
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-193
10.4103/jehp.jehp_1156_23
Review Article
Lifestyle interventions improving health-related quality of life: A systematic review and meta-analysis of randomized control trials
Amiri Sohrab
Mahmood Nailah 1
Junaidi Sameeha 2
Khan Moien AB 3
Quran and Hadith Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
1 Department of Clinical Psychology, Snö Healthcare, Abu Dhabi, United Arab Emirates
2 Department of Public Health, RAK Medical and Health Sciences, United Arab Emirates University, Ras Al Khaimah, United Arab Emirates
3 Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
Address for correspondence: Dr. Moien AB Khan, Health and Wellness Research Group, Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates. E-mail: moien.khan@uaeu.ac.ae
2024
05 7 2024
13 19302 8 2023
03 10 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Lifestyle interventions have garnered significant research interest for their potential to enhance health-related quality of life (HRQoL). Understanding the impact of these interventions on various dimensions of HRQoL is crucial for effective healthcare strategies. This study aims to systematically review and meta-analyze the effects of lifestyle interventions on HRQoL in randomized control trials. A systematic search was conducted across five scientific databases, including PubMed, Web of Science, Scopus, the Cochrane Library, and gray literature, with a filter applied to include only English language publications. Study selection was carried out by two independent reviewers in several steps, including duplicate removal and eligibility evaluation for meta-analysis. Information extracted from the studies included authors, countries, study designs, target populations, ages, genders, number of participants, interventions, outcomes, and results. A total of 61 randomized control trials were included in this meta-analysis. The meta-analysis revealed that lifestyle interventions significantly improved healthrelated quality of life compared to control groups, with Hedges’ g of 0.38 (95% CI 0.25–0.50, Z = 5.94; P < 0.001; I2 = 84.59%). This positive effect was consistently observed in patients with heart-related diseases and metabolic disorders. Meta-regression analysis indicated that lifestyle interventions had the most substantial impact on health-related quality of life in the 1-month follow-up period. Considering the cost-effectiveness of lifestyle interventions compared to other intervention types, they can benefit various patient groups. This systematic review contributes to health policy goals by advocating focused preventive strategies in alignment with the observed benefits of lifestyle interventions.

Health lifestyle behaviors
health-related quality of life
lifestyle
lifestyle modification
lifestyle training
==== Body
pmcIntroduction

The burden of physical and mental diseases on the healthcare system is significant, resulting in health issues and social problems. Among the top global causes of death, noncommunicable diseases (NCDs) include diabetes, hypertension, and cardiovascular disease.[1,2] Furthermore, NCDs like cancer, obesity, and mental disorders contribute significantly to the burden of disease.[3] In the last three decades, NCD-adjusted life years (DALYs) have increased from 43.2% to 63.8%.[4] The prevalence of NCDs among adolescents is also high.[5]

A number of lifestyle factors contribute to the development of NCDs, including smoking, diet, physical activity, obesity, and alcohol consumption.[3,6,7] It is common for these behaviors to develop early in life and to persist throughout one’s life.[6] More than 200 million deaths have been caused by smoking alone in the past three decades, resulting in a US$ 1 trillion economic burden every year.[8,9] It is estimated that overweight and obesity have an economic impact of 2.19% to 3.3% of the Gross Domestic Product.[10] Health systems around the world were estimated to spend $53.8 billion on physical inactivity in 2013, causing 13.4 billion disability-adjusted life years.[11] In 2017, dietary risk factors were attributed to 11 million deaths and 255 million disabilities related to NCDs.[12,13,14] Various aspects of lifestyle affect different dimensions of health,[15] such as cardiometabolic health,[16,17] weight,[18] hypertension,[19] obstructive sleep apnea,[20] and mental health and well-being.[21,22,23]

Health-related quality of life (HRQoL) is a crucial aspect in assessing the impact of lifestyle interventions. It encompasses how well individuals can function in various aspects of their lives and their perceived well-being across the physical, mental, and social domains of health. In simpler terms, it focuses on evaluating how individuals are doing in their daily lives and how they perceive their overall well-being in relation to their physical, mental, and social health.[24] Another definition refers to ‘those aspects of self-perceived well-being that are related to or affected by the presence of disease or treatment.[25] Multiple factors affect the HRQoL, such as socio-economic status,[26] age,[27] unemployment,[28] and social support.[29] The impact of lifestyle interventions on HRQoL has been examined in previous review studies. In these studies, improvements in HRQoL were consistently demonstrated in individuals with chronic diseases such as metabolic disorders[30,31] and cancer.[32,33,34]

