The 6 Pillars of Lifestyle Medicine and Headache Disability in Brazil: A Cross-sectional, Population-Based Study

The 6 Pillars of Lifestyle Medicine and Headache Disability in Brazil: A Cross-sectional, Population-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The 6 Pillars of Lifestyle Medicine and Headache Disability in Brazil: A Cross-sectional, Population-Based Study Arão Belitardo Oliveira, Suellen Abib, Maria Ivone Oliveira Dantas, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6957841/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Oct, 2025 Read the published version in The Journal of Headache and Pain → Version 1 posted 6 You are reading this latest preprint version Abstract Background Several lifestyle factors have been independently associated with headache disorders; however, less is known on the aggregated impact of lifestyle factors on headache disability. We aimed to explore the relationship between a healthy lifestyle score based on the six pillars of lifestyle medicine and prevalence of headache disability in Brazil. Methods Data were derived from the 2019 Brazilian National Health Survey, a nationwide, cross-sectional study. Prevalence estimates for disease-related disability were based on days missed from work, school, domestic chores, or recreation due to disease or health condition in the past 2 weeks. A healthy lifestyle score (0–14 points) incorporated self-reported data on physical activity, diet, sleep, mental health, risky substance use, and social connections. Weighted Poisson regression models with robust variance assessed the relationship between the healthy lifestyle scores and prevalence of headache-specific disability. Models were adjusted for age, sex, and socioeconomic and geographic disparities. The results are presented as prevalence ratio (PR) and 95% confidence intervals (95% CI). Results Among 88,531 adults included in the analysis (mean age 47.1 years; 52.9% female), 8,693 participants [weighted point prevalence = 8.8% (8.2%-9.2%)] reported disease-related disability. Headache-specific disability showed a weighted prevalence of 5.3% (4.6%-6.0%), the fifth most prevalent disease-related disability among Brazilian adults. The headache-specific disability group had a lower healthy lifestyle score than the no disability group [mean (SD): 7.8 (2.4) vs. 8.8 (2.4), p < 0.001]. Compared to participants who reported no disability over the past 2 weeks, the adjusted models revealed a significant inverse linear association between healthy lifestyle scores and the prevalence of headache-specific disability [PR = 0.85 (95% CI: 0.81, 0.89), p for linear trend: < 0.001]. Conclusions The adherence to the six pillars of lifestyle medicine is associated with lower prevalence of headache-specific disability in Brazil, supporting the adoption of lifestyle medicine approach in clinical practice as a strategy to reduce headache burden. migraine headache disorders healthy lifestyle sleep physical activity diet Figures Figure 1 Figure 2 Introduction Primary headache disorders are a leading cause of disability worldwide [ 1 ]. Migraine, the most prevalent headache disorder in Brazil [ 2 ], is responsible for impaired quality of life, reduced productivity, enormous indirect costs, and higher health care utilization [ 3 , 4 ]. In Brazil, headache-specific disability ranks as the fifth most common cause of disease-related absenteeism [ 5 , 6 ]. Migraine is influenced both by genetic and environmental factors, as well as their complex interactions [ 7 , 8 ]. There has been an emerging interest in better understanding the influence of lifestyle factors on migraine burden and management [ 9 – 12 ]. The most prevalent lifestyle factors associated with migraine burden are psychosocial stress [ 13 – 15 ], physical inactivity [ 16 – 18 ], sleep problems [ 19 , 20 ], dietary factors [ 21 , 22 ], and smoking [ 23 , 24 ]. Most lifestyle factors associated with headache disorders are encompassed by the American College of Lifestyle Medicine (ACLM)’s 6 pillars of lifestyle medicine for healthier life, which includes physical activity, sleep health, plant-based diet, stress management, avoidance of risky substances, and social connections [ 25 ]. However, less is known regarding the combination of these lifestyle factors on headache-related disability. Several healthy lifestyle scores have been developed to estimate the aggregated effect of lifestyle factors on several chronic diseases [ 26 – 29 ]. Overall, the higher the lifestyle score, the lower the disease outcome (e.g., mortality, cardiovascular diseases, etc) [ 26 – 29 ]. Moreover, previous lifestyle scores associated with migraine, such as the Life’s Essential 8 factors (LE8) [ 9 ], have not accounted for stress or mental health factors - despite their crucial role in headache disability [ 13 ], nor have they included the social support component outlined in the ACLM’s 6 pillars framework. Therefore, there is a research gap in developing a composite score that quantifies the aggregated influence of lifestyle factors, including mental health and social support, on headache-related disability. The National Health Survey (PNS), initiated in 2013, is a nationally representative household survey that tracked chronic diseases, disability, and lifestyle factors in Brazil, in line with the Ministry of Health’s 2021–2030 chronic disease plan [ 30 ]. The 2019 edition provided updated epidemiological data [ 31 ]. Using PNS2019, we aimed at examining whether higher adherence to the six pillars of lifestyle medicine was associated with lower headache-related disability. We hypothesized that better lifestyle scores would be associated with lower odds for headache-related disability, even after adjusting for socioeconomic and geographic disparities, which have been found associated with headache-related disability in the PNS2019 survey [ 5 ]. Methods This is a subanalysis of the PNS2019 database, a nationwide, cross-sectional, door-to-door survey of a representative sample of the civilian noninstitutionalized Brazilian population. The survey was conducted by the Ministry of Health in partnership with the Fundação Oswaldo Cruz (Fiocruz) and Instituto Brasileiro de Geografia e Estatística (IBGE) between August 2019 and March 2020. PNS2019 adopted a complex sampling design [ 31 ], based on three-stage cluster sampling with stratification of primary sampling units (PSU) from census tracts or sets of tracts and selection of PSUs for the main sample. Households were selected from the National Register of Addresses for Statistical Purposes and finally, the definition of the PSU sample size [ 31 ]. The survey sampling weights were defined considering the weight of the corresponding PSU. Corrections for non-response and calibration of the estimates were made according to the population totals estimated by the IBGE [ 31 ]. The PNS2019 sample consisted of 8,015 PSUs, composing 574 strata. In the sample with individual responses from the dwellers, there were 94,111 household visits, with 90,846 participants interviewed (96.5% response rate). In this study, the data were obtained from Brazilian adults ≥ 18 years old who responded to questions about general sociodemographic information, health service utilization (Module J), lifestyle behavior (Module P), and chronic diseases (Module Q). The National Research Ethics Committee (#3.529.376) has reviewed and approved PNS2019. All participants gave written consent before enrollment. Assessment of Variables Outcomes: Headache-Specific Disability Disease-related disability was assessed through a series of questions about the number of days in the past two weeks during which individuals were unable to carry out their usual daily activities (work, school, household tasks, or recreation) due to disease or health condition. Responses were collected through single-choice questions, including 14 categories of major diseases or health conditions. Among these, "Headache or Migraine" was listed as an option and here we defined it as headache-specific disability. Table 1 presents the full set of questions, response options, and the complete list of conditions assessed. Table 1 – Disease-related disability questions in the PNS2019 Survey Questions Answer options 1 - In the past 2 weeks, did you miss any habitual activities (work, school, household chores, or recreation) due to a health condition? Yes/ No 2 - In the past 2 weeks, how many days have you lost from your habitual activities due to any health condition? 1–14 days 3 - In the past 2 weeks, which was the main health condition that prevent you from doing your habitual activities? 1 - musculoskeletal disorders (Back or neck pain, pain in the limbs/hands, arthritis, or rheumatism), 2 - headache or migraine, 3 - gyneco-obstetrics problems (menstrual, pregnancy, or delivery problems), 4 - dental problems, 5 - respiratory diseases (Cold, flu, sinusitis, asthma, bronchitis, or pneumonia), 6 - gastrointestinal diseases (Diarrhea, vomit, nausea, gastritis, or stomach-ache), 7 - tropical infections (Dengue fever, Chikungunya, Zika, or yellow fever), 8 - CVDs (hypertension or heart diseases) or stroke, 9 - diabetes, 10 - cancer (including chemotherapy), 11 - neurodegenerative diseases (Alzheimer, sclerosis, Parkinson, or other dementias), 12 - psychiatric disorders (Depression, bipolar disorders, schizophrenia, anxiety disorders, or other mental health issues), 13 - injury by accident or violence, or 14 - other health conditions. Exposure to Lifestyle Factors: The Healthy Lifestyle Score The healthy lifestyle score was developed based on the six pillars of lifestyle medicine: physical activity, sleep health, diet, mental health symptoms, risky substances, and social connection. It incorporated variables from the PNS 2019, including leisure-time physical activity (LTPA); dietary patterns such as consumption of whole foods, vegetables, fruits, and fish; intake of ultra-processed, junk, and fast foods; sleep problem symptoms; alcohol consumption; smoking status; and participation in social activities like cultural, sports, recreational, or religious group events. Table 2 summarizes the components of the 6-pillar framework and their respective scoring system Table 2 Categories and scores of the 6 pillars of lifestyle medicine and their components. Healthy Lifestyle 6 Pillars and Components Category Score 1. Physical Activity Inactive (no activity) 0 Somewhat active (< 149 min.week) 1 Active (≥ 150 min.week) 2 2. Diet Weekly consumption of beans 0 to once a week 0 2–5 times.week 1 6–7 times.week 2 Weekly consumption of greens and vegetables 0 to once a week 0 2–5 times.week 1 6–7 times.week 2 Weekly consumption of fruits 0 to once a week 0 2–5 times.week 1 6–7 times.week 2 Weekly consumption of fish 0 to once a week 0 2–5 times.week 1 6–7 times.week 2 Weekly consumption of sodas beverages 6–7 times.week 0 2–5 times.week 1 0 to once a week 2 Weekly consumption of sweets 6–7 times.week 0 2–5 times.week 1 0 to once a week 2 Weekly consumption of replaced meals 6–7 times.week 0 2–5 times.week 1 0 to once a week 2 3. Sleep Health Sleep Drugs + PHQ9-Sleep ≥ 2 0 Sleep Drugs or PHQ9-Sleep ≥ 2 1 No Sleep Drugs + PHQ9-Sleep < 2 2 4. Mental Health PHQ9 ≥ 10 0 PHQ9 5–9 1 PHQ9 < 5 2 5. Risky Substance: Drinking More than once/month 0 Less than once/month 1 Never 2 6. Risky Substance: Smoking Current smoker 0 Former smoker 1 Never smoker 2 7. Social Connection Group Cultural, Sports, or Recreative Activities Never or once a year 0 Sometimes every year to 3 times a month 1 Weekly or more 2 Religious Attendance Never or once a year 0 Sometimes every year to 3 times a month 1 Weekly or more 2 Lifestyle components were scored as 0, 1, or 2 points, corresponding to the poorest, intermediate, or healthiest options, depending on exposure levels. For diet and social connection, which consisted of multiple questions, unweighted mean scores were calculated. Scores for unhealthy food groups were inverted, thus, the values of 0 and 2 points represented the highest and lowest consumption frequencies, respectively ( Table 2 ) . Given the significant impact of alcohol consumption [ 32 ] and smoking [ 33 ] on mortality and disease burden, these factors were analyzed separately under the “risky substances” pillar. Consequently, the total healthy lifestyle score included seven items, ranging from 0 to 14 points as the unweighted sum. Higher scores reflected a healthier lifestyle profile. The details of the assessment of each component and the methodology of the scoring system adopted for each pillar of lifestyle medicine are described in the following subsections. Assessment of the 6-Pillar Lifestyle Medicine Framework 1. Physical Activity Leisure-time physical activity (LTPA) was the domain of interest due to its more consistent associations with reduced CVDs and CMB risk [ 34 – 36 ]. LTPA was surveyed by the following questions: (i) “In the previous 3 months, did you engage in any physical exercise or sport?” (excluding physiotherapy, yes/no answer options); (ii) “How many days per week do you practice any physical exercise or sport?” (never/less than once per week, or 1–7 days options); (iii) “In general, how much time in hours do you spend performing physical exercise or sport?”; and (iv) “In general, how much time in minutes do you spend performing physical exercise or sport?”. The total weekly minutes of leisure-time physical activity were calculated and categorized according to the World Health Organization's (WHO) 2020 physical activity guidelines. 79 Participants were defined as “active” if they met at least one of the following criteria: engaging in a minimum of 150 minutes per week of moderate to vigorous physical activity or 75 minutes per week of vigorous physical activity. Those who reported no physical activity were defined as “inactive.” Participants who engaged in physical activity but did not meet the thresholds for the “active” category were defined as “somewhat active” [ 37 ]. The score values of 0, 1, and 2 were attributed to inactive, somewhat active, and active, respectively. 2. Diet Dietary patterns were assessed using the Food Frequency Questionnaire (FFQ), which enquires about the frequency food consumption over the past week (0 to 7 days). For our scoring, we selected the following food groups: (a) beans; (b) raw and cooked vegetables (lettuce, carrots, tomato, chayote, collard greens, eggplants, zucchini, etc) ; (c) fruits; (d) fish; (e) sodas; (f) sweets (such as cakes, pies, chocolates, candies, cookies, or sweet biscuits); and (g) meals replaced with sandwiches, hot dogs, snacks, or pizzas. Each food group was assigned a score ranging from 0 to 2. For healthy food groups (a to d), a weekly consumption frequency of 0 to 1 time was scored as 0, 2 to 5 times as 1, and 6 to 7 times as 2. In contrast, for unhealthy food groups (e to g), a weekly intake of 0 to 1 time was scored as 2, 2 to 5 times as 1, and 6 to 7 times as 0. The diet score was calculated as the unweighted average of the scores across all food groups. 3. Sleep The categorization of sleep health was based on the questions “In the past 2 weeks did you take any sleep medicine?” (answer options were yes/no) and the item 3 of the Patient Health Questionnaire-9 (PHQ-9) "In the past two weeks, how often have you had sleep problems, such as difficulty falling asleep, waking up frequently during the night, or sleeping more than usual?" with response options and their respective values being “Not at all” (0)“Several days”(1), “More than half the days”(2) or “Almost every day”(3) [ 38 ]. The score value of 0 was assigned to participants who reported taking sleep medicine and/or experiencing sleep problems “More than half the days” or “Almost every day.” A value of 1 was given to respondents reporting sleep problems on “Several days,” while a value of 2 was attributed to respondents reporting no sleep problems (“Not at all”). 