In the JournalsPerspective

Healthy lifestyle lowers CVD risk in type 2 diabetes

Patients with type 2 diabetes who adhered to a healthy lifestyle had decreased risk for CVD and CVD mortality, according to a study published in the Journal of the American College of Cardiology.

Men and women with diabetes

Gang Liu, PhD, research fellow in the department of nutrition at Harvard T.H. Chan School of Public Health, and colleagues assessed data from 8,970 women from the Nurses’ Health Study (mean age, 63 years) and 2,557 men from the Health Professionals Follow-Up Study (mean age, 63 years) with incident diabetes. Patients were excluded if they had CVD, diabetes or cancer at baseline, were diagnosed with CVD or cancer before a diabetes diagnosis during follow-up or had implausible daily caloric intake. Questionnaires were completed every 2 to 4 years to collect information on lifestyle and dietary factors, disease status and medical history.

Four modifiable lifestyle factors were considered: smoking status, diet, physical activity and alcohol consumption. Researchers calculated a low-risk lifestyle score for each patient, with a higher score signifying a healthier lifestyle.

The primary exposures of interest were changes in lifestyle before and after a diabetes diagnosis and lifestyle factors assessed after a diabetes diagnosis. The outcomes of interest were CVD mortality and CVD incidence.

Patients were followed up for a mean of 13.3 years.

During follow-up, there were 2,311 cases of incident CVD and 858 CVD deaths.

Compared with patients with a low-risk lifestyle factor score of 0, those with a score of 3 or more had a decreased risk for total CVD (HR = 0.48; 95% CI, 0.4-0.59), stroke (HR = 0.33; 95% CI, 0.21-0.51), CHD (HR = 0.53; 95% CI, 0.42-0.66) and CVD mortality (HR = 0.32; 95% CI, 0.22-0.47). Poor adherence to an overall healthy lifestyle was associated with a population-attributable risk for CVD mortality of 40.9% (95% CI, 28.5-52).

Improved lifestyle factors

Each number increment in low-risk lifestyle factors was linked to a 12% decreased risk for CHD, a 14% decreased risk for total CVD and a 27% decreased risk for CVD mortality (P for all < .001).

Results were similar when analyses were stratified by smoking status after diabetes diagnosis, age at diabetes diagnosis, BMI at diabetes diagnosis, number of low-risk lifestyle factors before diabetes diagnosis, sex and diabetes duration.

“Our study has provided further evidence to suggest that adopting an overall healthy lifestyle, consisting of eating a high-quality diet, nonsmoking, engaging in moderate to vigorous physical activity and drinking alcohol in moderation, could be an affordable and effective prevention strategy for patients with [type 2 diabetes] to reduce the risk of developing cardiovascular complications,” Liu and colleagues wrote.

“As practitioners managing patients with [type 2 diabetes], we need to send a clear message that health care promotion, advocacy and research should continue to focus on these healthy lifestyle factors not only to improve glycemic control, but to reduce overall cardiovascular risk,” Kim Connelly, MBBS, PhD, scientist at Keenan Research Centre for Biomedical Science at St. Michael’s Hospital at University of Toronto, and colleagues wrote in a related editorial. “As society continues to evolve and becomes increasingly complex, it is important that we do not overlook the so-called simple and fundamental aspects of patient care and always return ‘back to basics.’” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures. Connelly reports he received research support from and served on the advisory board for AstraZeneca, Boehringer Ingelheim, Janssen, Merck, Novartis and Servier. Please see the editorial for all other authors’ relevant financial disclosures.

Patients with type 2 diabetes who adhered to a healthy lifestyle had decreased risk for CVD and CVD mortality, according to a study published in the Journal of the American College of Cardiology.

Men and women with diabetes

Gang Liu, PhD, research fellow in the department of nutrition at Harvard T.H. Chan School of Public Health, and colleagues assessed data from 8,970 women from the Nurses’ Health Study (mean age, 63 years) and 2,557 men from the Health Professionals Follow-Up Study (mean age, 63 years) with incident diabetes. Patients were excluded if they had CVD, diabetes or cancer at baseline, were diagnosed with CVD or cancer before a diabetes diagnosis during follow-up or had implausible daily caloric intake. Questionnaires were completed every 2 to 4 years to collect information on lifestyle and dietary factors, disease status and medical history.