There are, however, several issues that remain unresolved in the existing literature. A first limitation of previous meta-analyses is that they have focused solely on metabolic diseases and cancer, ignoring other common conditions. Furthermore, lifestyle interventions have not been studied comprehensively in diabetes, overweight/obesity, and mental disorders, despite their potential insights. In addition, there is uncertainty about the impact of intervention duration on quality of life. Furthermore, no consideration has been given to the sex differences between men and women. Finally, various tools used to measure HRQoL need to be examined. This systematic review and meta-analysis aim to address these gaps by evaluating the effects of lifestyle interventions on health-related quality of life through randomized controlled trials. Unique to this study, separate meta-analyses will consider specific physical and mental illnesses, gender disparities, follow-up durations, and the health-related quality of life assessment tools employed, adding novel insights to the field.

Materials and Methods

The methodology of this manuscript follows the guidelines and adheres to the reporting standards set by the Preferred Reporting Items for Systematic Reviews and Meta-analyses.[35] The review protocol has been registered in the PROSPERO International Register of Systematic Reviews under the registration number CRD42023397903.

Since the data for this systematic review and meta-analysis were obtained from publicly available databases and internet searches, ethical committee approval and informed consent from study populations were not required.

Inclusion and exclusion criteria

1) Randomized control trial studies were eligible to be selected for this research, while non-randomized control trials, quasi-experimental, pre-post studies, and cluster randomized control trials were excluded from the study because the number of clusters and the degree of intra-class correlation was not reported in cluster randomized control trials, and it was not possible to estimate the effect size correctly.[36,37] 2) Lifestyle intervention should include at least two components of lifestyle, and studies that included only one dimension such as nutrition and physical activity were excluded from the study. 3) Studies must have a control group or a waiting list group, and studies that did not have this group were excluded from the study. 4) Studies that did not report the necessary data to calculate the effect size were not eligible for this study. Some studies also did not provide this information after contacting the authors. 5) Studies that had several published reports from the same trial, only one of them was included in this meta-analysis.

Information sources

Five scientific databases were used to search for articles, including PubMed, Web of Science, Scopus, the Cochrane Library, and Google Scholar. The syntax of keywords used in this research is list. To find articles from all the manuscripts available in these scientific sources until December 2022, they were searched systematically and manually. This search is limited to articles published in English. One of the authors also screened all references of previous review studies that were related to the current study to find eligible articles.

Search strategy

A systematic review was conducted using comprehensive keyword searches across multiple databases until December 2022. The primary focus was on lifestyle interventions, including terms such as “Lifestyle intervention,” “Lifestyle modification, ” “Lifestyle training,” “Life Style,” “Healthy Lifestyle,” “Lifestyle change,” “lifestyle behaviors,” and “Healthy Lifestyle Behaviors.” Additionally, the review encompassed the domain of Quality of Life, employing terms such as “Quality of Life,” “Health-Related Quality of Life,” “36-Item Short Form Survey,” and “WHOQOL.” The databases searched included PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar. The syntax of keywords used in this research is list.

Selection process

The process of selecting studies was carried out in several steps. First, the citations obtained from the scientific information sources were extracted into the Endnote software. In the next step, duplicate studies were identified and removed, and after this step, the studies were screened and those with possible eligibility were evaluated and selected for meta-analysis.

Data collection process

The information extracted from the studies included the following variables: authors, country, design, target population, age of the study population, sex of participants based on percentage, number of participants in each study, intervention variable, outcome variable, and results of each study.

Data items

The intervention variable in this study was the lifestyle. Based on this, each of the studies had a protocol for lifestyle-based intervention, and those studies that included at least two aspects of lifestyle (such as diet and exercise) in the intervention protocol were defined as “lifestyle intervention.”