4. Mental Health Because PNS 2019 has no specific question on stress, the pillar of mental health was operationalized based on the PHQ-9 score, which has been translated and validated for the Brazilian population [ 38 , 39 ]. The PHQ-9 assesses the severity of depression with nine questions about symptoms over the past two weeks, using a 4-point Likert scale. Depression severity is categorized into five levels based on the PHQ-9 scores: minimal or none (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27). For our healthy lifestyle scoring system, the following PHQ-9 categories/values were assigned: minimal or none (0–4) = 2, mild (5–9) = 1, and scores > 9 = 0. 5. Risky Substances Smoking Status Current smoking status was assessed by the questions: “Do you currently smoke any tobacco products?” or “Did you use to smoke any tobacco products?”. Answer options for both questions were “yes” or “no”. The score value of 0 was assigned to current smokers, the value of 1 was assigned to former smokers, and the value of 2 was assigned to non-smokers Alcohol Consumption We used the question “How often do you usually consume any alcoholic beverage?” to assess drinking habits. Response options were “never”, “less than once/month”, and “once or more/month”. The score value of 0 was assigned to the drinking frequency “once or more/month”, the value of 1 was assigned to “less than once/month”, and the value of 2 was assigned to abstemious participants (“never”). 6. Social Connections We selected the two following questions to assess social connection: “In the past 12 months, how often have you met with others to engage in sports, recreational, or cultural activities? and “"In the past 12 months, how often have you attended collective activities of your religion or another religion, excluding situations such as weddings, baptisms, or funerals?". For both questions, response options were: “More than once a week”, “Once a week”, “From 2 to 3 times a month”, “A few times a year”, “Once a year”, “Never”. The religious attendance was selected as a social connection component, based on the high prevalence of religious affiliation in Brazil and as a major social activity with potential impact on health.[ 40 – 43 ] The social connection score was calculated as the unweighted average score of the two questions. Covariates: Sociodemographic Factors Sociodemographic variables included the 5 main geopolitical regions of Brazil (North, Northeast, Central West, Southeast, and South), age, sex assigned at birth (Female, Male), housing place (Urban, or Rural), self-reported skin color (White, Black, Brown, Others – Asian, Indigenous) [ 5 ], marital status (Single, Married, Separated/Divorced, or Widower), household Income (per capita), separated into quartiles, Q4 Income (lowest), Q3 Income, Q2 Income, Q1 Income (highest), educational attainment ( No formal/incomplete primary, Complete primary, Complete high school, and Complete college), labor force status (Inside the labor force, Outside the labor force), excluding income from the pension, and job status (Employed or Unemployed). People inside the labor force were defined as working-aged people employed or unemployed and outside the labor force. People outside the labor force were defined as working-aged people not classed as employed or unemployed. Statistics The population estimates were based on the number of strata, the number of selected PSUs in each stratum, and the number of households and residents included in the PSU and their respective expansion factors and sample weighting. The data on weights, number of PSUs, and strata were provided in the dictionary of variables file along with the PNS2019 database. In the PNS2019 survey, it was necessary to define expansion factors or sample weights of the PSUs, of the households and all their residents, and of the selected residents. The weights of the PSUs considered the probabilities of selection of these units for the main sample and the research sample. In the descriptive analyses, we reported the weighted prevalence of disease-related disability as a proportion (%) with a 95% confidence interval (CI). In the hypothesis’s tests, we utilized weighted Poisson regression models with robust variance to assess the relationship between the healthy lifestyle scores (“predictor”) and presence of headache-specific disability (outcome). The results are presented as prevalence ratio (PR) and 95% confidence intervals (95% CI). The no disability group was set as the reference group. Crude and adjusted models were fitted to assess the independent effect of the healthy lifestyle score on headache-specific disability. The adjusted models controlled for the effect of age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status. To identify possible non-linear relationships between the healthy lifestyle scores and headache-specific disability that cannot be verified using linear regression models, we modeled these relationships using restricted cubic splines with 4 knots positioned at the 5th, 35th, 65th, and 95th percentiles of healthy lifestyle scores, following Harrell´s method [ 44 ]. Reference values for healthy lifestyle scores (0 to 14) were set at 9 points, which was the whole sample´s median value. The regression models built for the cubic splines were also adjusted for age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status. A type I error rate < 0.05 was accepted as statistically significant in all analyses. All analyses were conducted with Stata software (version 17.0, StataCorp LLC). Complex sampling design svy commands with weights for the non-response sample corrections and post-stratification adjustments were performed. Results In this study, 88,531 adult participants provided full data regarding variables of interest. The mean (SDI) age was 47.1 (17.1) years, and 52.9% were female. Figure 1 depicts the flowchart of the participants included in this study. Of these, 8,693 [weighted point prevalence = 8.8% (8.2%-9.2%)] lost at least one day of work, school, domestic chores, or recreation in the previous 2 weeks due to disease or health condition, representing 14,134,980 million Brazilian adults. Headache-specific disability was the fifth most prevalent disease-specific cause of disability in Brazil, with a weighted prevalence of 5.3% (4.6%-6.0%) of all disease-related disability, representing 751,092 Brazilian adults. Headache-specific disability caused a mean (SD) of 3.5 (3.2) days lost in the past 2 weeks. Considering the sex and age range subgroups, headache-specific disability was the 4th and 3rd most prevalent cause among female and adults between 18 and 35 years, respectively, representing around 11% of all disease-related disability within these subgroups. Table 3 summarizes the sociodemographic profiles of no disability and headache-specific disability groups (n = 80,402). Compared to the general population, Brazilians reporting headache disability showed a higher proportion [% (95% CI)] of female [74.0% (67.2%, 79.8%) vs 51.9% (51.3%, 52.5%), people from the Northeast region [45.1% (38.8%, 51.6%) vs 26.3% (25.7%, 26.8%)], living in rural areas [20.6%(16.3%, 25.7%) vs 13.9% (13.5%, 14.3%), of brown color [53.2%(46.5%, 59.7%) vs 43.7% (43.0%, 44.4%)], with lower education [no formal/incomplete primary: 40.6% (34.6%, 47.0%) vs 33.7% (33.0%, 34.4%)] and lower household income [lowest quartile: 38.0% (31.8%, 44.6%) vs 22.0% (21.4%, 22.6%)] ( Table 3 ) . Table 3 Weighted distribution of socioeconomic and demographic variables by groups in the PNS 2019 survey (n = 80,402) General Sample * ( n = 79,838) Headache-Specific Disability ( n = 564) N % weighted (95% CI) N % weighted (95% CI) Region Southeast 17,505 43.5 (42.6, 44.3) 81 25.6 (19.4, 33.0) South 10,284 14.8 (14.4, 15.3) 40 8.2 (5.6, 12.0) Central West 9,236 7.6 (7.3,7.9) 52 8.2 (5.5, 12.2) Northeast 27,520 26.3 (25.7, 26.8) 257 45.1 (38.8, 51.6) North 15,293 7.8 (7.6, 8.1) 134 12.8 (10.0, 16.2) Housing Place Urban 61,416 86.1 (85.7, 86.5) 417 79.4 (74.3, 83.7) Rural 18,422 13.9 (13.5, 14.3) 147 20.6 (16.3, 25.7) Sex Female 41,240 51.9 (51.3, 52.5) 420 74.0 (67.2, 79.8) Male 38,598 48.1 (47.5,48.7) 144 26.0 (20.2, 32.8) Age Group, yrs. 18–35 24,236 35.1 (34.4, 35.8) 179 37.7 (31.4, 44.4) 36–45 16,319 20.2 (19.7, 20.7) 122 22.4 (17.3, 28.5) 46–55 14,130 17.6 (17.1,18.0) 112 16.2 (12.4, 21.0) 56–65 12,446 14.1 (13.7, 14.5) 81 15.6 (11.4, 20.9) > 65 12,707 13.0 (12.6, 13.5) 70 8.1 (5.9, 11.0) Skin Color White 29,335 43.5 (42.7, 44.2) 160 31.9 (26.0, 38.4) Brown 40,227 43.7 (43.0, 44.4) 316 53.2 (46.5, 59.7) Black 9,078 11.4 (11.0, 11.8) 79 13.9 (10.5, 18.4) Others (Asian, Indigenous) 1,190 1.4 (1.3, 1.6) 9 1.0 (0.4, 2.4) Marital Status Married 31,896 43.9 (43.2, 44.6) 202 43.5 (37.1, 50.1) Single 34,938 42.9 (42.2, 43.6) 261 41.6 (35.5, 48.0) Separated/Divorced 6,495 6.8 (6.5,7.1) 50 8.7 (5.7, 12.9) Widow(er) 6,509 6.5 (6.2, 6.7) 51 6.2 (4.3, 9.0) Schooling No formal/Incomplete Primary 31,241 33.7 (33.0, 34.4) 271 40.6 (34.6, 47.0) Complete Primary 10,925 14.6 (14.2, 15.1) 74 12.4 (8.9,17.0) Complete High-School 25,206 35.6 (35.0, 36.3) 147 32.2 (26.2, 38.8) Complete College 12,466 16.1 (15.4, 16.8) 72 14.8 (10.1, 21.3) Household Income ( per capita ) † Q4 Income (lowest) 20,257 22.0 (21.4, 22.6) 214 38.0 (31.8, 44.6) Q3 Income 22,921 28.8 (28.2, 29.5) 187 32.6 (26.5, 39.4) Q2 Income 16,485 23.3 (22.7, 23.8) 79 14.5 (10.1, 20.4) Q1 Income (highest) 20,153 25.9 (25.2,26.7) 84 14.9 (11.0,19.7) Labor Force Status † † Inside the labor force 51,777 67.8 (67.2, 68.4) 343 64.8 (58.2, 70.8) Outside the labor force 28,061 32.2 (31.6,32.8) 221 35.2 (29.2,41.8) Employment Status † † † Employed 48,350 92.1 (91.6,92.6) 317 93.0 (87.8, 96.1) Unemployed 3,427 7.9 (7.4, 8.4) 26 7.0 (3.9, 12.2) Data are presented as unweighted frequencies (n) and weighted proportions. *: Excluded other disease-related disability groups. Q4-1: Quartiles; † : Household income ( per capita excluding income from the pension. Quartile income values in International Dollars (Int$): Q1 Int$ 738, based on exchange rate of 2.26:1 (as for 2020, according to World Economic Bank ( https://data.worldbank.org/indicator/PA.NUS.PPP? view = chart&locations = BR, accessed 03/01/2024); †† : People inside the labor force: working-aged people employed or unemployed and outside the labor force. People outside the labor force: working-aged people not classed as employed or unemployed.[ 73 ] † † † : Job status data are from people inside the labor force. The headache-specific disability group showed lower mean (SD) healthy lifestyle score than no disability group [7.8(2.4) vs 8.8(2.4), p < 0.001, respectively]. The crude models showed that the healthy lifestyle score was inversely associated with headache-specific disability [PR = 0.87 (95% CI: 0.83, 0.92), p < 0.001). After adjusting for age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status, the healthy lifestyle score activity remained inversely associated with headache-specific disability [PR = 0.85 (95% CI: 0.81, 0.89), p < 0.001], indicating that for each one-point increase in the healthy lifestyle score, there was a 14.7% reduced prevalence of headache-specific disability, assuming all other variables are held constant. The plots with restricted cubic splines for the adjusted models revealed a strong, linear inverse relationships ( p for linear trend: < 0.001) between healthy lifestyle score and presence of headache-specific disability ( Fig. 2 ) . Discussion Here, we aimed to examine the associations between healthy lifestyle score and headache-specific disability using data from the PNS2019 survey. Confirming our hypothesis, we observed a strong inverse association between the healthy lifestyle score and the prevalence of headache-specific disability, even after adjusting for several sociodemographic and geographic disparities previously shown to influence headache burden in Brazil [ 5 ]. In PNS2019, headache disability was defined as days missed from work, school, recreation, or chores activities in the past 2 weeks. In other surveys and datasets, presenteeism-related disability is estimated to represent the largest share of headache disability [ 45 – 48 ], including in Brazil [ 4 ]. Thus, our data is generalizable to disability within this definition only and cannot be extrapolated to headache prevalence in general. Furthermore, the cross-sectional design limits causal inference between lifestyle factors and headache disability. Reverse causality is plausible given the bidirectional relationship between lifestyle and headache disorders. For instance, disabling headache attacks may reduce adherence to healthy behaviors - such as physical activity, social engagement, and sleep quality - or worsen anxiety symptoms [ 6 , 8 , 17 , 49 ]. Nevertheless, our findings concur with data from both cross-sectional and prospective studies investigating the associations between lifestyle factors and migraine. A recent prospective analysis of the UK BioBank showed a higher incidence of migraine with lower adherence to healthy lifestyle factors and the LE8 factors among 332,895 participants (3,225 cases) followed up for 13.5 years [ 9 ]. Likewise, results from the ELSA-Brasil study pointed to a strong, inverse association between high adherence to the LE8 factors and migraine disorders occurrence and chronification [ 50 ]. Importantly, LE8 does not cover the mental health and social support pillars of lifestyle medicine. Mental health symptoms play a central role for headache disability and burden [ 6 , 13 , 15 , 51 – 53 ], while growing evidence suggests that lack social support and feeling of loneliness are associated with chronic headache at the population level [ 54 ]. This underscores the clinical utility in using healthy lifestyle score based on the ACLM’s 6 pillars framework in headache care. The strong, linear inverse association between healthy lifestyle scores and headache disability suggests additive - and potentially interactive - effects of each lifestyle component, which resonates with their known independent associations with major headache disorders prevalence [ 14 , 18 , 19 , 21 – 24 , 55 – 58 ], as well as the therapeutic effects of interventions targeting the pillars of lifestyle to reduce headache burden, such as stress management [ 59 , 60 ], sleep health [ 10 , 61 ], diet [ 56 ], and exercise [ 62 – 67 ]. Using healthy lifestyle scores in headache care may prove clinically and epidemiologically useful. Addressing modifiable behaviors not only complements pharmacological therapy but also potentiate functional recovery and quality of life [ 10 , 11 , 67 ]. Strategies must adopt evidence-based approach that enhances intrinsic motivation and adherence to lifestyle changes, such as motivational interviewing [ 68 , 69 ]. The tenets of the motivational interviewing such as expressing empathy, resolving ambivalence, and fostering self-efficacy, concur with the needs of people struggling with disabling headaches regarding lifestyle modifications [ 52 , 68 ]. From the public health’s perspective, considering that major primary headache disorders are highly prevalent [ 2 ], costly [ 3 ], and disabling chronic diseases [ 4 , 5 ] in Brazil, they should be included within the current and future nationwide health promotion programs (e.g., The Brazilian Ministry of Health's Strategic Action Plan for Coping with Chronic Diseases) [ 30 ]. These programs should include headache-tailored approaches targeting modifiable lifestyle factors specific for this population. The strength of this study lies in its use of a representative sample of the Brazilian population, with data collected through a complex sampling design. This ensures that the estimates of prevalence, distribution, and projections related to recent headache disability are robust and generalizable to the broader Brazilian population. However, an important limitation is the cross-sectional nature of this study, which restricts the ability to establish causal relationships. Additionally, lifestyle variables were self-reported, introducing potential biases such as recall bias and social desirability bias. The PNS2019 did not specifically investigate headache prevalence, nor did it employ a more detailed headache-related instrument, such as the Migraine Disability Assessment (MIDAS), to assess headache disability over a longer period. It also