardiovascular function in humans. Psychosom Med. 2023;85:34–41.

    PubMed 

    Google Scholar 


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