The outcome variable that was considered as the outcome was the HRQoL. Various tools have been used to measure this outcome, which was eligible for the present research, including the Short Form Health Survey, World Health Organization quality of life assessment (WHOQOL), European Quality of Life questionnaire, Impact of Weight on Quality of Life, Functional Assessment of Cancer Therapy (FACT), Pediatric Quality of Life Inventory, European Organization of Research and Treatment for Cancer, Icelandic HRQoL scale, Child Health Questionnaire- PF50, Weight-specific Quality of Life, Diabetes Quality of Life questionnaire, and self-administered Asthma Quality of Life Questionnaire.

Study risk of bias assessment

The quality of the studies in the randomized clinical trial was measured using the Cochrane Collaboration[38] tool which includes five dimensions of quality assessment selection bias, performance bias, detection bias, attrition bias, and reporting bias (Table 1).

Effect measures

In this research, the effect size used was Hedges’s g effect size and 95% confidence interval (CI). The necessary data to calculate Hedges’s g were the mean, standard deviation, and sample size in the intervention group and the control group in post-intervention.

Meta-analysis

After the intervention in the two lifestyle groups and the control group, the effect size was calculated using the Cochrane Handbook procedure.[39] In some studies, instead of the standard deviation, the standard error or the 95% CI was reported. For these studies, existing procedures were used to extract the standard deviation.[39] Existing processes were used to combine dependent outcomes,[40] which were implemented in comprehensive meta-analysis-3 software.[41] Then Hedges’s g effect size was calculated, which can be explained in three levels including 0.20 (low), 0.50 (medium), and 0.80 (large).[42] For each of the analyses, Hedges’s g was reported with a 95% CI based on the random-effects method. In this study, Hedges’s g test was used for these reasons, which is sensitive to the sample size and gives a more accurate estimate of the effect size and the studies used different sample sizes.[43] Also, a sub-group meta-analysis based on types of physical and mental illness, sex, follow-up duration, and HRQoL scale was done. The heterogeneity tests were the Q test and I2;[44,45] I2 has different interpretations, including low, medium, and high heterogeneity.[46] Publication bias evaluation was done with funnel plots,[47,48] Egger’s test,[49,50] and the Trim and fill.[51] Comprehensive meta-analysis-3 software was used for analysis.[41]

Result

Screened studies

The studies included in this meta-analysis were screened step by step according to Figure 1. The screening was done based on the title, abstract, and full texts, and the study was selected based on the inclusion and exclusion criteria. Finally, 62 randomized control trial studies were included in this research.[52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112] The included studies were from these countries: Australia, Brazil, the UK, the USA, Spain, Taiwan, Iran, China, Iceland, Sweden, Germany, South Korea, the Netherlands, India, Italy, and Turkey.

Figure 1 Flowchart diagram of screening studies included in this meta-analysis

Quality assessment of studies

Five areas of quality assessment were performed for each of the studies included in the meta-analysis, and the quality assessment of each study is listed in Table 1.

Lifestyle intervention and health-related quality of life

Figure 2 shows that the lifestyle intervention resulted in an increase in HRQoL compared to those who did not receive the lifestyle intervention. Hedges’ g was 0.38 with 95% CI 0.25–0.50 (Z = 5.94; P < 0.001; I2 = 84.59%).

Figure 2 Forest plot of lifestyle intervention on health-related quality of life

Sub-group analysis

Figure 3 shows that the lifestyle intervention resulted in an increase in HRQoL compared to those who did not receive the lifestyle intervention based on different diseases. Hedges’ g was nonsignificant for the cancer, mental disorders, diabetic, and overweight/obesity groups. Hedges’ g was 0.39 with 95% CI 0.18–0.59 (Z = 3.69; P < 0.001; I2 = 16.63%) for heart-related diseases. Hedges’ g was 0.49 with 95% CI 0.08–0.91 (Z = 2.36; P = 0.018; I2 = 83.75%) for metabolic disorders.

Figure 3 Forest plot of lifestyle intervention on health-related quality of life based on diseases

Figure 4 shows that the lifestyle intervention resulted in an increase in HRQoL compared to those who did not receive the lifestyle intervention based on sex. Hedges’ g was 0.59 with 95% CI 0.29–0.90 (Z = 3.81; P < 0.001; I2 = 92.56%) for women. Hedges g was nonsignificant for men.