lacked detailed information on which daily activities are most affected by headache-related disability and did not explore presenteeism (reduced productivity while working). Furthermore, the PNS2019 did not differentiate between headache subtypes, leaving it unclear which subtype contributes most significantly to the overall burden. Nevertheless, based on general headache prevalence estimates and observational studies conducted in primary care settings, migraine has been identified as the most disabling, most frequently encountered in emergency rooms, and the costliest headache subtype in Brazil [ 3 , 70 – 72 ]. In conclusion, the healthy lifestyle score was inversely associated with prevalence of headache-specific disability regardless of sociodemographic and geographic disparities in the PNS2019 survey. This finding should substantiate the prioritization of lifestyle-based interventions within public health promotion policies targeting to reduce headache burden in Brazil. Declarations Ethical approval The National Research Ethics Committee (#3.529.376) has reviewed and approved the PNS2019 survey. Consent to participate All participants gave written consent before enrollment. Consent for publication Not applicable. Availability of data and material The PNS 2019 microdata are openly available in the Instituto Brasileiro de Geografia e Estatística – IBGE website at https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html Competing interests The authors declare there is no conflict of interest related to this work. Funding This research did not receive any specific grant or funding. Authors' contributions ABO designed the study, obtained the data, and conducted the statistical analysis; ABO, SA, MIOD, MNPS, GH, PP, and MRYB interpreted the data, drafted the manuscript, and revised it for intellectual content. All authors approved the final version of the manuscript. Acknowledgements Not applicable. Arão Belitardo de Oliveira, Suellen Abib, Maria Ivone Oliveira Dantas, Marcio Nattan Portes Souza, Giselle Hech, Priscila Papassidero, and Marcelo Rezende Young Blood are members of the collaboration group Brazilian Headache Society´s Lifestyle Medicine Committee. References GBD2021NervousSystemDisordersCollaborators (2024) Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Neurol 23:344–381. https://doi.org/10.1016/S1474-4422(24)00038-3 Queiroz L, Peres M, Piovesan E et al (2009) A nationwide population-based study of migraine in Brazil. Cephalalgia 29:642–649. https://doi.org/10.1111/j.1468-2982.2008.01782.x Oliveira AB, Queiroz LP, Rocha-Filho PS et al (2020) Annual Indirect Costs Secondary to Headache Disability in Brazil. Cephalalgia 40:597–605 Souza MNP, Cohen JM, Piha T et al (2022) Burden of migraine in Brazil: A cross-sectional real-world study. Headache 62. https://doi.org/10.1111/head.14413 Oliveira A, Bensenor I, Goulart A et al (2023) Socioeconomic and geographic inequalities in headache disability in Brazil: The 2019 National Health Survey. Headache 63:114–126. https://doi.org/10.1111/head.14462 Oliveira A, Mercante JPP, Bensenor IM et al (2022) Headache disability, lifestyle factors, health perception, and mental disorder symptoms: a cross-sectional analysis of the 2013 National Health Survey in Brazil. Neurol Sci 43:2723–2734. https://doi.org/10.1007/s10072-021-05618-z Harder AVE, Terwindt GM, Nyholt DR, van den Maagdenberg AMJM (2023) Migraine genetics: Status and road forward. Cephalalgia 43. https://doi.org/10.1177/03331024221145962 Seng EK, Martin PR, Houle TT (2022) Lifestyle factors and migraine. Lancet Neurol 21:911–921. https://doi.org/10.1016/S1474-4422(22)00211-3 Lei Y, Zhang L, Shan Z et al (2024) Poor healthy lifestyle and life’s essential 8 are associated with higher risk of new-onset migraine: a prospective cohort study. J Headache Pain 25:1–13. https://doi.org/10.1186/s10194-024-01785-4 Woldeamanuel Y, Cowan R (2016) The impact of regular lifestyle behavior in migraine: a prevalence case-referent study. J Neurol 263:669–676. https://doi.org/10.1007/s00415-016-8031-5 Robblee J, Starling AJ (2019) SEEDS for success: Lifestyle management in migraine. Cleve Clin J Med 86:741–749. https://doi.org/10.3949/ccjm.86a.19009 Dantas MIO, Carneiro NM, Abib S (2024) Integrated Approach to Migraine Management: A narrative review of the Pillars of Lifestyle Medicine. Headache Med 15:64–71. https://doi.org/10.48208/headachemed.2024.15 Stubberud A, Buse DC, Kristoffersen ES et al (2021) Is there a causal relationship between stress and migraine? Current evidence and implications for management. J Headache Pain 22:1–11. https://doi.org/10.1186/s10194-021-01369-6 Belitardo de Oliveira A, Winter Schytz H, Fernando Prieto Peres M et al (2024) Does physical activity and inflammation mediate the job stress-headache relationship? A sequential mediation analysis in the ELSA-Brasil study. Brain Behav Immun 120:187–198. https://doi.org/10.1016/j.bbi.2024.06.002 Santos IS, Griep RH, Alves MGM et al (2014) Job stress is associated with migraine in current workers: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Eur J Pain (United Kingdom) 18:1290–1297. https://doi.org/10.1002/j.1532-2149.2014.489.x Pitanga FJG, Almeida MCC, Queiroz CO et al (2017) Physical activity in Brazil: lessons from ELSA-Brasil. Narrative review. Sao Paulo Med J 135:391–395. https://doi.org/10.1590/1516-3180.2017.0023190317 Oliveira AB, Mercante JPP, Peres MFP et al (2021) Physical inactivity and headache disorders: a cross-sectional analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cephalalgia 41:1467–1485. https://doi.org/10.1177/03331024211029217 Hagen K, Åsberg AN, Stovner L et al (2018) Lifestyle factors and risk of migraine and tension-type headache. Follow-up data from the Nord-Trøndelag Health Surveys 1995–1997 and 2006–2008. Cephalalgia 38:1919–1926. https://doi.org/10.1177/0333102418764888 Stanyer EC, Creeney H, Nesbitt AD et al (2021) Subjective Sleep Quality and Sleep Architecture in Patients with Migraine: A Meta-analysis. Neurology 97:E1620–E1631. https://doi.org/10.1212/WNL.0000000000012701 Tiseo C, Vacca A, Felbush A et al (2020) Migraine and sleep disorders: a systematic review. J Headache Pain 21:1–13. https://doi.org/10.1186/s10194-020-01192-5 Martin VT, Vij B (2016) Diet and Headache: Part 1. Headache 56:1543–1552. https://doi.org/10.1111/head.12953 Razeghi Jahromi S, Ghorbani Z, Martelletti P et al (2019) Association of diet and headache. J Headache Pain 20:1–11. https://doi.org/10.1186/s10194-019-1057-1 Weinberger AH, Seng EK (2023) The Relationship of Tobacco Use and Migraine: A Narrative Review. Curr Pain Headache Rep 27 Gan WQ, Estus E, Smith J (2016) Association Between Overall and Mentholated Cigarette Smoking With Headache in a Nationally Representative Sample. Headache 56:511–518. https://doi.org/10.1111/head.12778 AmericanCollegeofLifestyleMedicine (2025) 6 Pillars of Lifestyle Medicine Oliveira AB, Mota J, Woldeamanuel YW et al (2025) The 6 Pillars of Lifestyle Medicine and Prevalence of Cardiovascular and Cardiometabolic Diseases in Brazil: A Cross-Sectional, Population-Based Study. Am J Lifestyle Med 0:1–16. https://doi.org/10.1177/15598276251348170 Guasch-Ferré M, Li Y, Bhupathiraju SN et al (2022) Healthy Lifestyle Score Including Sleep Duration and Cardiovascular Disease Risk. Am J Prev Med 63:33–42. https://doi.org/10.1016/j.amepre.2022.01.027 Viallon V, Freisling H, Matta K et al (2024) On the use of the healthy lifestyle index to investigate specific disease outcomes. Sci Rep 14:1–12. https://doi.org/10.1038/s41598-024-66772-w Zhang YBo, Chen C, Pan XF et al (2021) Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: Two prospective cohort studies. BMJ 373. https://doi.org/10.1136/bmj.n604 Ministério da Saúde (2021) Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas e Agravos não Transmissíveis no Brasil 2021–2030. In: Secretaria de Vigilância em Saúde. https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf/view . Accessed 4 May 2024 Stopa SR, Szwarcwald CL, de Oliveira MM et al (2020) National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 29:e2020315. https://doi.org/10.1590/S1679-49742020000500004 GBD2020AlcoholCollaborators (2022) Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020. Lancet 400:185–235. https://doi.org/10.1016/S0140-6736(22)00847-9 GBD2019TobaccoCollaborators (2021) Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet 397:2337–2360. https://doi.org/10.1016/S0140-6736(21)01169-7 Al Tunaiji H, Davis JC, Mansournia MA, Khan KM (2019) Population attributable fraction of leading non-communicable cardiovascular diseases due to leisure-time physical inactivity: A systematic review. BMJ Open Sport Exerc Med 5:1–12. https://doi.org/10.1136/bmjsem-2019-000512 Zhao G, Li C, Ford ES et al (2014) Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: The NHANES linked mortality study. Br J Sports Med 48:244–249. https://doi.org/10.1136/bjsports-2013-092731 Coenen P, Huysmans MA, Holtermann A et al (2024) Associations of occupational and leisure-time physical activity with all-cause mortality: an individual participant data meta-analysis. Br J Sports. https://doi.org/10.1136/bjsports-2024-108117 . Med bjsports-2024-108117 World Health Organization (2020) WHO Gudelines on Physical Activity and Sedentary Behaviour. World Health Organization, Geneva Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 16:606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x Santos IS, Tavares BF, Munhoz TN et al (2013) Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saude Publica 29:1533–1543. https://doi.org/10.1590/0102-311X00144612 Peres MFP, de Oliveira AB, Leão FC et al (2018) Religious landscape in Brazil: Comparing different representative nationwide approaches to obtain sensitive information in healthcare research. SSM Popul Health 6:85–90. https://doi.org/10.1016/j.ssmph.2018.08.007 Faries MD, Corrêa Fernandes C, Phillips E et al (2024) Religion and Spirituality in Lifestyle Medicine. Am J Lifestyle Med 0:1–10. https://doi.org/10.1177/15598276241276770 VanderWeele T, Balboni T, Koh H (2017) Health and Spirituality. JAMA 318:519–520. https://doi.org/10.1001/jama.2017.8136 Peres MFP, Swerts D, De Oliveira AB et al (2020) Mental Health and Quality of Life among Adults with Single, Multiple, and No Religious Affiliations. J Nerv Mental Disease 208:288–293. https://doi.org/10.1097/NMD.0000000000001115 Harrell FEJ (2001) Regression modeling strategies: With applications to linear models, logistic regression, and survival analysis, 1st Editio. Springer, New York, NY Goetzel RZ, Long SR, Ozminkowski RJ et al (2004) Health, Absence, Disability, and Presenteeism Cost Estimates of Certain Physical and Mental Health Conditions Affecting U.S. Employers. J Occup Environ Med 46:398–412. https://doi.org/10.1097/01.jom.0000121151.40413.bd Selekler MH, Gökmen G, Steiner TJ (2013) Productivity impact of headache on a heavy- manufacturing workforce in Turkey. J Headache Pain 14:1–7. https://doi.org/10.1186/1129-2377-14-88 Stewart WF, Wood GC, Razzaghi H et al (2008) Work impact of migraine headaches. Journal of occupational and environmental medicine /. Am Coll Occup Environ Med 50:736–745. https://doi.org/10.1097/JOM.0b013e31818180cb Stewart WF, Wood GC, Manack A et al (2010) Employment and work impact of chronic migraine and episodic migraine. J Occup Environ Med 52:8–14. https://doi.org/10.1097/JOM.0b013e3181c1dc56 Yamada AML, Mercante JPP (2022) The bidirectional relation of migraine and affective disorders. Headache Med 13. https://doi.org/10.48208/headachemed.2022.12 Oliveira AB, Santos IS, Peres MFP et al (2024) What is AHA Life´s Essential 8 factors’ role in preventing migraine chronification? Insights from a 4-year follow-up with 4,193 participants in the ELSA-Brasil study. Headache Med 15:48208. https://doi.org/10.48208/HeadacheMed.2024.Supplement.127 Mercante JPP, Oliveira AB, Peres MFP et al (2024) Association of mental health symptoms with the migraine-tension-type headache spectrum in the Brazilian longitudinal study of adult health. J Psychosom Res 179:111624. https://doi.org/10.1016/J.JPSYCHORES.2024.111624 Peres MFP, Swerts DB, De Oliveira AB, Silva-Neto RP (2019) Migraine patients’ journey until a tertiary headache center: An observational study. J Headache Pain 20:1–8. https://doi.org/10.1186/s10194-019-1039-3 Westergaard ML, Glümer C, Hansen EH, Jensen RH (2016) Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey. Cephalalgia 36:15–28. https://doi.org/10.1177/0333102415578430 Westergaard ML, Lau CJ, Allesøe K et al (2021) Poor social support and loneliness in chronic headache: Prevalence and effect modifiers. Cephalalgia 41:1318–1331. https://doi.org/10.1177/03331024211020392 Oliveira AB, Fernando M, Peres P et al (2022) Physical activity pattern and migraine according to aura symptoms in the Brazilian Longitudinal Study of Adult Health Brasil) cohort: A cross- sectional study. Headache 62:977–988. https://doi.org/10.1111/head.14380 Finkel A, Yerry J, Mann J (2013) Dietary considerations in migraine management: does a consistent diet improve migraine? Curr Pain Headache Rep 17:373. https://doi.org/10.1007/s11916-013-03 Waliszewska-Prosół M, Nowakowska-Kotas M, Chojdak-łukasiewicz J, Budrewicz S (2021) Migraine and sleep—an unexplained association? Int J Mol Sci 22. https://doi.org/10.3390/ijms22115539 Ferini-Strambi L, Galbiati A, Combi R (2019) Sleep disorder-related headaches. Neurol Sci 40:S107–S113. https://doi.org/10.1007/s10072-019-03837-z Peres M, Mercante J, Belitardo de Oliveira A (2019) Non-Pharmacological Treatment for Primary Headaches Prevention and Lifestyle Changes in a Low-Income Community of Brazil: A Randomized Clinical Trial. Headache: J Head Face Pain 59:86–96. https://doi.org/10.1111/head.13457 Wells RE, Connell NO, Pierce CR et al (2021) Effectiveness of Mindfulness Meditation vs Headache Education for Adults With Migraine A Randomized Clinical Trial. JAMA Intern Med 181:317–328. https://doi.org/10.1001/jamainternmed.2020.7090 Peres M, Zukerman E, da, Cunha Tanuri F et al (2004) Melatonin, 3 mg, is effective for migraine prevention. Neurology 63:757 Woldeamanuel YW, Oliveira ABD (2022) What is the efficacy of aerobic exercise versus strength training in the treatment of migraine ? A systematic review and network meta analysis of clinical trials. J Headache Pain 23:1–12. https://doi.org/10.1186/s10194-022-01503-y Oliveira AB, Ribeiro RT, Mello MT et al (2019) Anandamide Is Related to Clinical and Cardiorespiratory Benefits of Aerobic Exercise Training in Migraine Patients: A Randomized Controlled Clinical Trial. Cannabis Cannabinoid Res 4:275–284. https://doi.org/10.1089/can.2018.0057 Thompson J (1987) Exercise-induced migraine prodrome symptoms. Headache 275:250–251 Oliveira AB, Bachi ALL, Ribeiro RT et al (2017) Exercise-Induced Change in Plasma IL-12p70 Is Linked to Migraine Prevention and Anxiolytic Effects in Treatment-Naïve Women: A Randomized Controlled Trial. Neuroimmunomodulation 24:293–299. https://doi.org/10.1159/000487141 Reina- Á, Pt V, Madroñero- B et al (2024) Efficacy of various exercise interventions for migraine treatment: A systematic review and network meta- analysis. Headache 1–28. https://doi.org/10.1111/head.14696 Reina-Varona Á, Madroñero-Miguel B, Gaul C et al (2023) Therapeutic Exercise Parameters, Considerations, and Recommendations for Migraine Treatment: An International Delphi Study. Phys Ther 103:1–10. https://doi.org/10.1093/ptj/pzad080 La Touche R, Oliveira AB, Paris-Alemany A, Reina-Varona A (2024) Incorporating therapeutic education and exercise in migraine management: a biobehavioral approach. J Clin Med 13:6273. https://doi.org/10.3390/jcm13206273 Rollnick S, Miller WR (1995) What is motivational interviewing? Behavioral and Cognitive Psychotherapy. Behav Cogn Psychother 23:325–334 Bigal ME, Bordini CA, Speciali JG (2000) Etiology and Distribution of Headaches in Two Brazilian Primary Care Units. Headache: The Journal of Head and Face Pain 40:241–47 Bigal ME, Rapoport AM, Bordini CA et al (2003) Burden of Migraine in Brazil: Estimate of Cost of Migraine to the Public Health System and an Analytical Study of the