A healthy lifestyle pattern and mortality risk in patients with type 2 diabetes mellitus: A prospective cohort study in China

Abstract

This study aimed to evaluate the association of a healthy lifestyle pattern with mortality risk among patients with type 2 diabetes mellitus (T2DM). Data were derived from a prospective cohort study enrolling 13776 Chinese patients with T2DM. A healthy lifestyle pattern was constructed based on six lifestyle factors, including smoking status, alcohol consumption, dietary habits, physical activity, sedentary time, and sleep duration. Multivariate Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality. During a median follow-up of 9.78 years, 2497 deaths were recorded. Compared with T2DM patients with a lifestyle pattern scoring 0-2, those scoring 5-6 had a 40% lower risk for all-cause mortality (HR = 0.60, 95% CI: 0.52-0.69), a 33% lower risk for cardiovascular disease mortality (HR = 0.67, 95% CI: 0.52-0.86), and a 25% lower risk for cancer mortality (HR = 0.75, 95% CI: 0.58-0.97). Additionally, we found that the association between the lifestyle pattern and all-cause mortality risk was stronger in females than in males (P for interaction < 0.05). In conclusion, adherence to a healthy lifestyle pattern is associated with a decreased risk of all-cause, cardiovascular disease, and cancer mortality. These findings have important implications for reducing premature mortality among patients with T2DM.

Keywords

healthy lifestyle / mortality / type 2 diabetes mellitus / prospective cohort study

Fundings

This work was supported by the Jiangsu Provincial Health Commission Medical Research Project (Grant Nos. M2020085 to J.S. and H2023022 to X.F.), the Outstanding Youth Fund of Jiangsu Natural Science Foundation (Grant No. BK20230005 to D.H.), and Suzhou Science and Technology Bureau Livelihood Technology-Technology Demonstration Project (Grant No. SS202010 to Y.L.).

Acknowledgments

The authors thank all participants and staff of Suzhou and Huai'an City Centers for Disease Control and Prevention of the "Comprehensive Research on the Prevention and Control of Diabetes" project for their contributions.

References

[1] Zheng Y, Ley SH, Hu FB. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications[J]. Nat Rev Endocrinol, 2018, 14(2): 88-98. doi: 10.1038/nrendo.2017.151

[2] Ahmad E, Lim S, Lamptey R, et al. Type 2 diabetes[J]. Lancet, 2022, 400(10365): 1803-1820. doi: 10.1016/S0140-6736(22)01655-5

[3] Bommer C, Sagalova V, Heesemann E, et al. Global economic burden of diabetes in adults: Projections from 2015 to 2030[J]. Diabetes Care, 2018, 41(5): 963-970. doi: 10.2337/dc17-1962

[4] Sun Z, Hu Y, Yu C, et al. Low-risk lifestyle and health factors and risk of mortality and vascular complications in Chinese patients with diabetes[J]. J Clin Endocrinol Metab, 2022, 107(9): e3919-e3928. doi: 10.1210/clinem/dgac264

[5] Hiyoshi T, Fujiwara M, Yao Z. Postprandial hyperglycemia and postprandial hypertriglyceridemia in type 2 diabetes[J]. J Biomed Res, 2019, 33(1): 1-16. doi: 10.7555/JBR.31.20160164

[6] Liu G, Li Y, Hu Y, et al. Influence of lifestyle on incident cardiovascular disease and mortality in patients with diabetes mellitus[J]. J Am Coll Cardiol, 2018, 71(25): 2867-2876. doi: 10.1016/j.jacc.2018.04.027

[7] Carter N, Li J, Xu M, et al. Lifestyle behaviours and associated factors among people with type 2 diabetes attending a diabetes clinic in Ningbo, China: A cross-sectional study[J]. PLoS One, 2023, 18(11): e0294245. doi: 10.1371/journal.pone.0294245

[8] Lin CC, Li CI, Liu CS, et al. Impact of lifestyle-related factors on all-cause and cause-specific mortality in patients with type 2 diabetes: The Taichung Diabetes Study[J]. Diabetes Care, 2012, 35(1): 105-112. doi: 10.2337/dc11-0930

[9] Ganguly S, Tan HC, Lee PC, et al. Metabolic bariatric surgery and type 2 diabetes mellitus: An endocrinologist's perspective[J]. J Biomed Res, 2015, 29(2): 105-111. doi: 10.7555/JBR.29.20140127

[10] Han H, Wang Y, Li T, et al. Sleep duration and risks of incident cardiovascular disease and mortality among people with type 2 diabetes[J]. Diabetes Care, 2023, 46(1): 101-110. doi: 10.2337/dc22-1127

[11] Wilmot EG, Edwardson CL, Achana FA, et al. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: Systematic review and meta-analysis[J]. Diabetologia, 2012, 55(11): 2895-2905. doi: 10.1007/s00125-012-2677-z

[12] Li M, Wu M, Qin Y, et al. ACTB variants confer the genetic susceptibility to diabetic kidney disease in a Han Chinese population[J]. Front Genet, 2019, 10: 663. doi: 10.3389/fgene.2019.00663

