Development and validation of a healthy lifestyle and behavioral score for predicting metabolic syndrome: evidence from a 24-year longitudinal health check-up cohort in Taiwan

Background Metabolic syndrome (MetS) is a multifactorial condition characterized by obesity, hypertension, hyperglycemia, and dyslipidemia, often resulting from unhealthy lifestyle and behavioral patterns. This study aimed to develop and validate a Healthy Lifestyle and Behavioral Scale (HLBS) that reflects the combined influence of key pillars of lifestyle medicine and to examine its longitudinal association with MetS risk in a large Taiwanese cohort. Methods Data were drawn from 201,123 participants of the Mei Jau Health Management Institution between 2000 and 2023. Item selection followed a rigorous construct validation process and selection criteria, including exploratory and confirmatory factor analyses, item response theory modeling, and reliability testing. We then combined the HLBS components such as diet, physical activity, sleep, and substance use, and performed a log binomial generalized estimating equation model to assess its risk association with MetS development. Results The HLBS demonstrated acceptable model fit and strong internal consistency. Moderate (RR = 1.12; 95% CI = 1.09–1.16) and low (RR = 1.46; 95% CI = 1.41–1.50) adherence to healthy lifestyle behaviors were associated with an increased risk of developing MetS compared with high adherence, and each HLBS component independently contributed to elevate MetS risk. Stratified analyses showed consistent linear associations across all age and sex groups, with stronger effects observed among adults and the elderly. Conclusions The HLBS provides a reliable, culturally adapted tool for assessing lifestyle behaviors and identifying populations at risk for metabolic disorders. These findings emphasize the importance of promoting comprehensive lifestyle interventions to reduce MetS risk in the general population.