Cost-Effectiveness of a Stratified Model of Care. Headache 43:742–754 Queiroz LP, Junior AAS (2015) The Prevalence and Impact of Headache in Brazil. Headache 55:32–39. https://doi.org/10.1111/head.12511 Instituto Brasileiro de Geografia e Estatistica (2019) Pesquisa Nacional de Saúde 2019: Informações sobre domicílios. acesso e utilização dos serviços de saúde Additional Declarations No competing interests reported. Supplementary Files GraphicalAbstract.png Cite Share Download PDF Status: Published Journal Publication published 14 Oct, 2025 Read the published version in The Journal of Headache and Pain → Version 1 posted Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 24 Jun, 2025 Editor assigned by journal 23 Jun, 2025 Submission checks completed at journal 23 Jun, 2025 First submitted to journal 23 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6957841","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475625843,"identity":"2c4e628c-dd54-4b9f-830e-555eb62a4818","order_by":0,"name":"Arão Belitardo Oliveira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYLCCBwYMDPwgRkIBsVoSgFokG6AMIrUAscEBEIsYLfyzDz98kFBwWN74/OrED0AXyvOLHcCvReJcmrFBgsFhw2033m6WADrMcObsBALWnGEwA6pMY9x24+wGkJYEg9sEtMifYf8G0mK/ecbZzT+I0mJwhgdki03iBv7ebcTZYniGpxjoF5vkGTd4t1kkGEgQ9ovcGfaNDz78kbDt7z+7+eaPCht5fmkCWhBAAqxSgljlIMB/gBTVo2AUjIJRMJIAAFTEQ2QHe4NtAAAAAElFTkSuQmCC","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Arão","middleName":"Belitardo","lastName":"Oliveira","suffix":""},{"id":475625844,"identity":"c80e116e-119c-46db-9d57-65143c35d66c","order_by":1,"name":"Suellen Abib","email":"","orcid":"","institution":"I.Cranio - Instituto de Reabilitação, Educação e Saúde","correspondingAuthor":false,"prefix":"","firstName":"Suellen","middleName":"","lastName":"Abib","suffix":""},{"id":475625846,"identity":"a53d9cea-bc98-44a0-8c98-1d247fb36056","order_by":2,"name":"Maria Ivone Oliveira Dantas","email":"","orcid":"","institution":"Universidade Federal de Sergipe","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Ivone Oliveira","lastName":"Dantas","suffix":""},{"id":475625848,"identity":"506fef89-8570-471c-963d-86aa6448282d","order_by":3,"name":"Marcio Nattan Portes Souza","email":"","orcid":"","institution":"Hospital das Clínicas da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Marcio","middleName":"Nattan Portes","lastName":"Souza","suffix":""},{"id":475625849,"identity":"f25f2c67-3579-43a6-80ba-1d7a289d8d70","order_by":4,"name":"Giselle Hech","email":"","orcid":"","institution":"NECEFAC- Núcleo de Estudos em Cefaleias e algias cranianas do Oeste do Paraná","correspondingAuthor":false,"prefix":"","firstName":"Giselle","middleName":"","lastName":"Hech","suffix":""},{"id":475625851,"identity":"52c159ec-0b45-445e-9b1c-45389b80d8a0","order_by":5,"name":"Priscila Papassidero","email":"","orcid":"","institution":"Clínica Lumité","correspondingAuthor":false,"prefix":"","firstName":"Priscila","middleName":"","lastName":"Papassidero","suffix":""},{"id":475625852,"identity":"f47b3747-03b7-4843-8a34-e330dc7d64c4","order_by":6,"name":"Marcelo Rezende Young Blood","email":"","orcid":"","institution":"Hospital Universitário, Universidade Estadual de Ponta Grossa","correspondingAuthor":false,"prefix":"","firstName":"Marcelo","middleName":"Rezende Young","lastName":"Blood","suffix":""}],"badges":[],"createdAt":"2025-06-23 14:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6957841/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6957841/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s10194-025-02137-6","type":"published","date":"2025-10-14T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85725444,"identity":"b8e9262f-44fe-4436-8318-c42765b6c3a0","added_by":"auto","created_at":"2025-07-01 06:33:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44081,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipants´ flow in the PNS2019 survey\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6957841/v1/69f12e4edcca9601014a3ba6.png"},{"id":85726336,"identity":"6e724573-2c19-4f3d-9db4-fb2d207d17f6","added_by":"auto","created_at":"2025-07-01 06:41:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":67618,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRestricted cubic splines of the associations between healthy lifestyle score and prevalence of headache-specific disability in 80,402 Brazilian adults from the PNS 2019 survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePR: Prevalence ratio; CI: Confidence interval; The X-axes were trimmed at the 0.5th to 99.5th percentile of the healthy lifestyle score. The dashed vertical line sets the sample’s median. The models were controlled for the effects of age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6957841/v1/92518193aaca6254a504340f.png"},{"id":93955926,"identity":"f520b72b-2442-4cb0-a51b-6aa2350bca9e","added_by":"auto","created_at":"2025-10-20 16:07:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1316455,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6957841/v1/e3ad121e-d2db-4538-a01b-86242f4747c8.pdf"},{"id":85726705,"identity":"16f12a43-a958-4860-ab0b-242cc6ae7a3a","added_by":"auto","created_at":"2025-07-01 06:49:11","extension":"png","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":517975,"visible":true,"origin":"","legend":"","description":"","filename":"GraphicalAbstract.png","url":"https://assets-eu.researchsquare.com/files/rs-6957841/v1/4be2622faf76c183e6ae0ee8.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"The 6 Pillars of Lifestyle Medicine and Headache Disability in Brazil: A Cross-sectional, Population-Based Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary headache disorders are a leading cause of disability worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Migraine, the most prevalent headache disorder in Brazil [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], is responsible for impaired quality of life, reduced productivity, enormous indirect costs, and higher health care utilization [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Brazil, headache-specific disability ranks as the fifth most common cause of disease-related absenteeism [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMigraine is influenced both by genetic and environmental factors, as well as their complex interactions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There has been an emerging interest in better understanding the influence of lifestyle factors on migraine burden and management [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The most prevalent lifestyle factors associated with migraine burden are psychosocial stress [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], physical inactivity [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], sleep problems [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], dietary factors [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and smoking [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost lifestyle factors associated with headache disorders are encompassed by the American College of Lifestyle Medicine (ACLM)\u0026rsquo;s 6 pillars of lifestyle medicine for healthier life, which includes physical activity, sleep health, plant-based diet, stress management, avoidance of risky substances, and social connections [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, less is known regarding the combination of these lifestyle factors on headache-related disability. Several healthy lifestyle scores have been developed to estimate the aggregated effect of lifestyle factors on several chronic diseases [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Overall, the higher the lifestyle score, the lower the disease outcome (e.g., mortality, cardiovascular diseases, etc) [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, previous lifestyle scores associated with migraine, such as the Life\u0026rsquo;s Essential 8 factors (LE8) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], have not accounted for stress or mental health factors - despite their crucial role in headache disability [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], nor have they included the social support component outlined in the ACLM\u0026rsquo;s 6 pillars framework. Therefore, there is a research gap in developing a composite score that quantifies the aggregated influence of lifestyle factors, including mental health and social support, on headache-related disability.\u003c/p\u003e \u003cp\u003eThe National Health Survey (PNS), initiated in 2013, is a nationally representative household survey that tracked chronic diseases, disability, and lifestyle factors in Brazil, in line with the Ministry of Health\u0026rsquo;s 2021\u0026ndash;2030 chronic disease plan [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The 2019 edition provided updated epidemiological data [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Using PNS2019, we aimed at examining whether higher adherence to the six pillars of lifestyle medicine was associated with lower headache-related disability. We hypothesized that better lifestyle scores would be associated with lower odds for headache-related disability, even after adjusting for socioeconomic and geographic disparities, which have been found associated with headache-related disability in the PNS2019 survey [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a subanalysis of the PNS2019 database, a nationwide, cross-sectional, door-to-door survey of a representative sample of the civilian noninstitutionalized Brazilian population. The survey was conducted by the Ministry of Health in partnership with the Funda\u0026ccedil;\u0026atilde;o Oswaldo Cruz (Fiocruz) and Instituto Brasileiro de Geografia e Estat\u0026iacute;stica (IBGE) between August 2019 and March 2020.\u003c/p\u003e \u003cp\u003ePNS2019 adopted a complex sampling design [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], based on three-stage cluster sampling with stratification of primary sampling units (PSU) from census tracts or sets of tracts and selection of PSUs for the main sample. Households were selected from the National Register of Addresses for Statistical Purposes and finally, the definition of the PSU sample size [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The survey sampling weights were defined considering the weight of the corresponding PSU. Corrections for non-response and calibration of the estimates were made according to the population totals estimated by the IBGE [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe PNS2019 sample consisted of 8,015 PSUs, composing 574 strata. In the sample with individual responses from the dwellers, there were 94,111 household visits, with 90,846 participants interviewed (96.5% response rate). In this study, the data were obtained from Brazilian adults\u0026thinsp;\u0026ge;\u0026thinsp;18 years old who responded to questions about general sociodemographic information, health service utilization (Module J), lifestyle behavior (Module P), and chronic diseases (Module Q).\u003c/p\u003e \u003cp\u003e The National Research Ethics Committee (#3.529.376) has reviewed and approved PNS2019. All participants gave written consent before enrollment.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of Variables\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eOutcomes: Headache-Specific Disability\u003c/h2\u003e \u003cp\u003eDisease-related disability was assessed through a series of questions about the number of days in the past two weeks during which individuals were unable to carry out their usual daily activities (work, school, household tasks, or recreation) due to disease or health condition. Responses were collected through single-choice questions, including 14 categories of major diseases or health conditions. Among these, \"Headache or Migraine\" was listed as an option and here we defined it as headache-specific disability. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the full set of questions, response options, and the complete list of conditions assessed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Disease-related disability questions in the PNS2019 Survey\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnswer options\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1 - In the past 2 weeks, did you miss any habitual activities (work, school, household chores, or recreation) due to a health condition?\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes/ No\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2 - In the past 2 weeks, how many days have you lost from your habitual activities due to any health condition?\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1\u0026ndash;14\u003c/em\u003e days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3 - In the past 2 weeks, which was the main health condition that prevent you from doing your habitual activities?\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e1 - musculoskeletal disorders (Back or neck pain, pain in the limbs/hands, arthritis, or rheumatism), 2 - headache or migraine, 3 - gyneco-obstetrics problems (menstrual, pregnancy, or delivery problems), 4 - dental problems, 5 - respiratory diseases (Cold, flu, sinusitis, asthma, bronchitis, or pneumonia), 6 - gastrointestinal diseases (Diarrhea, vomit, nausea, gastritis, or stomach-ache), 7 - tropical infections (Dengue fever, Chikungunya, Zika, or yellow fever), 8 - CVDs (hypertension or heart diseases) or stroke, 9 - diabetes, 10 - cancer (including chemotherapy), 11 - neurodegenerative diseases (Alzheimer, sclerosis, Parkinson, or other dementias), 12 - psychiatric disorders (Depression, bipolar disorders, schizophrenia, anxiety disorders, or other mental health issues), 13 - injury by accident or violence, or 14 - other health conditions.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eExposure to Lifestyle Factors: The Healthy Lifestyle Score\u003c/h3\u003e\n\u003cp\u003eThe healthy lifestyle score was developed based on the six pillars of lifestyle medicine: physical activity, sleep health, diet, mental health symptoms, risky substances, and social connection. It incorporated variables from the PNS 2019, including leisure-time physical activity (LTPA); dietary patterns such as consumption of whole foods, vegetables, fruits, and fish; intake of ultra-processed, junk, and fast foods; sleep problem symptoms; alcohol consumption; smoking status; and participation in social activities like cultural, sports, recreational, or religious group events. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the components of the 6-pillar framework and their respective scoring system\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories and scores of the 6 pillars of lifestyle medicine and their components.