Sex differences in the association between marital status and ...

Low marital quality appears to be linked to women's health behaviors and disease markers including low HDL cholesterol, high triglycerides, and ... Skiptomaincontent Advertisement SearchallBMCarticles Search Sexdifferencesintheassociationbetweenmaritalstatusandtheriskofcardiovascular,cancer,andall-causemortality:asystematicreviewandmeta-analysisof7,881,040individuals DownloadPDF DownloadPDF Review OpenAccess Published:28February2020 Sexdifferencesintheassociationbetweenmaritalstatusandtheriskofcardiovascular,cancer,andall-causemortality:asystematicreviewandmeta-analysisof7,881,040individuals YafengWang1 na1,YuruiJiao2 na1,JingNie3 na1,AdrienneO’Neil4,WentaoHuang5,LeiZhang6,JiafeiHan7,HaoLiu8,YikunZhu2,ChuanhuaYu1&…MarkWoodward9,10,11 Showauthors GlobalHealthResearchandPolicy volume 5,Article number: 4(2020) Citethisarticle 5315Accesses 23Citations 54Altmetric Metricsdetails AbstractPurposeToascertainwhethersexdifferencesexistintherelationshipbetweenmaritalstatusandcardiovasculardiseases(CVD),coronaryheartdisease(CHD),cancerandall-causemortalityinthegeneralpopulationandtoexplorethepotentialeffectofage,location,thedurationoffollow-upandpublicationyearsontheseoutcomes.MethodsAsystematicsearchwasperformedinPubMedandEMBASEfrominceptionthroughtoApril2018andreviewofreferencestoobtainsex-specificrelativerisksandtheir95%confidenceintervals.Thesewereusedtoderivethewomen-to-menratioofRRs(RRR)and95%CIforeachstudy.RRsandRRRsforeachoutcomewerethenpooledusingrandomeffectsinverse-varianceweightedmeta-analysis.ResultsTwenty-onestudieswith7,891,623individualsand1,888,752deathswereincludedinthemeta-analysis.Comparedwithmarriedindividuals,beingunmarriedwassignificantlyassociatedwithall-cause,cancer,CVDandcoronaryheartdiseasemortalitiesforbothsexes.However,theassociationwithCVDandall-causemortalitywasstrongerinmen.Beingdivorced/separatedwasassociatedwithahigherriskofall-causemortalityinmenandastrongerriskofcancerandCVDmortality.Thepooledratioforwomenversusmenshowed31and9%greaterriskofstrokemortalityandall-causemortalityassociatedwithnevermarriedinmenthaninwomen.ConclusionsBeingunmarriedconferredhigherriskofstrokeandall-causemortalityformenthanwomen.Moreover,divorced/separatedmenhadhigherriskofcancermortalityandCVDmortality.Furtherstudiesarewarrantedtoclarifythebiological,behavioral,and/orsocialmechanismsinvolvedinsexdifferencesbytheseassociations. BackgroundMaritalstatushasbeenidentifiedasanimportantsocialfactorassociatedwithmortality.Incurrentepidemiologicresearch,beingunmarriedwasobservedtobeasuboptimalhealthstatusintheglobalpopulation[1].In2017,morethan45%ofAmericanswereunmarriedandapproximately35.25millionpeoplewerelivingalone[2].InChina,thepopulationofunmarriedpeoplehasalsosteadilyincreased;reachingupto218millionintheendof2016,ofwhich129millionweremenand89millionwerewomen[3].Thegrowingnumberofunmarriedpeoplehashealthimplications,inlightofevidencesuggestingthatitisassociatedwithanincreaseintheincidenceofvariousdiseasesandhighmortality.Thebeneficialeffectofmarriageonhealthisoneofthemostconsistentlypositivefindingsinmedicalsociologyandepidemiology[4].Marriageoffersadirectformofsocialsupport[5,6]anditcanreducetheriskofunhealthybehaviorssuchaspoordietoralcoholuse[5,6,7].Incontrast,beingunmarriedhasbeensuggestedtocontributetolessintimatesocialnetworks,lonelinessandincreasedlevelsofstresshormones[8],whichmayincreaseriskfromcardiovasculardiseases(CVD)[9,10],cancer[11,12]ormetabolicsyndrome[