Four modifiable lifestyle factors were considered: smoking status, diet, physical activity and alcohol consumption. Researchers calculated a low-risk lifestyle score for each patient, with a higher score signifying a healthier lifestyle.

The primary exposures of interest were changes in lifestyle before and after a diabetes diagnosis and lifestyle factors assessed after a diabetes diagnosis. The outcomes of interest were CVD mortality and CVD incidence.

Patients were followed up for a mean of 13.3 years.

During follow-up, there were 2,311 cases of incident CVD and 858 CVD deaths.

Compared with patients with a low-risk lifestyle factor score of 0, those with a score of 3 or more had a decreased risk for total CVD (HR = 0.48; 95% CI, 0.4-0.59), stroke (HR = 0.33; 95% CI, 0.21-0.51), CHD (HR = 0.53; 95% CI, 0.42-0.66) and CVD mortality (HR = 0.32; 95% CI, 0.22-0.47). Poor adherence to an overall healthy lifestyle was associated with a population-attributable risk for CVD mortality of 40.9% (95% CI, 28.5-52).

Improved lifestyle factors

Each number increment in low-risk lifestyle factors was linked to a 12% decreased risk for CHD, a 14% decreased risk for total CVD and a 27% decreased risk for CVD mortality (P for all < .001).

Results were similar when analyses were stratified by smoking status after diabetes diagnosis, age at diabetes diagnosis, BMI at diabetes diagnosis, number of low-risk lifestyle factors before diabetes diagnosis, sex and diabetes duration.

“Our study has provided further evidence to suggest that adopting an overall healthy lifestyle, consisting of eating a high-quality diet, nonsmoking, engaging in moderate to vigorous physical activity and drinking alcohol in moderation, could be an affordable and effective prevention strategy for patients with [type 2 diabetes] to reduce the risk of developing cardiovascular complications,” Liu and colleagues wrote.

“As practitioners managing patients with [type 2 diabetes], we need to send a clear message that health care promotion, advocacy and research should continue to focus on these healthy lifestyle factors not only to improve glycemic control, but to reduce overall cardiovascular risk,” Kim Connelly, MBBS, PhD, scientist at Keenan Research Centre for Biomedical Science at St. Michael’s Hospital at University of Toronto, and colleagues wrote in a related editorial. “As society continues to evolve and becomes increasingly complex, it is important that we do not overlook the so-called simple and fundamental aspects of patient care and always return ‘back to basics.’” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures. Connelly reports he received research support from and served on the advisory board for AstraZeneca, Boehringer Ingelheim, Janssen, Merck, Novartis and Servier. Please see the editorial for all other authors’ relevant financial disclosures.

    Perspective

    Robert Eckel

    The findings of this study emphasize more support for a healthy lifestyle, especially in a population with type 2 diabetes wherein emphasis has been placed on biochemical markers that include risk factors and related medications. This was not true here, as researchers focused on all lifestyle factors.

    These results absolutely have an implication for clinical practice, but of course these data are observational, not an intervention.

    It would be interesting to do a randomized controlled trial on health care professionals — mostly physicians — who practice routine CVD prevention vs. those who spend 5-10 minutes addressing lifestyle.  The MD /DO needs to play a much more important role here. 

    Limitations are numerous, as stated in the discussion section by the authors. The study included all health care professionals and mostly Caucasians. The impact of lifestyle on biomarkers was not included, in addition to a focus on the association, rather than the cause and effect.

    • Robert Eckel, MD
    • Professor of Medicine, Division of Endocrinology, Metabolism and Diabetes,
      Division of Cardiology
      Professor of Physiology and Biophysics
      Charles A. Boettcher II Chair in Atherosclerosis
      University of Colorado Anschutz Medical Campus

    Disclosures: Eckel reports no relevant financial disclosures.