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthy Lifestyle 6 Pillars and Components\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1. \u003cb\u003ePhysical Activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInactive (no activity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomewhat active (\u0026lt;\u0026thinsp;149 min.week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive (\u0026ge;\u0026thinsp;150 min.week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. \u003cb\u003eDiet\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of beans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of greens and vegetables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of fruits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of fish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of sodas beverages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of sweets\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWeekly consumption of replaced meals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;7 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;5 times.week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to once a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3. \u003cb\u003eSleep Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSleep Drugs\u0026thinsp;+\u0026thinsp;PHQ9-Sleep\u0026thinsp;\u0026ge;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSleep Drugs or PHQ9-Sleep\u0026thinsp;\u0026ge;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Sleep Drugs\u0026thinsp;+\u0026thinsp;PHQ9-Sleep\u0026thinsp;\u0026lt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4. \u003cb\u003eMental Health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHQ9\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHQ9 5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHQ9\u0026thinsp;\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e5. \u003cb\u003eRisky Substance: Drinking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than once/month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than once/month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e6. \u003cb\u003eRisky Substance: Smoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormer smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. \u003cb\u003eSocial Connection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGroup Cultural, Sports, or Recreative Activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever or once a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes every year to 3 times a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeekly or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eReligious Attendance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever or once a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSometimes every year to 3 times a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeekly or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLifestyle components were scored as 0, 1, or 2 points, corresponding to the poorest, intermediate, or healthiest options, depending on exposure levels. For diet and social connection, which consisted of multiple questions, unweighted mean scores were calculated. Scores for unhealthy food groups were inverted, thus, the values of 0 and 2 points represented the highest and lowest consumption frequencies, respectively \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eGiven the significant impact of alcohol consumption [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and smoking [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] on mortality and disease burden, these factors were analyzed separately under the \u0026ldquo;risky substances\u0026rdquo; pillar. Consequently, the total healthy lifestyle score included seven items, ranging from 0 to 14 points as the unweighted sum. Higher scores reflected a healthier lifestyle profile. The details of the assessment of each component and the methodology of the scoring system adopted for each pillar of lifestyle medicine are described in the following subsections.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssessment of the 6-Pillar Lifestyle Medicine Framework\u003c/b\u003e \u003c/p\u003e \u003cp\u003e1. Physical Activity\u003c/p\u003e \u003cp\u003eLeisure-time physical activity (LTPA) was the domain of interest due to its more consistent associations with reduced CVDs and CMB risk [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. LTPA was surveyed by the following questions: (i) \u0026ldquo;In the previous 3 months, did you engage in any physical exercise or sport?\u0026rdquo; (excluding physiotherapy, yes/no answer options); (ii) \u0026ldquo;How many days per week do you practice any physical exercise or sport?\u0026rdquo; (never/less than once per week, or 1\u0026ndash;7 days options); (iii) \u0026ldquo;In general, how much time in hours do you spend performing physical exercise or sport?\u0026rdquo;; and (iv) \u0026ldquo;In general, how much time in minutes do you spend performing physical exercise or sport?\u0026rdquo;. The total weekly minutes of leisure-time physical activity were calculated and categorized according to the World Health Organization's (WHO) 2020 physical activity guidelines. \u003csup\u003e79\u003c/sup\u003e Participants were defined as \u0026ldquo;active\u0026rdquo; if they met at least one of the following criteria: engaging in a minimum of 150 minutes per week of moderate to vigorous physical activity or 75 minutes per week of vigorous physical activity. Those who reported no physical activity were defined as \u0026ldquo;inactive.\u0026rdquo; Participants who engaged in physical activity but did not meet the thresholds for the \u0026ldquo;active\u0026rdquo; category were defined as \u0026ldquo;somewhat active\u0026rdquo; [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The score values of 0, 1, and 2 were attributed to inactive, somewhat active, and active, respectively.\u003c/p\u003e \u003cp\u003e2. Diet\u003c/p\u003e \u003cp\u003eDietary patterns were assessed using the Food Frequency Questionnaire (FFQ), which enquires about the frequency food consumption over the past week (0 to 7 days). For our scoring, we selected the following food groups: (a) beans; (b) raw and cooked vegetables (lettuce, carrots, tomato, chayote, collard greens, eggplants, zucchini, etc) ; (c) fruits; (d) fish; (e) sodas; (f) sweets (such as cakes, pies, chocolates, candies, cookies, or sweet biscuits); and (g) meals replaced with sandwiches, hot dogs, snacks, or pizzas. Each food group was assigned a score ranging from 0 to 2. For healthy food groups (a to d), a weekly consumption frequency of 0 to 1 time was scored as 0, 2 to 5 times as 1, and 6 to 7 times as 2. In contrast, for unhealthy food groups (e to g), a weekly intake of 0 to 1 time was scored as 2, 2 to 5 times as 1, and 6 to 7 times as 0. The diet score was calculated as the unweighted average of the scores across all food groups.\u003c/p\u003e \u003cp\u003e3. Sleep\u003c/p\u003e \u003cp\u003eThe categorization of sleep health was based on the questions \u0026ldquo;In the past 2 weeks did you take any sleep medicine?\u0026rdquo; (answer options were yes/no) and the item 3 of the Patient Health Questionnaire-9 (PHQ-9) \"In the past two weeks, how often have you had sleep problems, such as difficulty falling asleep, waking up frequently during the night, or sleeping more than usual?\" with response options and their respective values being \u0026ldquo;Not at all\u0026rdquo; (0)\u0026ldquo;Several days\u0026rdquo;(1), \u0026ldquo;More than half the days\u0026rdquo;(2) or \u0026ldquo;Almost every day\u0026rdquo;(3) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The score value of 0 was assigned to participants who reported taking sleep medicine and/or experiencing sleep problems \u0026ldquo;More than half the days\u0026rdquo; or \u0026ldquo;Almost every day.\u0026rdquo; A value of 1 was given to respondents reporting sleep problems on \u0026ldquo;Several days,\u0026rdquo; while a value of 2 was attributed to respondents reporting no sleep problems (\u0026ldquo;Not at all\u0026rdquo;).\u003c/p\u003e \u003cp\u003e4. Mental Health\u003c/p\u003e \u003cp\u003eBecause PNS 2019 has no specific question on stress, the pillar of mental health was operationalized based on the PHQ-9 score, which has been translated and validated for the Brazilian population [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The PHQ-9 assesses the severity of depression with nine questions about symptoms over the past two weeks, using a 4-point Likert scale. Depression severity is categorized into five levels based on the PHQ-9 scores: minimal or none (0\u0026ndash;4), mild (5\u0026ndash;9), moderate (10\u0026ndash;14), moderately severe (15\u0026ndash;19), and severe (20\u0026ndash;27). For our healthy lifestyle scoring system, the following PHQ-9 categories/values were assigned: minimal or none (0\u0026ndash;4)\u0026thinsp;=\u0026thinsp;2, mild (5\u0026ndash;9)\u0026thinsp;=\u0026thinsp;1, and scores\u0026thinsp;\u0026gt;\u0026thinsp;9\u0026thinsp;=\u0026thinsp;0.\u003c/p\u003e \u003cp\u003e5. Risky Substances\u003c/p\u003e \u003cp\u003eSmoking Status\u003c/p\u003e \u003cp\u003eCurrent smoking status was assessed by the questions: \u0026ldquo;Do you currently smoke any tobacco products?\u0026rdquo; or \u0026ldquo;Did you use to smoke any tobacco products?\u0026rdquo;. Answer options for both questions were \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;. The score value of 0 was assigned to current smokers, the value of 1 was assigned to former smokers, and the value of 2 was assigned to non-smokers\u003c/p\u003e \u003cp\u003eAlcohol Consumption\u003c/p\u003e \u003cp\u003eWe used the question \u0026ldquo;How often do you usually consume any alcoholic beverage?\u0026rdquo; to assess drinking habits. Response options were \u0026ldquo;never\u0026rdquo;, \u0026ldquo;less than once/month\u0026rdquo;, and \u0026ldquo;once or more/month\u0026rdquo;. The score value of 0 was assigned to the drinking frequency \u0026ldquo;once or more/month\u0026rdquo;, the value of 1 was assigned to \u0026ldquo;less than once/month\u0026rdquo;, and the value of 2 was assigned to abstemious participants (\u0026ldquo;never\u0026rdquo;).\u003c/p\u003e \u003cp\u003e6. Social Connections\u003c/p\u003e \u003cp\u003eWe selected the two following questions to assess social connection: \u0026ldquo;In the past 12 months, how often have you met with others to engage in sports, recreational, or cultural activities? and \u0026ldquo;\"In the past 12 months, how often have you attended collective activities of your religion or another religion, excluding situations such as weddings, baptisms, or funerals?\". For both questions, response options were: \u0026ldquo;More than once a week\u0026rdquo;, \u0026ldquo;Once a week\u0026rdquo;, \u0026ldquo;From 2 to 3 times a month\u0026rdquo;, \u0026ldquo;A few times a year\u0026rdquo;, \u0026ldquo;Once a year\u0026rdquo;, \u0026ldquo;Never\u0026rdquo;. The religious attendance was selected as a social connection component, based on the high prevalence of religious affiliation in Brazil and as a major social activity with potential impact on health.[\u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] The social connection score was calculated as the unweighted average score of the two questions.\u003c/p\u003e\n\u003ch3\u003eCovariates: Sociodemographic Factors\u003c/h3\u003e\n\u003cp\u003eSociodemographic variables included the 5 main geopolitical regions of Brazil (North, Northeast, Central West, Southeast, and South), age, sex assigned at birth (Female, Male), housing place (Urban, or Rural), self-reported skin color (White, Black, Brown, Others \u0026ndash; Asian, Indigenous) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], marital status (Single, Married, Separated/Divorced, or Widower), household Income (per capita), separated into quartiles, Q4 Income (lowest), Q3 Income, Q2 Income, Q1 Income (highest), educational attainment \u003cb\u003e(\u003c/b\u003eNo formal/incomplete primary, Complete primary, Complete high school, and Complete college), labor force status (Inside the labor force, Outside the labor force), excluding income from the pension, and job status (Employed or Unemployed). People inside the labor force were defined as working-aged people employed or unemployed and outside the labor force. People outside the labor force were defined as working-aged people not classed as employed or unemployed.\u003c/p\u003e\n\u003ch3\u003eStatistics\u003c/h3\u003e\n\u003cp\u003eThe population estimates were based on the number of strata, the number of selected PSUs in each stratum, and the number of households and residents included in the PSU and their respective expansion factors and sample weighting. The data on weights, number of PSUs, and strata were provided in the dictionary of variables file along with the PNS2019 database. In the PNS2019 survey, it was necessary to define expansion factors or sample weights of the PSUs, of the households and all their residents, and of the selected residents. The weights of the PSUs considered the probabilities of selection of these units for the main sample and the research sample.\u003c/p\u003e \u003cp\u003eIn the descriptive analyses, we reported the weighted prevalence of disease-related disability as a proportion (%) with a 95% confidence interval (CI). In the hypothesis\u0026rsquo;s tests, we utilized weighted Poisson regression models with robust variance to assess the relationship between the healthy lifestyle scores (\u0026ldquo;predictor\u0026rdquo;) and presence of headache-specific disability (outcome). The results are presented as prevalence ratio (PR) and 95% confidence intervals (95% CI). The no disability group was set as the reference group. Crude and adjusted models were fitted to assess the independent effect of the healthy lifestyle score on headache-specific disability. The adjusted models controlled for the effect of age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status.\u003c/p\u003e \u003cp\u003eTo identify possible non-linear relationships between the healthy lifestyle scores and headache-specific disability that cannot be verified using linear regression models, we modeled these relationships using restricted cubic splines with 4 knots positioned at the 5th, 35th, 65th, and 95th percentiles of healthy lifestyle scores, following Harrell\u0026acute;s method [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Reference values for healthy lifestyle scores (0 to 14) were set at 9 points, which was the whole sample\u0026acute;s median value. The regression models built for the cubic splines were also adjusted for age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status.\u003c/p\u003e \u003cp\u003eA type I error rate\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was accepted as statistically significant in all analyses. All analyses were conducted with Stata software (version 17.0, StataCorp LLC). Complex sampling design \u003cem\u003esvy\u003c/em\u003e commands with weights for the non-response sample corrections and post-stratification adjustments were performed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, 88,531 adult participants provided full data regarding variables of interest. The mean (SDI) age was 47.1 (17.1) years, and 52.9% were female. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the flowchart of the participants included in this study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOf these, 8,693 [weighted point prevalence\u0026thinsp;=\u0026thinsp;8.8% (8.2%-9.2%)] lost at least one day of work, school, domestic chores, or recreation in the previous 2 weeks due to disease or health condition, representing 14,134,980\u0026nbsp;million Brazilian adults. Headache-specific disability was the fifth most prevalent disease-specific cause of disability in Brazil, with a weighted prevalence of 5.3% (4.6%-6.0%) of all disease-related disability, representing 751,092 Brazilian adults. Headache-specific disability caused a mean (SD) of 3.5 (3.2) days lost in the past 2 weeks. Considering the sex and age range subgroups, headache-specific disability was the 4th and 3rd most prevalent cause among female and adults between 18 and 35 years, respectively, representing around 11% of all disease-related disability within these subgroups.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the sociodemographic profiles of no disability and headache-specific disability groups (n\u0026thinsp;=\u0026thinsp;80,402). Compared to the general population, Brazilians reporting headache disability showed a higher proportion [% (95% CI)] of female [74.0% (67.2%, 79.8%) \u003cem\u003evs\u003c/em\u003e 51.9% (51.3%, 52.5%), people from the Northeast region [45.1% (38.8%, 51.6%) \u003cem\u003evs\u003c/em\u003e 26.3% (25.7%, 26.8%)], living in rural areas [20.6%(16.3%, 25.7%) vs 13.9% (13.5%, 14.3%), of brown color [53.2%(46.5%, 59.7%) \u003cem\u003evs\u003c/em\u003e 43.7% (43.0%, 44.4%)], with lower education [no formal/incomplete primary: 40.6% (34.6%, 47.0%) \u003cem\u003evs\u003c/em\u003e 33.7% (33.0%, 34.4%)] and lower household income [lowest quartile: 38.0% (31.8%, 44.6%) \u003cem\u003evs\u003c/em\u003e 22.0% (21.4%, 22.6%)] \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWeighted distribution of socioeconomic and demographic variables by groups in the PNS 2019 survey (n\u0026thinsp;=\u0026thinsp;80,402)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGeneral Sample *\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;79,838)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eHeadache-Specific Disability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;564)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003csub\u003eweighted\u003c/sub\u003e (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003csub\u003eweighted\u003c/sub\u003e (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoutheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,505\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.5 (42.6, 44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.6 (19.4, 33.