13,14].WhilethelinksbetweenmaritalstatusandCVDmortalityriskhavebeenwidelyreported[15,16,17,18,19],comparativelylesshasbeenobservedregardingotherconditionsincludingcancermortalityandall-causesmorebroadly.Whatalsoremainsuncleariswhether(andtowhatdegree)specifictypesofnon-maritalstatuses(widowed,divorced/separatedornevermarried)aredifferentiallyassociatedwiththeaforementionedoutcomes.Explicatingtheselinksarelikelytobeimportantinunderstandingthemechanismsthatmightunderpintherelationshipbetweenmaritalstatusanddiseaserisk,particularlyassocietaltrendsandattitudestowardsmaritalstatuschange.Whatismore,fewattemptshavebeenmadetoproduceanoverallestimateandsufficientlyclarifiedofthesexdifferencebetweenunmarriedstatusandmortalityrisks,thisisstillamatterofdebate.Evidenceshowsthatmentendtobenefitmorefrombeingmarriedthandowomenwithrespecttotheirhealth[20,21,22,23,24].AprospectiveregisterstudyofFinnishmenandwomenfoundthatlivingalonewasapredictorofCVDmortalityformen,whileriskwashigherforwomenwhocohabitated[25].Thus,itstandstoreasonthatmenwouldexperiencethegreatesthealthlossesintheabsenceof,ordissolution,ofamarriage.Therefore,weperformedameta-analysisofprospectivecohortstudiestoascertainthesexdifferencebetweenmaritalstatusandCVD,cancer,all-causemortalityinthegeneralpopulationandtoexplorethepotentialeffectofage,location,thedurationoffollow-upandpublicationyearsontheseoutcomes.MethodsThismeta-analysiswasconductedinaccordancewiththeMOOSE(Meta-analysisOfObservationalStudiesinEpidemiology)guidelines[26].LiteraturesearchstrategyAsystematicsearchwasperformedinPubMedandEMBASEfromtheirinception(1966and1947,respectively)throughtoApril2018usingthekeywords“maritalstatus”,“married”,“unmarried”,“widowed”,“divorced”,“single”,“separated”,“mortality”and“prospectivecohortstudies”.ThedetailedsearchstrategieswereshownintheSupplementalMaterial.OnlypaperspublishedinEnglishlanguagewereconsidered.Inaddition,wealsoscrutinizedthereferencesofallidentifiedreportsforotherpotentiallyrelevantpublicationsandrelevantreviews.Iftheinformationofthestudieswereincomplete,wealsocontactedtheauthortoobtainsufficientdata.StudyselectionStudieswereincludedinthismeta-analysisthatmetthefollowinginclusioncriteria:(1)Beingaprospectivecohortstudy;(2)Evaluatingtheassociationbetweenmaritalstatusandmortalitybysex;(3)Theincludedstudieshadatleasttwogroupspertainingtomaritalstatus(e.gmarriedandnotmarried),andthemaritalstatusofthosenon-marriedwasdefinedbya“no”responsetothequestion,“Haveyoueverbeenmarried?”,whichincludeddivorced/separated,widowedandnevermarried(4)Theoutcomesofthestudiesincludedatleastoneofthefollowing:all-causemortality,cancermortality,CVDmortality,CHDmortalityand/orstrokemortality;(5)Providinginformationaboutthemultiple-adjustedriskratio(RR),oddsratio(OR)andhazardratio(HR)aswellascorresponding95%confidenceinterval(CI)oftheassociationbetweenmaritalstatusandmortalityinmenandwomen;(6)Ifmorethanonearticlewaspublishedthatbasedonthesamepopulation,weincludedonlythearticlethatprovidedresultswithmostrecentdataandthelargestnumberofparticipants.Theexclusioncriteriawereasfollows:(1)studiesthatwerematchedcohortdesign;(2)theresultsofthestudieswerenotadjustedforatleastage.Moreover,wealsousedindividualparticipantdatafromtheUSNationalHealthInterviewSurveys(1997to2009)whichlinkedNationalDeathIndexrecordsthroughDecember31,2011.DataextractionandriskofbiasassessmentDetailsonstudycharacteristics(firstauthor’slastname,publicationyear,locationandethnicity,studydesign,durationoffollow-up),informationregardingtheincludedpopulation(populationsource,numberofparticipantswiththemartialstatusofmarriedandnotmarried,meanage,numberofmenandwomen)andthedataontheoutcomes[(all-causemortality,cancermortality,CVDmortality,CHDmortality,andstrokemortality),ICDcode(ifavailable)]wereextractedbytwoauthors(YRJandJFH)fromeachidentifiedstudybyusingastandardizedextractionsheetindependently,withdisagreementsresolvedbydiscussion.Wealsoextractedsex-specificmultiple-adjustedmeasuresofrelativerisk(RR;orequivalents)and95%confidenceintervals.ThequalityofeachstudywasestimatedaccordingtotheNOS(Newcastle-OttawaQualityAssessmentScale)[27],whichconsistsof3variablesofqualityasfollows:objectselection(4points),comparability(2points),andexposureandoutcome(3points)andeachsatisfactoryanswerreceivedonestar.Ninestarsrepresentsthebest.Weconsideredthestudieswithascoreof≥6reflectinghighquality,while≤4tobeoflowquality(SupplementTable1).StatisticalanalysisForeachstudy,weobtainedthesex-specificRRorequivalentsforindividualswhowerenotmarriedorsubcategoriesoftheunmarried(i.e.divorced/separated,widowedornevermarried)vsindividualswhoweremarriedand95%CIs.WelogtransformedtheseRRsorequivalentsandcomputedwomen-to-menratioofRRs(RRR)and95%CIstocomparethesexesdirectly.TheseRRRswerecalculatedforstudieswithmultiple-adjustedestimates[28].Wesubsequentlypooledthedifferencesacrossstudiesusingrandom-effectsmeta-analysisweightedbytheinverseofthevariancesofthelogRRRs,andthenbacktransformedthedatatoobtainthepooledwomen-to-menratiooftheRR(RRR).Inaddition,fortheindividualparticipantdatafromtheNHIS(1997to2009)linkedmortalitydata,wealsoassessedtheRRs,women-to-menratioofRRs(RRR)and95%CIsusedthesamemethod.Wealsopooledrelativerisksformenandwomenseparately.Foronestudy,whichreportedseparatehazardratiosformenandwomenindifferentdivorced/separated,widowedandsinglegroups,wefirstusedinversevarianceweightedrandom-effectsmeta-analysistogenerateasummaryhazardratioofnotmarriedorthesubsetsofunmarriedformenandforwomen.Inaddition,onlyoneortwoofthreetypesofmaritalstatuscategory(i.e.divorced/separated,widowedornevermarried),couldnotbecombinedastheestimatesofnotmarried.HeterogeneitybetweenstudieswasevaluatedbyusingtheQtestandI2statistic.ThelevelofsignificancefortheQtestwasdefinedasP  50%indicatednoandsignificantheterogeneityrespectively[29,30].Sensitivityanalyseswereperformedbylocation(Asian,European,Americanandothers),meanagegroups( 0.05;Fig.4).Additionally,beingdivorced/separatedwasassociatedwithhigherriskofcancermortalityinmenthaninwomen(Women-to-menRRR,0.93,0.90–0.96,P  0.05;SupplementFigure4).MaritalstatusandCVDmortalityForCVDmortality,theriskwashigherinnon-marriedparticipantsthaninmarriedparticipants(RRformen,1.60,1.39–1.84,P  0.05,SupplementFigure6).Inaddition,althoughasimilarassociationwasalsoobservedinCHDandstrokemortality,therewerewiderCIsbecausetheirsamplesizeisprobablysmall(SupplementFigures7–10).Menwhonevermarriedwereata31%excessriskofstrokewhencomparedwithwomenwhonevermarried(Women-to-menRRR:0.69,0.47–1.00,P = 0.05;SupplementFigure10d). Fig.5Women-to-menratiosofrelativerisks(RRRs)forCVDmortalitycomparingmarriedtonon-marriedpeople.TheboxesandlinesindicatetheRRRsandtheir95%confidenceintervals(CIs)onalogscaleforeachstudy.Thepooledoddsratioisrepresentedbyadiamond.ThesizeofthegraysquaresindicatetherelativeweightofeachestimateFullsizeimageMeta-regression,subgroupanalyses,sensitivityanalysesandpublicationbiasForall-causemortality,meta-regressionanalysesindicatedthatthewomen-to-menRRRforall-causemortalityinthewidowedgroupdecreasedby2%foreveryyearincreaseinmeanage(P = 0.003,SupplementFigure11).Itwasalsoslightlyassociatedwithpublicationyearandmeanbaselineage(Pforinteraction 0.05).Moreover,therewasnoeffectofthedurationoffollow-up,locationandthepublicationyearofstudiesinparticipantswhowereunmarried,divorced/separatedandnevermarriedforall-causemortality(AllP > 0.05;Table2).Inaddition,thesensitivityanalysesremovingeachstudyoneatatime,showedthatthepooledestimateswerenotinfluencedbyanysinglestudy,highlightingrobustnessofthesefindings. Table2Sensitivityanalysesofwomen-to-menratioofrelativerisksforall-causemortalityassociatedwithmaritalstatusFullsizetablePublicationbiaswasfoundforCHDmortalityindivorced/separatedgroup(Egger’stestP = 0.03)andforall-causemortalityinwidowedandnevermarriedgroups(BothP = 0.003;SupplementFigure13);however,thetrim-and-fillanalysisdidnotchangetheoverallresults,andtherewasnoevidenceofpublicationbiasforotherendpoints(AllP > 0.05).DiscussionThismeta-analysis,whichincludeddataofmorethan7,000,000menandwomen,indicatedthatcomparedwithbeingmarried,beingunmarriedwasassociatedwithhigherriskofall-causemortality,cancermortality,CVDmortalityandCHDmortality.Thiswasespeciallytrueforthosewhohadneverbeenmarriedregardlessoftheirgender.However,theassociationwithdeathfromall-causeandCVDwasstrongerinmen.Comparedwithwomenwhoweredivorcedorseparated,menhadhigherriskofall-causemortality,cancermortalityandCVDmortalityafterthedissolutionofmarriage.Moreover,menwhonevermarriedwereat31and9%separatelyhigherexcessriskofstrokemortalityandall-causemortalitycomparedwithnevermarriedwomen,butnotCHDmortality.Maritalstatusappearstobeacriticalfactorofmortalityoutcomesacrossdifferentcountriesandcultures[23,24].Arecentmeta-analysisalsoshowedthatbeingunmarriedwasassociatedwithincreasedriskofCHDdeathorstrokedeathinbothmenandwomencomparedwithmarriedparticipants[19].Comparedwithmarriedpeople,unmarriedindividualsmayobtainlessemotional,financialandcompanionshipsupportandcanevenexperiencemoresub-clinicalsymptomsofdepressionandanxiety[49,50,51],andmajormentaldisorder[52].Inaddition,marriageselectiontheoryproposesthathealthierindividualsweremorelikelytomarryorstaymarriedbecauseofthephysicalandpsychologicaladvantageousattributes[53].Thismayhelpexplainwhyunmarriedpeoplehadhighermortalitythanmarriedpeopleinthepresentstudy.OurresultsshowedthatbeingunmarriedisparticularlymoredangerousformenthanforwomenwithrespecttoCVDandall-causemortality.Thisisconsistentwithfindingsfromthepreviousmeta-analysiswhichindicatedthatmenwhoweresinglegenerallyhadthepooresthealthoutcomesofanytypeamongallunmarriedconditions[54].Thepotentialmechanismsforsuchfindingsarelikelytobebiological,psychologicalandsocialinnature.Fromabiologicalstandpoint,acutestressorswhichtriggeractivitiesofHypothalamic-Pituitary-Adrenal(HPA)axisandsympatheticnervoussystem[8,35]andresultinoutputofstresshormonessuchascortisol,havebeenfoundtobepronouncedinmenwhencomparedtowomen[55,56].Increasedcortisolproductionhasbeenlinkedtohigherrateofmorbidityandpoorerhealthoutcomes[8].Inaddition,HPAaxiscanmediatetheproductionofsexhormones[57].Inwomen,estrogencanprotectwomenagainstheartdiseasebyreducingcirculatorylevelsofharmfulcholesterol[58],whereastestosteroneincreasedtheconcentrationsoflow-densitylipoproteinandinflammatorymarkersthatcandrivetheprogressionofatherosclerosisandstroke[59,60,61]inmen.Further,thereisevidencethatwomenhavestrongerimmunesystems,inpartbecausetestosteronecausedimmunosuppressionandmorefrequentlyinfection[60,62].Fromapsychologicalperspective