Objective: To examine the associations of individual and combined low-risk lifestyle practices, including non-smoking, engaging in moderate to vigorous intensity physical activity (≥150 min/week), drinking alcohol in moderation (5-15 g/day for women and 5-30 g/day for men), and eating a high quality diet (top two fifths of Alternative Healthy Eating Index), with the risk of subsequent cardiovascular events among adults with incident diabetes.
Methods: The prospective study included 11,527 participants with diabetes diagnosed during follow-up (8,970 women from the Nurses’ Health Study and 2,557 men from the Health Professionals Follow-Up Study), who were free of cardiovascular disease (CVD) and cancer at the time of diabetes diagnosis. Diet and lifestyle factors after diabetes diagnosis were repeatedly assessed every 2-4 years. Multivariable Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of total CVD, coronary heart disease (CHD), and stroke incidence, and CVD mortality.
Results: There were 2,311 incident CVD cases (including 498 stroke cases) and 858 CVD deaths during an average of 13.3 years of follow-up. After multivariate adjustment including medication use, the individual low-risk lifestyle factors after diabetes diagnosis were each significantly associated with a lower risk of CVD incidence and mortality. The multivariate-adjusted HR (95% CI) for participants with three or more low-risk lifestyle factors compared with zero was 0.48 (0.40-0.59) for total CVD incidence, 0.53 (0.42-0.66) for CHD incidence, 0.33 (0.21-0.51) for stroke incidence, and 0.32 (0.22-0.47) for CVD mortality (all P trend<0.001). The population-attributable-risk for poor adherence to low-risk lifestyle was 42.6% (26.7%-55.1%) for CVD mortality. In addition, greater improvements in lifestyle factors from pre- to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and mortality. For per one number increment in low-risk lifestyle factors, there was a 16% reduced risk of incident total CVD, a 12% reduced risk of CHD, a 21% reduced risk of stroke, and a 30% reduced risk of CVD mortality (all P <0.001). Similar results were observed when analyses were stratified by diabetes duration, sex/cohort, body mass index at diabetes diagnosis, smoking status, and lifestyle factors before diabetes diagnosis.
Conclusions: Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and mortality among adults with type 2 diabetes. These findings further support the tremendous benefits of adopting a healthy lifestyle in reducing the subsequent burden of cardiovascular complications in diabetic patients.