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8 (14.4, 15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.2 (5.6, 12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral West\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6 (7.3,7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.2 (5.5, 12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNortheast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27,520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.3 (25.7, 26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.1 (38.8, 51.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,293\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8 (7.6, 8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.8 (10.0, 16.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousing Place\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61,416\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.1 (85.7, 86.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.4 (74.3, 83.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18,422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.9 (13.5, 14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.6 (16.3, 25.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41,240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.9 (51.3, 52.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.0 (67.2, 79.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38,598\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.1 (47.5,48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.0 (20.2, 32.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Group, yrs.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24,236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.1 (34.4, 35.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.7 (31.4, 44.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16,319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.2 (19.7, 20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.4 (17.3, 28.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.6 (17.1,18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.2 (12.4, 21.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e56\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1 (13.7, 14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.6 (11.4, 20.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,707\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0 (12.6, 13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.1 (5.9, 11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSkin Color\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29,335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.5 (42.7, 44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.9 (26.0, 38.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40,227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.7 (43.0, 44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.2 (46.5, 59.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.4 (11.0, 11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.9 (10.5, 18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (Asian, Indigenous)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4 (1.3, 1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 (0.4, 2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31,896\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.9 (43.2, 44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.5 (37.1, 50.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34,938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.9 (42.2, 43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.6 (35.5, 48.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated/Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8 (6.5,7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.7 (5.7, 12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow(er)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5 (6.2, 6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.2 (4.3, 9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchooling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal/Incomplete Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31,241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.7 (33.0, 34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.6 (34.6, 47.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,925\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6 (14.2, 15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.4 (8.9,17.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete High-School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25,206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.6 (35.0, 36.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.2 (26.2, 38.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete College\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,466\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.1 (15.4, 16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.8 (10.1, 21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Income (\u003c/b\u003e\u003cb\u003eper capita\u003c/b\u003e\u003cb\u003e)\u003c/b\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ4 Income (lowest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0 (21.4, 22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.0 (31.8, 44.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ3 Income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22,921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.8 (28.2, 29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.6 (26.5, 39.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ2 Income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16,485\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.3 (22.7, 23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.5 (10.1, 20.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1 Income (highest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.9 (25.2,26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.9 (11.0,19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLabor Force Status\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInside the labor force\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51,777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.8 (67.2, 68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.8 (58.2, 70.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutside the labor force\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28,061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.2 (31.6,32.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.2 (29.2,41.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u0026dagger;\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48,350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.1 (91.6,92.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93.0 (87.8, 96.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,427\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9 (7.4, 8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.0 (3.9, 12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are presented as unweighted frequencies (n) and weighted proportions. *: Excluded other disease-related disability groups. Q4-1: Quartiles; \u003csup\u003e\u0026dagger;\u003c/sup\u003e: Household income (\u003cem\u003eper capita\u003c/em\u003e excluding income from the pension. Quartile income values in International Dollars (Int$): Q1\u0026thinsp;\u0026lt;\u0026thinsp;Int$ 220, Q2\u0026thinsp;=\u0026thinsp;Int$ 220\u0026ndash;441, Q2\u0026thinsp;=\u0026thinsp;Int$ 442\u0026ndash;737, and Q1\u0026thinsp;\u0026gt;\u0026thinsp;Int$ 738, based on exchange rate of 2.26:1 (as for 2020, according to World Economic Bank (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.worldbank.org/indicator/PA.NUS.PPP?\u003c/span\u003e\u003cspan address=\"https://data.worldbank.org/indicator/PA.NUS.PPP?\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e view\u0026thinsp;=\u0026thinsp;chart\u0026amp;locations\u0026thinsp;=\u0026thinsp;BR, accessed 03/01/2024); \u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e: People inside the labor force: working-aged people employed or unemployed and outside the labor force. People outside the labor force: working-aged people not classed as employed or unemployed.[\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e] \u003csup\u003e\u003cb\u003e\u0026dagger;\u003c/b\u003e\u0026dagger;\u003cb\u003e\u0026dagger;\u003c/b\u003e\u003c/sup\u003e: Job status data are from people inside the labor force.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe headache-specific disability group showed lower mean (SD) healthy lifestyle score than no disability group [7.8(2.4) \u003cem\u003evs\u003c/em\u003e 8.8(2.4), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively].\u003c/p\u003e \u003cp\u003eThe crude models showed that the healthy lifestyle score was inversely associated with headache-specific disability [PR\u0026thinsp;=\u0026thinsp;0.87 (95% CI: 0.83, 0.92), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After adjusting for age, sex, skin color, marital status, educational attainment, household income, housing place, region, and labor force status, the healthy lifestyle score activity remained inversely associated with headache-specific disability [PR\u0026thinsp;=\u0026thinsp;0.85 (95% CI: 0.81, 0.89), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001], indicating that for each one-point increase in the healthy lifestyle score, there was a 14.7% reduced prevalence of headache-specific disability, assuming all other variables are held constant.\u003c/p\u003e \u003cp\u003eThe plots with restricted cubic splines for the adjusted models revealed a strong, linear inverse relationships (\u003cem\u003ep\u003c/em\u003e for linear trend: \u0026lt; 0.001) between healthy lifestyle score and presence of headache-specific disability \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eHere, we aimed to examine the associations between healthy lifestyle score and headache-specific disability using data from the PNS2019 survey. Confirming our hypothesis, we observed a strong inverse association between the healthy lifestyle score and the prevalence of headache-specific disability, even after adjusting for several sociodemographic and geographic disparities previously shown to influence headache burden in Brazil [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn PNS2019, headache disability was defined as days missed from work, school, recreation, or chores activities in the past 2 weeks. In other surveys and datasets, presenteeism-related disability is estimated to represent the largest share of headache disability [\u003cspan additionalcitationids=\"CR46 CR47\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], including in Brazil [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Thus, our data is generalizable to disability within this definition only and cannot be extrapolated to headache prevalence in general. Furthermore, the cross-sectional design limits causal inference between lifestyle factors and headache disability. Reverse causality is plausible given the bidirectional relationship between lifestyle and headache disorders. For instance, disabling headache attacks may reduce adherence to healthy behaviors - such as physical activity, social engagement, and sleep quality - or worsen anxiety symptoms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, our findings concur with data from both cross-sectional and prospective studies investigating the associations between lifestyle factors and migraine. A recent prospective analysis of the UK BioBank showed a higher incidence of migraine with lower adherence to healthy lifestyle factors and the LE8 factors among 332,895 participants (3,225 cases) followed up for 13.5 years [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Likewise, results from the ELSA-Brasil study pointed to a strong, inverse association between high adherence to the LE8 factors and migraine disorders occurrence and chronification [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, LE8 does not cover the mental health and social support pillars of lifestyle medicine. Mental health symptoms play a central role for headache disability and burden [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], while growing evidence suggests that lack social support and feeling of loneliness are associated with chronic headache at the population level [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This underscores the clinical utility in using healthy lifestyle score based on the ACLM\u0026rsquo;s 6 pillars framework in headache care.\u003c/p\u003e \u003cp\u003eThe strong, linear inverse association between healthy lifestyle scores and headache disability suggests additive - and potentially interactive - effects of each lifestyle component, which resonates with their known independent associations with major headache disorders prevalence [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e], as well as the therapeutic effects of interventions targeting the pillars of lifestyle to reduce headache burden, such as stress management [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], sleep health [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e], diet [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], and exercise [\u003cspan additionalcitationids=\"CR63 CR64 CR65 CR66\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUsing healthy lifestyle scores in headache care may prove clinically and epidemiologically useful. Addressing modifiable behaviors not only complements pharmacological therapy but also potentiate functional recovery and quality of life [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Strategies must adopt evidence-based approach that enhances intrinsic motivation and adherence to lifestyle changes, such as motivational interviewing [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The tenets of the motivational interviewing such as expressing empathy, resolving ambivalence, and fostering self-efficacy, concur with the needs of people struggling with disabling headaches regarding lifestyle modifications [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom the public health\u0026rsquo;s perspective, considering that major primary headache disorders are highly prevalent [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], costly [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and disabling chronic diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] in Brazil, they should be included within the current and future nationwide health promotion programs (e.g., The Brazilian Ministry of Health's Strategic Action Plan for Coping with Chronic Diseases) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These programs should include headache-tailored approaches targeting modifiable lifestyle factors specific for this population.\u003c/p\u003e \u003cp\u003eThe strength of this study lies in its use of a representative sample of the Brazilian population, with data collected through a complex sampling design. This ensures that the estimates of prevalence, distribution, and projections related to recent headache disability are robust and generalizable to the broader Brazilian population.