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Association of Combined Healthy Lifestyles With Cardiovascular Disease and Mortality of Patients With Diabetes: An International Multicohort Study

  • Yan-Bo Zhang
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Xiong-Fei Pan
    Affiliations
    Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China

    Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt University Medical Center, Nashville, TN
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  • Qi Lu
    Affiliations
    Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Yan-Xiu Wang
    Affiliations
    Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
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  • Ting-Ting Geng
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Yan-Feng Zhou
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Linda M. Liao
    Affiliations
    Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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  • Zhou-Zheng Tu
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Jun-Xiang Chen
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Peng-Fei Xia
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Yi Wang
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Zhen-Zhen Wan
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Kun-Quan Guo
    Affiliations
    Affiliated Dongfeng Hospital, Hubei University of Medicine, Shiyan, China
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  • Kun Yang
    Affiliations
    Affiliated Dongfeng Hospital, Hubei University of Medicine, Shiyan, China
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  • Han-Dong Yang
    Affiliations
    Affiliated Dongfeng Hospital, Hubei University of Medicine, Shiyan, China
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  • Shuo-Hua Chen
    Affiliations
    Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
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  • Guo-Dong Wang
    Affiliations
    Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
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  • Xu Han
    Affiliations
    Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
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  • Yi-Xin Wang
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Danxia Yu
    Affiliations
    Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt University Medical Center, Nashville, TN
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  • Mei-An He
    Affiliations
    Department of Occupational and Environmental Health, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Xiao-Min Zhang
    Affiliations
    Department of Occupational and Environmental Health, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Lie-Gang Liu
    Affiliations
    Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Tangchun Wu
    Affiliations
    Department of Occupational and Environmental Health, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Shou-Ling Wu
    Correspondence
    Shou-Ling Wu, MD, PhD, Kailuan Hospital, North China University of Science and Technology, 57 Xinhua East Rd, Tangshan 063000, China.
    Affiliations
    Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
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  • Gang Liu
    Correspondence
    Gang Liu, PhD, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Rd, Wuhan 430030, China.
    Affiliations
    Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • An Pan
    Correspondence
    Correspondence: Address to An Pan, PhD, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Rd, Wuhan 430030, China.
    Affiliations
    Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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      Abstract

      Objective

      To prospectively examine the associations of combined lifestyle factors with incident cardiovascular disease (CVD) and mortality in patients with diabetes.

      Patients and Methods

      Patients with prevalent diabetes were included from 5 prospective, population-based cohorts in China (Dongfeng-Tongji cohort and Kailuan study), the United Kingdom (UK Biobank study), and the United States (National Health and Nutrition Examination Survey and National Institutes of Health–AARP Diet and Health Study). Healthy lifestyle scores were constructed according to non–current smoking, low to moderate alcohol drinking, regular physical activity, healthy diet, and optimal body weight; the healthy level of each lifestyle factor was assigned 1 point, or 0 for otherwise, and the range of the score was 0 to 5. Cox proportional hazards models were used to estimate hazard ratios for incident CVD, CVD mortality, and all-cause mortality adjusting for sociodemographic, medical, and diabetes-related factors, and outcomes were obtained by linkage to medical records and death registries. Data were collected from October 18, 1988, to September 30, 2020.

      Results

      A total of 6945 incident CVD cases were documented in 41,350 participants without CVD at baseline from the 2 Chinese cohorts and the UK Biobank during 389,330 person-years of follow-up, and 40,353 deaths were documented in 101,219 participants from all 5 cohorts during 1,238,391 person-years of follow-up. Adjusted hazard ratios (95% CIs) comparing patients with 4 or 5 vs 0 or 1 healthy lifestyle factors were 0.67 (0.60 to 0.74) for incident CVD, 0.58 (0.50 to 0.68) for CVD mortality, and 0.60 (0.53 to 0.68) for all-cause mortality. Findings remained consistent across different cohorts, subgroups, and sensitivity analyses.

      Conclusion

      The international analyses document that adherence to multicomponent healthy lifestyles is associated with lower risk of CVD and premature death of patients with diabetes.

      Abbreviations and Acronyms:

      BMI (body mass index), CVD (cardiovascular disease), DFTJ (Dongfeng-Tongji cohort), FBG (fasting blood glucose), HbA1c (hemoglobin A1c), NHANES (National Health and Nutrition Examination Survey), NIH (National Institutes of Health)
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      Linked Article

      • Brave New World: Improving Obesity and Preventing Cardiovascular Disease
        Mayo Clinic ProceedingsVol. 98Issue 1
        • Preview
          For several decades, obesity and type 2 diabetes (T2D) have been rising in tandem so that today, they are worsening global pandemics with debilitating, expensive, and often lethal complications. The prevalence of T2D in the United States has risen more than 10-fold from 2.5 million in 1959 to more than 25 million in 2022.1 During the same time frame, obesity has risen 4-fold, so that now it affects 40% of US adults and is the leading cause of preventable disease and premature mortality. About 90% of people with T2D are overweight or obese, and traditional drugs for T2D, including insulin, sulfonylureas, and thiazolidinediones, cause further weight gain.
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