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Original Investigation
March 11, 2021

Association of Balance Function With All-Cause and Cause-Specific Mortality Among US Adults

Author Affiliations
  • 1Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri
  • 2Doctor of Physical Therapy Division, Department of Orthopedics, Duke University School of Medicine, Durham, North Carolina
  • 3Children’s Minnesota Research Institute, Children’s Hospitals and Clinics of Minnesota, Minneapolis
  • 4Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  • 5Department of Cancer Epidemiology and Prevention Research, Cancer Research & Analytics, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
  • 6Departments of Oncology and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
JAMA Otolaryngol Head Neck Surg. 2021;147(5):460-468. doi:10.1001/jamaoto.2021.0057
Key Points

Question  Is balance function associated with all-cause and cause-specific mortality among US adults?

Findings  In this cohort study that followed up 5816 participants for a median of 12.6 years, baseline balance disorder and vestibular balance disorder were associated with higher all-cause mortality and cardiovascular disease–specific and cancer-specific mortality.

Meaning  Balance disorder appears to be associated with higher risk of death from all causes, cardiovascular disease, and cancer in the long term.


Importance  Difficulty maintaining balance is common among individuals aged 40 years or older and increases the risk of falls. However, little is known about the association of balance function with long-term mortality outcomes in adults.

Objective  To investigate the association of balance function with all-cause and cause-specific mortality among US adults.

Design, Setting, and Participants  A prospective, population-based cohort study of a nationally representative sample of 5816 adults (weighted population, 92 260 641) from the US National Health and Nutrition Examination Survey was conducted from 1999 to 2004. Individuals aged 40 years or older who completed the modified Romberg Test of Standing Balance on Firm and Compliant Support Surfaces were included. Participants were linked to mortality data from the test date through December 31, 2015. Data analysis was conducted from February 1 to June 1, 2020.

Exposures  The modified Romberg Test of Standing Balance on Firm and Compliant Support Surfaces was used to measure balance function and define balance disorder according to sensory input.

Main Outcomes and Measures  Mortality associated with all causes, cardiovascular disease (CVD), and cancer.

Results  A total of 5816 adults (weighted mean [SE] age, 53.6 [0.2] years; 2897 [49.8%] women) were included in this cohort study. During up to 16.8 years of follow-up (median, 12.5 years; 68 919 person-years), 1530 deaths occurred, including 342 associated with CVD and 364 associated with cancer. Participants with balance disorder were at a higher risk of death from all causes, CVD, and cancer. After adjusting for sociodemographic characteristics, lifestyle factors, and chronic conditions, the hazard ratios (HRs) among participants with balance disorder compared with those without balance disorder were 1.44 (95% CI, 1.23-1.69) for all-cause mortality, 1.65 (95% CI, 1.17-2.31) for CVD mortality, and 1.37 (95% CI, 1.03-1.83) for cancer mortality. Furthermore, vestibular balance disorder was associated with increased mortality from all causes (HR, 1.31; 95% CI, 1.08-1.58), CVD (HR, 1.59; 95% CI, 1.12-2.27), and cancer (HR, 1.39; 95% CI, 1.04-1.86).

Conclusions and Relevance  In this nationally representative sample of US adults, balance disorder was associated with an increased risk of all-cause, CVD, and cancer mortality. Further studies are needed to confirm these findings and evaluate whether the observed associations represent a causal biological phenomenon and, if so, whether the effect is modifiable with a multicomponent exercise program.

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