\u003c/p\u003e \u003cp\u003eHowever, an important limitation is the cross-sectional nature of this study, which restricts the ability to establish causal relationships. Additionally, lifestyle variables were self-reported, introducing potential biases such as recall bias and social desirability bias. The PNS2019 did not specifically investigate headache prevalence, nor did it employ a more detailed headache-related instrument, such as the Migraine Disability Assessment (MIDAS), to assess headache disability over a longer period. It also lacked detailed information on which daily activities are most affected by headache-related disability and did not explore presenteeism (reduced productivity while working). Furthermore, the PNS2019 did not differentiate between headache subtypes, leaving it unclear which subtype contributes most significantly to the overall burden. Nevertheless, based on general headache prevalence estimates and observational studies conducted in primary care settings, migraine has been identified as the most disabling, most frequently encountered in emergency rooms, and the costliest headache subtype in Brazil [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn conclusion, the healthy lifestyle score was inversely associated with prevalence of headache-specific disability regardless of sociodemographic and geographic disparities in the PNS2019 survey. This finding should substantiate the prioritization of lifestyle-based interventions within public health promotion policies targeting to reduce headache burden in Brazil.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe National Research Ethics Committee (#3.529.376) has reviewed and approved the PNS2019 survey.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants gave written consent before enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PNS 2019 microdata are openly available in the Instituto Brasileiro de Geografia e Estat\u0026iacute;stica \u0026ndash; IBGE website at https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare there is no conflict of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant or funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eABO designed the study, obtained the data, and conducted the statistical analysis; ABO, SA, MIOD, MNPS, GH, PP, and MRYB interpreted the data, drafted the manuscript, and revised it for intellectual content. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAr\u0026atilde;o Belitardo de Oliveira, Suellen Abib, Maria Ivone Oliveira Dantas, Marcio Nattan Portes Souza, Giselle Hech, Priscila Papassidero, and Marcelo Rezende Young Blood\u003csup\u003e\u0026nbsp;\u003c/sup\u003eare members of the collaboration group Brazilian Headache Society\u0026acute;s Lifestyle Medicine Committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD2021NervousSystemDisordersCollaborators (2024) Global, regional, and national burden of disorders affecting the nervous system, 1990\u0026ndash;2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Neurol 23:344\u0026ndash;381. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1474-4422(24)00038-3\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(24)00038-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQueiroz L, Peres M, Piovesan E et al (2009) A nationwide population-based study of migraine in Brazil. Cephalalgia 29:642\u0026ndash;649. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1468-2982.2008.01782.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1468-2982.2008.01782.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Queiroz LP, Rocha-Filho PS et al (2020) Annual Indirect Costs Secondary to Headache Disability in Brazil. Cephalalgia 40:597\u0026ndash;605\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza MNP, Cohen JM, Piha T et al (2022) Burden of migraine in Brazil: A cross-sectional real-world study. Headache 62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.14413\u003c/span\u003e\u003cspan address=\"10.1111/head.14413\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira A, Bensenor I, Goulart A et al (2023) Socioeconomic and geographic inequalities in headache disability in Brazil: The 2019 National Health Survey. Headache 63:114\u0026ndash;126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.14462\u003c/span\u003e\u003cspan address=\"10.1111/head.14462\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira A, Mercante JPP, Bensenor IM et al (2022) Headache disability, lifestyle factors, health perception, and mental disorder symptoms: a cross-sectional analysis of the 2013 National Health Survey in Brazil. Neurol Sci 43:2723\u0026ndash;2734. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10072-021-05618-z\u003c/span\u003e\u003cspan address=\"10.1007/s10072-021-05618-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarder AVE, Terwindt GM, Nyholt DR, van den Maagdenberg AMJM (2023) Migraine genetics: Status and road forward. Cephalalgia 43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/03331024221145962\u003c/span\u003e\u003cspan address=\"10.1177/03331024221145962\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeng EK, Martin PR, Houle TT (2022) Lifestyle factors and migraine. Lancet Neurol 21:911\u0026ndash;921. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1474-4422(22)00211-3\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(22)00211-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLei Y, Zhang L, Shan Z et al (2024) Poor healthy lifestyle and life\u0026rsquo;s essential 8 are associated with higher risk of new-onset migraine: a prospective cohort study. J Headache Pain 25:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10194-024-01785-4\u003c/span\u003e\u003cspan address=\"10.1186/s10194-024-01785-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoldeamanuel Y, Cowan R (2016) The impact of regular lifestyle behavior in migraine: a prevalence case-referent study. J Neurol 263:669\u0026ndash;676. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00415-016-8031-5\u003c/span\u003e\u003cspan address=\"10.1007/s00415-016-8031-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobblee J, Starling AJ (2019) SEEDS for success: Lifestyle management in migraine. Cleve Clin J Med 86:741\u0026ndash;749. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3949/ccjm.86a.19009\u003c/span\u003e\u003cspan address=\"10.3949/ccjm.86a.19009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDantas MIO, Carneiro NM, Abib S (2024) Integrated Approach to Migraine Management: A narrative review of the Pillars of Lifestyle Medicine. Headache Med 15:64\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.48208/headachemed.2024.15\u003c/span\u003e\u003cspan address=\"10.48208/headachemed.2024.15\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStubberud A, Buse DC, Kristoffersen ES et al (2021) Is there a causal relationship between stress and migraine? Current evidence and implications for management. J Headache Pain 22:1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10194-021-01369-6\u003c/span\u003e\u003cspan address=\"10.1186/s10194-021-01369-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelitardo de Oliveira A, Winter Schytz H, Fernando Prieto Peres M et al (2024) Does physical activity and inflammation mediate the job stress-headache relationship? A sequential mediation analysis in the ELSA-Brasil study. Brain Behav Immun 120:187\u0026ndash;198. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bbi.2024.06.002\u003c/span\u003e\u003cspan address=\"10.1016/j.bbi.2024.06.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantos IS, Griep RH, Alves MGM et al (2014) Job stress is associated with migraine in current workers: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Eur J Pain (United Kingdom) 18:1290\u0026ndash;1297. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/j.1532-2149.2014.489.x\u003c/span\u003e\u003cspan address=\"10.1002/j.1532-2149.2014.489.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePitanga FJG, Almeida MCC, Queiroz CO et al (2017) Physical activity in Brazil: lessons from ELSA-Brasil. Narrative review. Sao Paulo Med J 135:391\u0026ndash;395. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1516-3180.2017.0023190317\u003c/span\u003e\u003cspan address=\"10.1590/1516-3180.2017.0023190317\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Mercante JPP, Peres MFP et al (2021) Physical inactivity and headache disorders: a cross-sectional analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cephalalgia 41:1467\u0026ndash;1485. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/03331024211029217\u003c/span\u003e\u003cspan address=\"10.1177/03331024211029217\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHagen K, \u0026Aring;sberg AN, Stovner L et al (2018) Lifestyle factors and risk of migraine and tension-type headache. Follow-up data from the Nord-Tr\u0026oslash;ndelag Health Surveys 1995\u0026ndash;1997 and 2006\u0026ndash;2008. Cephalalgia 38:1919\u0026ndash;1926. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0333102418764888\u003c/span\u003e\u003cspan address=\"10.1177/0333102418764888\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStanyer EC, Creeney H, Nesbitt AD et al (2021) Subjective Sleep Quality and Sleep Architecture in Patients with Migraine: A Meta-analysis. Neurology 97:E1620\u0026ndash;E1631. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1212/WNL.0000000000012701\u003c/span\u003e\u003cspan address=\"10.1212/WNL.0000000000012701\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiseo C, Vacca A, Felbush A et al (2020) Migraine and sleep disorders: a systematic review. J Headache Pain 21:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10194-020-01192-5\u003c/span\u003e\u003cspan address=\"10.1186/s10194-020-01192-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin VT, Vij B (2016) Diet and Headache: Part 1. Headache 56:1543\u0026ndash;1552. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.12953\u003c/span\u003e\u003cspan address=\"10.1111/head.12953\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazeghi Jahromi S, Ghorbani Z, Martelletti P et al (2019) Association of diet and headache. J Headache Pain 20:1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10194-019-1057-1\u003c/span\u003e\u003cspan address=\"10.1186/s10194-019-1057-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinberger AH, Seng EK (2023) The Relationship of Tobacco Use and Migraine: A Narrative Review. Curr Pain Headache Rep 27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGan WQ, Estus E, Smith J (2016) Association Between Overall and Mentholated Cigarette Smoking With Headache in a Nationally Representative Sample. Headache 56:511\u0026ndash;518. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.12778\u003c/span\u003e\u003cspan address=\"10.1111/head.12778\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmericanCollegeofLifestyleMedicine (2025) 6 Pillars of Lifestyle Medicine\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Mota J, Woldeamanuel YW et al (2025) The 6 Pillars of Lifestyle Medicine and Prevalence of Cardiovascular and Cardiometabolic Diseases in Brazil: A Cross-Sectional, Population-Based Study. Am J Lifestyle Med 0:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/15598276251348170\u003c/span\u003e\u003cspan address=\"10.1177/15598276251348170\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuasch-Ferr\u0026eacute; M, Li Y, Bhupathiraju SN et al (2022) Healthy Lifestyle Score Including Sleep Duration and Cardiovascular Disease Risk. Am J Prev Med 63:33\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amepre.2022.01.027\u003c/span\u003e\u003cspan address=\"10.1016/j.amepre.2022.01.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViallon V, Freisling H, Matta K et al (2024) On the use of the healthy lifestyle index to investigate specific disease outcomes. Sci Rep 14:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-024-66772-w\u003c/span\u003e\u003cspan address=\"10.1038/s41598-024-66772-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang YBo, Chen C, Pan XF et al (2021) Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: Two prospective cohort studies. BMJ 373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.n604\u003c/span\u003e\u003cspan address=\"10.1136/bmj.n604\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinist\u0026eacute;rio da Sa\u0026uacute;de (2021) Plano de A\u0026ccedil;\u0026otilde;es Estrat\u0026eacute;gicas para o Enfrentamento das Doen\u0026ccedil;as Cr\u0026ocirc;nicas e Agravos n\u0026atilde;o Transmiss\u0026iacute;veis no Brasil 2021\u0026ndash;2030. In: Secretaria de Vigil\u0026acirc;ncia em Sa\u0026uacute;de. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf/view\u003c/span\u003e\u003cspan address=\"https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf/view\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 4 May 2024\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStopa SR, Szwarcwald CL, de Oliveira MM et al (2020) National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 29:e2020315. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S1679-49742020000500004\u003c/span\u003e\u003cspan address=\"10.1590/S1679-49742020000500004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGBD2020AlcoholCollaborators (2022) Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020. Lancet 400:185\u0026ndash;235. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(22)00847-9\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(22)00847-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGBD2019TobaccoCollaborators (2021) Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet 397:2337\u0026ndash;2360. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(21)01169-7\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(21)01169-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Tunaiji H, Davis JC, Mansournia MA, Khan KM (2019) Population attributable fraction of leading non-communicable cardiovascular diseases due to leisure-time physical inactivity: A systematic review. BMJ Open Sport Exerc Med 5:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjsem-2019-000512\u003c/span\u003e\u003cspan address=\"10.1136/bmjsem-2019-000512\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao G, Li C, Ford ES et al (2014) Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: The NHANES linked mortality study. Br J Sports Med 48:244\u0026ndash;249. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bjsports-2013-092731\u003c/span\u003e\u003cspan address=\"10.1136/bjsports-2013-092731\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoenen P, Huysmans MA, Holtermann A et al (2024) Associations of occupational and leisure-time physical activity with all-cause mortality: an individual participant data meta-analysis. Br J Sports. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bjsports-2024-108117\u003c/span\u003e\u003cspan address=\"10.1136/bjsports-2024-108117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Med bjsports-2024-108117\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2020) WHO Gudelines on Physical Activity and Sedentary Behaviour. World Health Organization, Geneva\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 16:606\u0026ndash;613. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1046/j.1525-1497.2001.016009606.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1525-1497.2001.016009606.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantos IS, Tavares BF, Munhoz TN et al (2013) Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da popula\u0026ccedil;\u0026atilde;o geral. Cad Saude Publica 29:1533\u0026ndash;1543. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/0102-311X00144612\u003c/span\u003e\u003cspan address=\"10.1590/0102-311X00144612\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres MFP, de Oliveira AB, Le\u0026atilde;o FC et al (2018) Religious landscape in Brazil: Comparing different representative nationwide approaches to obtain sensitive information in healthcare research. SSM Popul Health 6:85\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ssmph.2018.08.