,womenwhoprovidemoresocialsupporttoothersandaremoreengagedintheirsocialnetworksareshowntobebufferedoratleastbetterequippedtodealwithstress.TheNewEnglandResearchInstitutereportedthat66%ofmenrelyontheirwivesfortheirprimarysocialsupports[63].Menlivingalonearemorelikelytodisregardprofessional’sadvice[64],havesmallerandlessintimatesocialnetworks,aremorelikelytobelonelyandsufferdepressionthanwomenwithsimilarpartnerhistories[65,66].Fromasocialbehavioralperspective,thesocialconditioningprocessmaycontributetotheinfluenceonmaritalstatusinmale’sincreasedriskofmortality.Indeed,marriedmenfarebetterthanthosewhohaveneverbeenorwerepreviouslymarried.InmostWesterncultures,boysandyoungmenareoftenconditionedtofeeltheyareresponsibleforprovidingfinanciallyforafamily.Alackofadherencetothisgendernormmayresultinfeelingsofperceivedhopelessnessorinadequacythatimpactphysicalhealth.Forthosemenwhowerepreviouslymarried,thereissomeevidencethattheassociationbetweenmaritalstatusandmortalityislargelyexplainedbythelengthofmarriageandearlylifehistorysuchaschildhooddisadvantage[25].Takentogether,thissuggeststhatalifecourseapproachisrequiredtounderstandthelinkbetweenmarriageandmortalityrisk.Incomparisonwithmostmenwhohadamoresedentarylifestyle[67,68,69,70],adultwomenundertheageof65whowerereportedmoredoctorvisitsandgotogymmoreoftenthanmen,withthegenderdifferencewidestamongindividualsaged18–44[71].Moreover,menwhodrinkmorealcoholandmoresmokingthanwomen[72]were4.5timesaslikelytodiefromCHDinmiddleage[73]andtwicefromcirrhosis[74,75]andmorevulnerabletorespiratoryillnesses,suchasCOPDandlungcancer,andhadmoreexcessriskofdeathfromthesediseases.Ourresultsprovideasocialcontextinwhichtoconsiderwhysex-specificdifferencesinindividuallevelriskfactorsmayexist.Recently,traditionalCVD-relatedriskfactors,suchassmokinganddiabeteshavebeendemonstratedtoconfergreaterexcessriskofCHDandstrokeforwomenthanmen.Forexample,bothAmericanHeartAssociationguidelinesandEuropeanSocietyofCardiologyguidelinesrecommendedthatwomenwithdiabetesshouldexercisemoretocounteractthehigherexcessriskofCVDconferredbydiabetesinwomenthanthatinmen[76,77,78].Ifwomendonotappeartobenefitfrommarriagetotheextentoftheirmalecounterparts,thisneedstobeconsidered.Lowmaritalqualityappearstobelinkedtowomen’shealthbehaviorsanddiseasemarkersincludinglowHDLcholesterol,hightriglycerides,andhigherBMI,bloodpressureandisalsoariskfactorforrecurrentheartattack[79].Expectationsofwomenasmothersandwivesastheyrelatetocaregivingandparentingplacesthemahigherriskofnon-fatalCHDinmiddleage[80].Ourfindingsthatmenyieldgreatermortalityriskowingtotheabsenceofmarriagesupporttheideathattheyhavemoretolosefrommarriagedissolutionorfromnevermarryingwhencomparedwithwomenwhodonotattractsuchamortalitybenefit.StrengthsandlimitationsStrengthsofthisstudyincludedtheuseofalargesampletoevaluatesexdifferencebetweenmaritalstatusandcause-specificoutcomes.Thisisadvantageousasitcanminimizetheroleofconfoundingfactors.However,severaloftheseissuesremain.Themeta-analysiswasbasedonprospectivecohortstudies,therefore,theconventionalproblemsofconfoundingeffectsandpotentialbiasinobservationalstudywereinevitable.Althoughourstudyhadalargesamplesizeandforeachstudyweusedtheestimatesfromthemultiple-adjustedmodels,whichcouldreducetheconfoundingandbias,thepossibleinfluenceofotherriskfactorscouldnotberuledoutandweareunabletodeterminecausation.Secondly,althoughwewerenotabletoadjustproperlyforbaselinedifferencesinconfoundingfactorsbothbetweenandwithinstudieswhichmayexplainthesmalldifferenceobservedinourmeta-analysis,thesensitivityandsubgroupanalyseswereusedtoassessthedisparitiesinallthesubgroups,andmoreoverthemeta-regressionwasalsoperformedtoevaluateandreducetheheterogeneityamongthestudies.Thirdly,furthersub-categoriesofmarriageorintimatepartnershipsremainedunexaminedinthisstudy.Forexample,marriageswithhighlevelsofdissatisfactionand/orconflictmayproducepoorhealthoutcomes(ashasbeenshownforwomenespecially);longtermpartnershipsthatarenotofficiallydefinedunderthetraditionaldefinitionofmarriagemayconferpositivehealthbenefitsparticularlythroughlongtermcohabitation;theroleofchildreninthemarriageandtheireffectofhealthrequiresfurtherexploration.Fourthly,therewasanevidenceofpublicationbiasforall-causemortalityinwidowedanddivorced/separatedgroups,forCVDmortalityinnevermarriedgroupandstrokemortalityinwidowedgroup.Althoughtheuseoftrimandfillproceduresdidnotresultinthechangeoftheresultsofourmeta-analysis,thepossibilityofanartifactofunpublishednegativestudiescouldnotbeignoredwiththismethod.Fifthly,theseincludedstudiesonlyinvolvedpaperspublishedinEnglishlanguage,althoughpublicationbiaswasanalyzed,lackofpaperspublishedinotherlanguageexceptEnglishlimitedmorein-depthanalysesthanwerereportedhere.ConclusionUnmarriedmen(divorced,widowedornevermarried)haveexcessriskofstrokemortalityandall-causemortalitycomparedtowomen.Moreover,menwhosemarriagesweredissolvedhadhigherriskofbothcancerandCVDmortality.Comparedtotheirsinglefemalecounterparts,singlemenwereathigherriskofstrokemortality.Ourresultsalsowarrantconsiderationastowhywomendonotappeartobenefitfrommarriagetothesameextentasmen.Furtherstudiesarewarrantedtoclarifythebiological,behavioral,orsocialmechanismsthatmaydrivetheseassociationsinordertomakeconclusionsaboutitsapplicationtopublichealthpolicyandallocationofpublichealthresources. Availabilityofdataandmaterials Thefollowinginformationwassuppliedregardingdataavailability:Thisisasystematicreviewoftheliterature.Norawdatawasanalysed. 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DownloadreferencesAcknowledgementsNotapplicable.FundingThisworkwassupportedbytheNationalNaturalScienceFoundationofChina(GrantNO.81773552)andtheNationalKeyR&DProgramofChina(GrantNo.2018YFC1315302and2017YFC1200502).AuthorinformationAuthornotesYafengWang,YuruiJiaoandJingNiecontributedequallytothiswork.AuthorsandAffiliationsDepartmentofEpidemiologyandBiostatistics,SchoolofHealthSciences,WuhanUniversity,185DonghuRoad,WuchangDistrict,Wuhan,430071,ChinaYafengWang & ChuanhuaYuDepartmentofendocrinology,TheSecondHospitalofShanxiMedicalUniversity,Taiyuan,ChinaYuruiJiao & YikunZhuDepartmentofSociology&InstituteforEmpiricalSocialScienceResearch,SchoolofHumanitiesandSocialSciences,Xi’anJiaotongUniversity,Xi’an,ChinaJingNieMelbourneSchoolofPopulationandGlobalHealth,UniversityofMelbourne,Carlton,AustraliaAdrienneO’NeilSchoolofNursing,GuangdongPharmaceuticalUniversity,Guangzhou,ChinaWentaoHuangShanghaiInstituteofCardiovascularDiseases,ZhongshanHospitalofFudanUniversity,Shanghai,ChinaLeiZhangFacultyofPsychology,BeijingNormalUniversity,Beijing,ChinaJiafeiHanDepartmentofOphthalmology,TheFirstPeople’sHospitalofXianyangCity,Xianyang,ChinaHaoLiuTheGeorgeInstituteforGlobalHealth,UniversityofOxford,Oxford,UKMarkWoodwardTheGeorgeInstituteforGlobalHealth,UniversityofNewSouthWales,Sydney,AustraliaMarkWoodwardDepartmentofEpidemiology,JohnsHopkinsUniversity,Baltimore,MD,USAMarkWoodwardAuthorsYafengWangViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarYuruiJiaoViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarJingNieViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarAdrienneO’NeilViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarWentaoHuangViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarLeiZhangViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarJiafeiHanViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarHaoLiuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarYikunZhuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarChuanhuaYuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarMarkWoodwardViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarContributionsConceptionanddesignofthestudy:YW,YJandCY.Acquisitionofdataandanalysis:YW,YJ,andJH.Statisticalanalysis:YJandYW.Writingandrevisionofthemanuscript:YW,YJ,JN,AO,WH,LZ,JH,HL,YZ,CY,andMW.Theauthor(s)readandapprovedthefinalmanuscript.CorrespondingauthorCorrespondenceto ChuanhuaYu.Ethicsdeclarations Ethicsapprovalandconsenttoparticipate Notapplicable. Consentforpublication Notapplicable. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. SupplementaryinformationAdditionalfile1SupplementalTable1.PRISMA2009Checklist.SupplementalTable2.QualityofincludedstudiesassessedwithNewcastle-OttawaScale.SupplementalTable3.Subgroupanalysesofwomen-to-menratioofrelativerisksforall-causemortalityassociatedwithmaritalstatus.SupplementalFigure1.Sex-specificrelativerisks(RRs)forall-causemortality,comparingwidowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Sex-specificRRsforall-causemortality,comparingwidowedtomarriedpeople;(b)Sex-specificRRsforall-causemortality,comparingdivorced/separatedtomarriedpeople;(c)Sex-specificRRsforall-causemortality,comparingnevermarriedtomarriedpeople.SupplementalFigure2.Women-to-menratiosofrelativerisks(RRRs)forall-causemortalitycomparingwidowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Women-to-menRRRsforall-causemortalitycomparingwidowedtomarriedpeople;(b)Women-to-menRRRsforall-causemortalitycomparingdivorced/separatedtomarriedpeople;(c)Women-to-menRRRsforall-causemortalitycomparingnevermarriedtomarriedpeople.SupplementalFigure3.Sex-specificrelativerisks(RRs)forcancermortality,comparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Sex-specificRRsforcancermortality,comparingnon-marriedtomarriedpeople;(b)Sex-specificRRsforcancermortality,comparingwidowedtomarriedpeople;(c)Sex-specificRRsforcancermortality,comparingdivorced/separatedtomarriedpeople;(d)Sex-specificRRsforcancermortality,comparingnevermarriedtomarriedpeople.SupplementalFigure4.Women-to-menratiosofrelativerisks(RRRs)forcancermortalitycomparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Women-to-menRRRsforcancermortalitycomparingnon-marriedtomarriedpeople;(b)Women-to-menRRRsforcancermortalitycomparingwidowedtomarriedpeople;(c)Women-to-menRRRsforcancermortalitycomparingdivorced/separatedtomarriedpeople;(d)Women-to-menRRRsforcancermortalitycomparingnevermarriedtomarriedpeople.SupplementalFigure5.Sex-specificrelativerisks(RRs)forcardiovascular(CV)mortality,comparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Sex-specificRRsforCVmortality,comparingnon-marriedtomarriedpeople;(b)Sex-specificRRsforCVmortality,comparingwidowedtomarriedpeople;(c)Sex-specificRRsforCVmortality,comparingdivorced/separatedtomarriedpeople;(d)Sex-specificRRsforCVmortality,comparingnevermarriedtomarriedpeople.SupplementalFigure6.Women-to-menratiosofrelativerisks(RRRs)forcardiovascular(CV)mortalitycomparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Women