Figure 4 Forest plot of lifestyle intervention on health-related quality of life based on sex

Figure 5 shows that the lifestyle intervention resulted in an increase in HRQoL compared to those who did not receive the lifestyle intervention-based HRQoL scale. Hedges’ g was 0.27 with 95% CI 0.10–0.45 (Z = 3.05; P = 0.002; I2 = 58.38%) for the European Quality of Life questionnaire. Hedges’ g was 0.31 with 95% CI 0.17–0.44 (Z = 4.50; P < 0.001; I2 = 79.66%) for Short Form Health Survey. Hedges’ g was not significant for other scales.

Figure 5 Forest plot of lifestyle intervention on health-related quality of life based on health-related quality of life scale

Additional analysis

Figure 6 shows that the lifestyle intervention effects on quality of life. Hedges’ g was 0.38 with 95% CI -0.04–0.80 (Z = 1.77; P = 0.076; I2 = 89.94%) was nonsignificant.

Figure 6 Forest plot of lifestyle intervention on quality of life

The evaluation of subgroups based on follow-up duration is included in Table 2, and meta-regression analysis was also reported to check whether the effect of lifestyle interventions on HRQoL depends on the follow-up period. Hedges’ g was 0.42 with 95% CI 0.23–0.60 (Z = 4.35; P < 0.001; I2 = 76.18%) for the 3-month follow-up. Hedges’ g was 0.34 with 95% CI 0.14–0.54 (Z = 3.28; P < 0.001; I2 = 83.83%) for the 6-month follow-up. Hedges’ g were nonsignificant for the 1-month, 9-month, and 12-month follow-ups.

Table 2 Lifestyle intervention on health-related quality of life based on follow-up duration

Follow-up duration	Number of studies	Hedges’ g	Lower limit	Upper limit	Z	P	I 2	
1-month	5	0.52	-0.02	1.07	1.87	0.061	86.49	
3-month	18	0.42	0.23	0.60	4.35	<001	76.18	
6-month	20	0.34	0.14	0.54	3.28	0.001	83.83	
9-month	4	0.13	-0.10	0.35	1.09	0.277	71.12	
12-month	8	0.19	-0.01	0.38	1.91	0.056	44.57	

Publication bias and heterogeneity

The Q test was equal to 331.046 (d.f 51; P < 0.001), I2 was 84.59%, and showed high heterogeneity.[46] The funnel plot in Figure 7 examines the publication bias in studies based on Egger’s test which is equal to P < 0.001 and was significant. This showed publication bias and the trim-and-fill[51] showed that 10 missing studies and new Hedges’ g were 0.50 with 95% CI 0.36–0.64.

Figure 7 Funnel plot of lifestyle intervention and health-related quality of life

Discussion

In this systematic review and meta-analysis, lifestyle interventions were examined for their impact on HRQoL. In this analysis, 61 randomized clinical trials were included, providing comprehensive evidence on the effects of lifestyle interventions on HRQoL. HRQoL was significantly improved by lifestyle interventions, in line with previous studies.[30,32] Although a few studies failed to show significant improvements,[31,33] this study’s comprehensive analysis further supports the positive impact of lifestyle interventions on HRQoL.

Nevertheless, this study showed that lifestyle interventions can increase HRQoL, making it the most comprehensive study conducted in this field to date Discrepancies in previous studies may be due to the focus on specific patient populations and the limited inclusion of studies. Lifestyle interventions can improve HRQoL by addressing unhealthy behaviors such as poor diet, physical inactivity, smoking, and alcohol consumption.[113] Physical and mental health can be improved by addressing these behaviors.[114,115,116,117,118,119,120] Furthermore, lifestyle interventions can improve patients’ self-esteem, improve their ability to control their diseases, and improve their quality of life.[121]

This study expands the scope of lifestyle interventions to include conditions such as heart-related diseases and metabolic disorders whereas previous studies have mainly focused on the impact of lifestyle interventions on HRQoL in patients with metabolic disorders[30,31] and cancer[32,33,34] in terms of HRQoL. HRQoL is positively affected by lifestyle interventions. Among metabolic disorders and heart-related diseases, lifestyle interventions were particularly effective in improving HRQoL, illustrating how they can be applied to both mental and physical health conditions.