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ssmph.2018.08.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaries MD, Corr\u0026ecirc;a Fernandes C, Phillips E et al (2024) Religion and Spirituality in Lifestyle Medicine. Am J Lifestyle Med 0:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/15598276241276770\u003c/span\u003e\u003cspan address=\"10.1177/15598276241276770\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanderWeele T, Balboni T, Koh H (2017) Health and Spirituality. JAMA 318:519\u0026ndash;520. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2017.8136\u003c/span\u003e\u003cspan address=\"10.1001/jama.2017.8136\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres MFP, Swerts D, De Oliveira AB et al (2020) Mental Health and Quality of Life among Adults with Single, Multiple, and No Religious Affiliations. J Nerv Mental Disease 208:288\u0026ndash;293. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NMD.0000000000001115\u003c/span\u003e\u003cspan address=\"10.1097/NMD.0000000000001115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarrell FEJ (2001) Regression modeling strategies: With applications to linear models, logistic regression, and survival analysis, 1st Editio. Springer, New York, NY\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoetzel RZ, Long SR, Ozminkowski RJ et al (2004) Health, Absence, Disability, and Presenteeism Cost Estimates of Certain Physical and Mental Health Conditions Affecting U.S. Employers. J Occup Environ Med 46:398\u0026ndash;412. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.jom.0000121151.40413.bd\u003c/span\u003e\u003cspan address=\"10.1097/01.jom.0000121151.40413.bd\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelekler MH, G\u0026ouml;kmen G, Steiner TJ (2013) Productivity impact of headache on a heavy- manufacturing workforce in Turkey. J Headache Pain 14:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1129-2377-14-88\u003c/span\u003e\u003cspan address=\"10.1186/1129-2377-14-88\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart WF, Wood GC, Razzaghi H et al (2008) Work impact of migraine headaches. Journal of occupational and environmental medicine /. Am Coll Occup Environ Med 50:736\u0026ndash;745. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/JOM.0b013e31818180cb\u003c/span\u003e\u003cspan address=\"10.1097/JOM.0b013e31818180cb\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStewart WF, Wood GC, Manack A et al (2010) Employment and work impact of chronic migraine and episodic migraine. J Occup Environ Med 52:8\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/JOM.0b013e3181c1dc56\u003c/span\u003e\u003cspan address=\"10.1097/JOM.0b013e3181c1dc56\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamada AML, Mercante JPP (2022) The bidirectional relation of migraine and affective disorders. Headache Med 13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.48208/headachemed.2022.12\u003c/span\u003e\u003cspan address=\"10.48208/headachemed.2022.12\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Santos IS, Peres MFP et al (2024) What is AHA Life\u0026acute;s Essential 8 factors\u0026rsquo; role in preventing migraine chronification? Insights from a 4-year follow-up with 4,193 participants in the ELSA-Brasil study. Headache Med 15:48208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.48208/HeadacheMed.2024.Supplement.127\u003c/span\u003e\u003cspan address=\"10.48208/HeadacheMed.2024.Supplement.127\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercante JPP, Oliveira AB, Peres MFP et al (2024) Association of mental health symptoms with the migraine-tension-type headache spectrum in the Brazilian longitudinal study of adult health. J Psychosom Res 179:111624. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.JPSYCHORES.2024.111624\u003c/span\u003e\u003cspan address=\"10.1016/J.JPSYCHORES.2024.111624\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres MFP, Swerts DB, De Oliveira AB, Silva-Neto RP (2019) Migraine patients\u0026rsquo; journey until a tertiary headache center: An observational study. J Headache Pain 20:1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10194-019-1039-3\u003c/span\u003e\u003cspan address=\"10.1186/s10194-019-1039-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWestergaard ML, Gl\u0026uuml;mer C, Hansen EH, Jensen RH (2016) Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey. Cephalalgia 36:15\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0333102415578430\u003c/span\u003e\u003cspan address=\"10.1177/0333102415578430\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWestergaard ML, Lau CJ, Alles\u0026oslash;e K et al (2021) Poor social support and loneliness in chronic headache: Prevalence and effect modifiers. Cephalalgia 41:1318\u0026ndash;1331. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/03331024211020392\u003c/span\u003e\u003cspan address=\"10.1177/03331024211020392\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Fernando M, Peres P et al (2022) Physical activity pattern and migraine according to aura symptoms in the Brazilian Longitudinal Study of Adult Health Brasil) cohort: A cross- sectional study. Headache 62:977\u0026ndash;988. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.14380\u003c/span\u003e\u003cspan address=\"10.1111/head.14380\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinkel A, Yerry J, Mann J (2013) Dietary considerations in migraine management: does a consistent diet improve migraine? Curr Pain Headache Rep 17:373. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11916-013-03\u003c/span\u003e\u003cspan address=\"10.1007/s11916-013-03\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaliszewska-Pros\u0026oacute;ł M, Nowakowska-Kotas M, Chojdak-łukasiewicz J, Budrewicz S (2021) Migraine and sleep\u0026mdash;an unexplained association? Int J Mol Sci 22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijms22115539\u003c/span\u003e\u003cspan address=\"10.3390/ijms22115539\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerini-Strambi L, Galbiati A, Combi R (2019) Sleep disorder-related headaches. Neurol Sci 40:S107\u0026ndash;S113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10072-019-03837-z\u003c/span\u003e\u003cspan address=\"10.1007/s10072-019-03837-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres M, Mercante J, Belitardo de Oliveira A (2019) Non-Pharmacological Treatment for Primary Headaches Prevention and Lifestyle Changes in a Low-Income Community of Brazil: A Randomized Clinical Trial. Headache: J Head Face Pain 59:86\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.13457\u003c/span\u003e\u003cspan address=\"10.1111/head.13457\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWells RE, Connell NO, Pierce CR et al (2021) Effectiveness of Mindfulness Meditation vs Headache Education for Adults With Migraine A Randomized Clinical Trial. JAMA Intern Med 181:317\u0026ndash;328. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamainternmed.2020.7090\u003c/span\u003e\u003cspan address=\"10.1001/jamainternmed.2020.7090\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeres M, Zukerman E, da, Cunha Tanuri F et al (2004) Melatonin, 3 mg, is effective for migraine prevention. Neurology 63:757\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoldeamanuel YW, Oliveira ABD (2022) What is the efficacy of aerobic exercise versus strength training in the treatment of migraine ? A systematic review and network meta analysis of clinical trials. J Headache Pain 23:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s10194-022-01503-y\u003c/span\u003e\u003cspan address=\"10.1186/s10194-022-01503-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Ribeiro RT, Mello MT et al (2019) Anandamide Is Related to Clinical and Cardiorespiratory Benefits of Aerobic Exercise Training in Migraine Patients: A Randomized Controlled Clinical Trial. Cannabis Cannabinoid Res 4:275\u0026ndash;284. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/can.2018.0057\u003c/span\u003e\u003cspan address=\"10.1089/can.2018.0057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson J (1987) Exercise-induced migraine prodrome symptoms. Headache 275:250\u0026ndash;251\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira AB, Bachi ALL, Ribeiro RT et al (2017) Exercise-Induced Change in Plasma IL-12p70 Is Linked to Migraine Prevention and Anxiolytic Effects in Treatment-Na\u0026iuml;ve Women: A Randomized Controlled Trial. Neuroimmunomodulation 24:293\u0026ndash;299. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000487141\u003c/span\u003e\u003cspan address=\"10.1159/000487141\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReina- \u0026Aacute;, Pt V, Madro\u0026ntilde;ero- B et al (2024) Efficacy of various exercise interventions for migraine treatment: A systematic review and network meta- analysis. Headache 1\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.14696\u003c/span\u003e\u003cspan address=\"10.1111/head.14696\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReina-Varona \u0026Aacute;, Madro\u0026ntilde;ero-Miguel B, Gaul C et al (2023) Therapeutic Exercise Parameters, Considerations, and Recommendations for Migraine Treatment: An International Delphi Study. Phys Ther 103:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ptj/pzad080\u003c/span\u003e\u003cspan address=\"10.1093/ptj/pzad080\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLa Touche R, Oliveira AB, Paris-Alemany A, Reina-Varona A (2024) Incorporating therapeutic education and exercise in migraine management: a biobehavioral approach. J Clin Med 13:6273. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm13206273\u003c/span\u003e\u003cspan address=\"10.3390/jcm13206273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRollnick S, Miller WR (1995) What is motivational interviewing? Behavioral and Cognitive Psychotherapy. Behav Cogn Psychother 23:325\u0026ndash;334\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBigal ME, Bordini CA, Speciali JG (2000) Etiology and Distribution of Headaches in Two Brazilian Primary Care Units. Headache: The Journal of Head and Face Pain 40:241\u0026ndash;47\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBigal ME, Rapoport AM, Bordini CA et al (2003) Burden of Migraine in Brazil: Estimate of Cost of Migraine to the Public Health System and an Analytical Study of the Cost-Effectiveness of a Stratified Model of Care. Headache 43:742\u0026ndash;754\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQueiroz LP, Junior AAS (2015) The Prevalence and Impact of Headache in Brazil. Headache 55:32\u0026ndash;39. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/head.12511\u003c/span\u003e\u003cspan address=\"10.1111/head.12511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstituto Brasileiro de Geografia e Estatistica (2019) Pesquisa Nacional de Sa\u0026uacute;de 2019: Informa\u0026ccedil;\u0026otilde;es sobre domic\u0026iacute;lios. acesso e utiliza\u0026ccedil;\u0026atilde;o dos servi\u0026ccedil;os de sa\u0026uacute;de\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-journal-of-headache-and-pain","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tjhp","sideBox":"Learn more about [The Journal of Headache and Pain](https://thejournalofheadacheandpain.biomedcentral.com/)","snPcode":"10194","submissionUrl":"https://submission.nature.com/new-submission/10194/3","title":"The Journal of Headache and Pain","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"migraine, headache disorders, healthy lifestyle, sleep, physical activity, diet","lastPublishedDoi":"10.21203/rs.3.rs-6957841/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6957841/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSeveral lifestyle factors have been independently associated with headache disorders; however, less is known on the aggregated impact of lifestyle factors on headache disability. We aimed to explore the relationship between a healthy lifestyle score based on the six pillars of lifestyle medicine and prevalence of headache disability in Brazil.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were derived from the 2019 Brazilian National Health Survey, a nationwide, cross-sectional study. Prevalence estimates for disease-related disability were based on days missed from work, school, domestic chores, or recreation due to disease or health condition in the past 2 weeks. A healthy lifestyle score (0\u0026ndash;14 points) incorporated self-reported data on physical activity, diet, sleep, mental health, risky substance use, and social connections. Weighted Poisson regression models with robust variance assessed the relationship between the healthy lifestyle scores and prevalence of headache-specific disability. Models were adjusted for age, sex, and socioeconomic and geographic disparities. The results are presented as prevalence ratio (PR) and 95% confidence intervals (95% CI).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 88,531 adults included in the analysis (mean age 47.1 years; 52.9% female), 8,693 participants [weighted point prevalence\u0026thinsp;=\u0026thinsp;8.8% (8.2%-9.2%)] reported disease-related disability. Headache-specific disability showed a weighted prevalence of 5.3% (4.6%-6.0%), the fifth most prevalent disease-related disability among Brazilian adults. The headache-specific disability group had a lower healthy lifestyle score than the no disability group [mean (SD): 7.8 (2.4) vs. 8.8 (2.4), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Compared to participants who reported no disability over the past 2 weeks, the adjusted models revealed a significant inverse linear association between healthy lifestyle scores and the prevalence of headache-specific disability [PR\u0026thinsp;=\u0026thinsp;0.85 (95% CI: 0.81, 0.89), p for linear trend: \u0026lt; 0.001].\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe adherence to the six pillars of lifestyle medicine is associated with lower prevalence of headache-specific disability in Brazil, supporting the adoption of lifestyle medicine approach in clinical practice as a strategy to reduce headache burden.\u003c/p\u003e","manuscriptTitle":"The 6 Pillars of Lifestyle Medicine and Headache Disability in Brazil: A Cross-sectional, Population-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 06:33:07","doi":"10.21203/rs.3.rs-6957841/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"196092994849954292545070147873418514898","date":"2025-06-27T13:50:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29922895295736740182086611648860906214","date":"2025-06-24T07:55:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T07:44:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-23T17:19:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-23T15:30:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Journal of Headache and Pain","date":"2025-06-23T14:32:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-journal-of-headache-and-pain","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tjhp","sideBox":"Learn more about [The Journal of Headache and Pain](https://thejournalofheadacheandpain.biomedcentral.com/)","snPcode":"10194","submissionUrl":"https://submission.nature.com/new-submission/10194/3","title":"The Journal of Headache and Pain","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e98c166-d3dc-4917-88c9-cfc5180a62ac","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:00:01+00:00","versionOfRecord":{"articleIdentity":"rs-6957841","link":"https://doi.org/10.1186/s10194-025-02137-6","journal":{"identity":"the-journal-of-headache-and-pain","isVorOnly":false,"title":"The Journal of Headache and Pain"},"publishedOn":"2025-10-14 15:57:12","publishedOnDateReadable":"October 14th, 2025"},"versionCreatedAt":"2025-07-01 06:33:07","video":"","vorDoi":"10.1186/s10194-025-02137-6","vorDoiUrl":"https://doi.org/10.1186/s10194-025-02137-6","workflowStages":[]},"version":"v1","identity":"rs-6957841","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6957841","identity":"rs-6957841","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}