-to-menRRRsforCVmortalitycomparingnon-marriedtomarriedpeople;(b)Women-to-menRRRsforCVmortalitycomparingwidowedtomarriedpeople;(c)Women-to-menRRRsforCVmortalitycomparingdivorced/separatedtomarriedpeople;(d)Women-to-menRRRsforCVmortalitycomparingnevermarriedtomarriedpeople.SupplementalFigure7.Sex-specificrelativerisks(RRs)forcoronaryheartdisease(CHD)mortality,comparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Sex-specificRRsforCHDmortality,comparingnon-marriedtomarriedpeople;(b)Sex-specificRRsforCHDmortality,comparingwidowedtomarriedpeople;(c)Sex-specificRRsforCHDmortality,comparingdivorced/separatedtomarriedpeople;(d)Sex-specificRRsforCHDmortality,comparingnevermarriedtomarriedpeople.SupplementalFigure8.Women-to-menratiosofrelativerisks(RRRs)forcoronaryheartdisease(CHD)mortalitycomparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Women-to-menRRRsforCHDmortalitycomparingnon-marriedtomarriedpeople;(b)Women-to-menRRRsforCHDmortalitycomparingwidowedtomarriedpeople;(c)Women-to-menRRRsforCHDmortalitycomparingdivorced/separatedtomarriedpeople;(d)Women-to-menRRRsforCVmortalitycomparingnevermarriedtomarriedpeople.SupplementalFigure9.Sex-specificrelativerisks(RRs)forstrokemortality,comparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Sex-specificRRsforstrokemortality,comparingnon-marriedtomarriedpeople;(b)Sex-specificRRsforstrokemortality,comparingwidowedtomarriedpeople;(c)Sex-specificRRsforstrokemortality,comparingdivorced/separatedtomarriedpeople;(d)Sex-specificRRsforstrokemortality,comparingnevermarriedtomarriedpeople.SupplementalFigure10.Women-to-menratiosofrelativerisks(RRRs)forstrokemortalitycomparingnon-married,widowed,divorced/separatedandnevermarriedtomarriedpeople:(a)Women-to-menRRRsforstrokemortalitycomparingnon-marriedtomarriedpeople;(b)Women-to-menRRRsforstrokemortalitycomparingwidowedtomarriedpeople;(c)Women-to-menRRRsforstrokemortalitycomparingdivorced/separatedtomarriedpeople;(d)Women-to-menRRRsforstrokemortalitycomparingnevermarriedtomarriedpeople.SupplementalFigure11.Meta-regressionformeanageatbaselineforpooledwomen-to-menratiosofrelativeriskforriskofall-causemortalitycomparingnon-marriedpeopletomarriedpeople.SupplementalFigure12.Subgroupanalysesforall-causemortalityforpooledwomen-to-menratiosofrelativerisk(RRRs)forriskofall-causemortalitycomparingwidowedpeopletomarriedpeople.SupplementalFigure13.Begg’spublicationbiasplotforthepooledratioofwomen-to-menrelativerisks:(a)Begg’spublicationbiasplotforCHDmortalityindivorced/separatedgroup;(b)Begg’spublicationbiasplotforall-causemortalityinwidowedgroup;(c)Begg’spublicationbiasplotforall-causemortalityinnevermarriedgroup;Abbreviations:CHD:coronaryheartdisease;RR:relativerisk;RRR:ratioofRR.Rightsandpermissions 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ReprintsandPermissionsAboutthisarticleCitethisarticleWang,Y.,Jiao,Y.,Nie,J.etal.Sexdifferencesintheassociationbetweenmaritalstatusandtheriskofcardiovascular,cancer,andall-causemortality:asystematicreviewandmeta-analysisof7,881,040individuals. globhealthrespolicy5,4(2020).https://doi.org/10.1186/s41256-020-00133-8DownloadcitationReceived:17October2019Accepted:12February2020Published:28February2020DOI:https://doi.org/10.1186/s41256-020-00133-8SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsMaritalstatusSexdifferenceMortalityMeta-analysis DownloadPDF Advertisement GlobalHealthResearchandPolicy ISSN:2397-0642 Contactus Submissionenquiries:AccesshereandclickContactUs Generalenquiries:[email protected]