Also examined were the effects of lifestyle interventions on HRQoL among different genders and follow-up periods. The quality of life for women improved. The discrepancy may be explained by the underrepresentation of men in the studies. In terms of follow-up duration, short-term interventions were more effective than long-term interventions in improving HRQoL. Lifestyle intervention adherence is crucial in achieving positive outcomes, and short-term adherence tends to be higher. Therefore, it is necessary to identify the factors that affect this adherence.[122]

Several clinical implications can be drawn from the results of this study. Healthcare professionals should recognize that lifestyle interventions have a significant impact on HRQoL and consider incorporating them into routine patient care. Lifestyle interventions that target unhealthy behaviors and promote healthy habits can improve not only physical health but also mental well-being and social functioning. In order to improve patients’ quality of life comprehensively, lifestyle interventions must address not only physical health but also mental well-being and social functioning. For sustained improvements in HRQoL, it is essential to promote long-term adherence to lifestyle interventions. In order to maintain positive lifestyle changes, healthcare providers should emphasize the importance of continuing to engage in healthy behaviors and provide ongoing support and motivation to patients. There is no doubt that lifestyle interventions are beneficial for both women and men, but it is important to understand that women and men may benefit differently from one another. The underrepresentation of men in studies should be addressed in future research as well as strategies to optimize the impact of lifestyle interventions on HRQoL in both sexes. Implementing lifestyle interventions effectively requires a multidisciplinary approach. In order to ensure the successful integration of lifestyle interventions into clinical practice, healthcare professionals, including physicians, nurses, dietitians, psychologists, and exercise specialists, can collaborate in order to provide comprehensive support and guidance to patients.

Among the strengths of this study is its comprehensive approach to examine lifestyle interventions’ effects on HRQoL. Through the systematic review and meta-analysis design, multiple randomized clinical trials were rigorously evaluated. Including a wide range of studies, this study provides a more comprehensive understanding of lifestyle interventions’ impact on HRQoL.

Moreover, this study addressed the limitations of previous research by conducting subgroup analyses based on specific diseases, gender, and follow-up duration. By applying this approach, we can gain valuable insight into the differential effects of lifestyle interventions in different patient groups and over varying time periods. The study contributes to the existing knowledge and provides a more nuanced understanding of how lifestyle interventions can improve HRQoL.

There are some limitations to this research. In the first place, there are few studies focusing on men, which limits the generalizability of the results. Secondly, lifestyle interventions can vary depending on cultural factors, which can lead to inconsistencies. It may be limited in its applicability to diverse populations because the majority of the studies included in this study were from developed countries. In addition, the included studies showed heterogeneity due to differences in interventions, populations, and tools for measuring health-related quality of life. In future studies, these limitations should be addressed as well as factors influencing adherence to lifestyle interventions should be explored.

Conclusion

This study provides compelling evidence that lifestyle interventions can improve HRQoL. Healthcare professionals can improve patient outcomes and well-being by targeting unhealthy behaviors and promoting healthy lifestyle choices. In order to address the burden of noncommunicable diseases and improve the quality of life of individuals, lifestyle interventions should be incorporated into healthcare practices. To better understand the factors influencing the effectiveness of lifestyle interventions across different patient populations, future research should address the identified limitations, such as gender representation and cultural variations. Based on the study’s findings, lifestyle interventions should be prioritized based on their cost-benefit ratio, allowing more targeted prevention efforts to be implemented. To improve HRQoL and reduce the overall burden of diseases, healthcare systems must devote more attention and resources to lifestyle interventions. In summary, the study supports a proactive and comprehensive approach to lifestyle interventions for health and well-being.

Registration and protocol

The review protocol has been registered in the PROSPERO International Register of Systematic Reviews under the registration number CRD42023397903. The present research protocol was based on standards Preferred reporting items for systematic reviews and meta-analyses.

Availability of data, code, and other materials

The data used in the meta-analysis was available in the imported articles.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JEHP/A21).
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