[13] Chinese Nutrition Society. Dietary guidelines for Chinese residents: 2022[M]. Beijing: People's Medical Publishing House, 2022. (in Chinese)

[14] Chen Z, Peto R, Zhou M, et al. Contrasting male and female trends in tobacco-attributed mortality in China: Evidence from successive nationwide prospective cohort studies[J]. Lancet, 2015, 386(10002): 1447-1456. doi: 10.1016/S0140-6736(15)00340-2

[15] The China Kadoorie Biobank Collaborative Group. Healthy lifestyle and life expectancy free of major chronic diseases at age 40 in China[J]. Nat Hum Behav, 2023, 7(9): 1542-1550. doi: 10.1038/s41562-023-01624-7

[16] Foley DJ, Vitiello MV, Bliwise DL, et al. Frequent napping is associated with excessive daytime sleepiness, depression, pain, and nocturia in older adults: Findings from the National Sleep Foundation '2003 Sleep in America' Poll[J]. Am J Geriatr Psychiatry, 2007, 15(4): 344-350. doi: 10.1097/01.JGP.0000249385.50101.67

[17] Stamatakis E, Gale J, Bauman A, et al. Sitting time, physical activity, and risk of mortality in adults[J]. J Am Coll Cardiol, 2019, 73(16): 2062-2072. doi: 10.1016/j.jacc.2019.02.031

[18] Tobias DK, Pan A, Jackson CL, et al. Body-mass index and mortality among adults with incident type 2 diabetes[J]. N Engl J Med, 2014, 370(3): 233-244. doi: 10.1056/NEJMoa1304501

[19] Yao X, Zhang J, Zhang X, et al. Age at diagnosis, diabetes duration and the risk of cardiovascular disease in patients with diabetes mellitus: A cross-sectional study[J]. Front Endocrinol (Lausanne), 2023, 14: 1131395. doi: 10.3389/fendo.2023.1131395

[20] Davis JE, McDonald JM, Jarett L. A high-performance liquid chromatography method for hemoglobin A_1c[J]. Diabetes, 1978, 27(2): 102-107. doi: 10.2337/diab.27.2.102

[21] Glaser RL, York AE, Dimitrakakis C. Incidence of invasive breast cancer in women treated with testosterone implants: A prospective 10-year cohort study[J]. BMC Cancer, 2019, 19(1): 1271. doi: 10.1186/s12885-019-6457-8

[22] Zhang Y, Pan X, Chen J, et al. Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: A systematic review and meta-analysis of prospective cohort studies[J]. Diabetologia, 2020, 63(1): 21-33. doi: 10.1007/s00125-019-04985-9

[23] Yun JS, Ko SH. Current trends in epidemiology of cardiovascular disease and cardiovascular risk management in type 2 diabetes[J]. Metabolism, 2021, 123: 154838. doi: 10.1016/j.metabol.2021.154838

[24] Ling S, Zaccardi F, Issa E, et al. Inequalities in cancer mortality trends in people with type 2 diabetes: 20 year population-based study in England[J]. Diabetologia, 2023, 66(4): 657-673. doi: 10.1007/s00125-022-05854-8

[25] Zhang Y, Pan X, Lu Q, et al. Associations of combined healthy lifestyles with cancer morbidity and mortality among individuals with diabetes: Results from five cohort studies in the USA, the UK and China[J]. Diabetologia, 2022, 65(12): 2044-2055. doi: 10.1007/s00125-022-05754-x

[26] Takao T, Suka M, Yanagisawa H, et al. Combined effect of diabetic retinopathy and diabetic kidney disease on all-cause, cancer, vascular and non-cancer non-vascular mortality in patients with type 2 diabetes: A real-world longitudinal study[J]. J Diabetes Invest, 2020, 11(5): 1170-1180. doi: 10.1111/jdi.13265

[27] Koene RJ, Prizment AE, Blaes A, et al. Shared risk factors in cardiovascular disease and cancer[J]. Circulation, 2016, 133(11): 1104-1114. doi: 10.1161/CIRCULATIONAHA.115.020406

[28] Martínez-Gómez D, Guallar-Castillon P, Mota J, et al. Physical activity, sitting time and mortality in older adults with diabetes[J]. Int J Sports Med, 2015, 36(14): 1206-1211. doi: 10.1055/s-0035-1555860

[29] Han H, Cao Y, Feng C, et al. Association of a healthy lifestyle with all-cause and cause-specific mortality among individuals with type 2 diabetes: A prospective study in UK Biobank[J]. Diabetes Care, 2022, 45(2): 319-329. doi: 10.2337/dc21-1512

[30] Qi Q, Strizich G, Merchant G, et al. Objectively measured sedentary time and cardiometabolic biomarkers in US Hispanic/Latino adults: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL)[J]. Circulation, 2015, 132(16): 1560-1569. doi: 10.1161/CIRCULATIONAHA.115.016938