, Volume 62, Issue 3, pp 426–437 | Cite as

Ideal cardiovascular health, glycaemic status and incident type 2 diabetes mellitus: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

  • Joshua J. JosephEmail author
  • Aleena Bennett
  • Justin B. Echouffo Tcheugui
  • Valery S. Effoe
  • James B. Odei
  • Bertha Hidalgo
  • Akilah Dulin
  • Monika M. Safford
  • Doyle M. Cummings
  • Mary Cushman
  • April P. Carson



Ideal cardiovascular health (CVH) is associated with lower diabetes risk. However, it is unclear whether this association is similar across glycaemic levels (normal [<5.6 mmol/l] vs impaired fasting glucose [IFG] [5.6–6.9 mmol/l]).


A secondary data analysis was performed in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Incident diabetes was assessed among 7758 participants without diabetes at baseline (2003–2007) followed over 9.5 years. Baseline cholesterol, blood pressure, diet, smoking, physical activity and BMI were used to categorise participants based on the number (0–1, 2–3 and ≥4) of ideal CVH components. Risk ratios (RRs) were calculated using modified Poisson regression, adjusting for cardiovascular risk factors.


Among participants (mean age 63.0 [SD 8.4] years, 56% female, 73% white, 27% African-American), there were 891 incident diabetes cases. Participants with ≥4 vs 0–1 ideal CVH components with normal fasting glucose (n = 6004) had 80% lower risk (RR 0.20; 95% CI 0.10, 0.37), while participants with baseline IFG (n = 1754) had 13% lower risk (RR 0.87; 95% CI 0.58, 1.30) (p for interaction by baseline glucose status <0.0001). Additionally, the magnitude of the association of ideal CVH components with lower diabetes risk was stronger among white than African-American participants (p for interaction = 0.0338).


A higher number of ideal CVH components was associated with a dose-dependent lower risk of diabetes for participants with normal fasting glucose but not IFG. Tailored efforts that take into account observed differences by race and glycaemic level are needed for the primordial prevention of diabetes.


African-Americans Diabetes Ideal cardiovascular health Impaired fasting glucose Life’s simple 7 



Albumin-to-creatinine ratio


American Heart Association


Cardiovascular disease


Cardiovascular health


Chronic Kidney Diseases Epidemiology Collaboration


Estimated GFR


Food frequency questionnaire


high-sensitivity C-reactive protein


Impaired fasting glucose


Interquartile range


Population-attributable risk


REasons for Geographic and Racial Differences in Stroke


Risk ratio



The authors thank the other investigators, the staff and the participants of the REGARDS study for their valuable contributions. A full list of participating REGARDS investigators and institutions can be found at

Parts of this study were presented as an oral presentation at the AHA EPI/LIFESTYLE 2018 Scientific Sessions, New Orleans, LA, USA 20–23 March 2018.

Contribution statement

JJJ researched data, performed data interpretation and wrote the manuscript. AB performed data analysis and contributed to data interpretation, methods and revision of the manuscript. JBET, VSE, JBO, BH, AD, MMS, DMC, MC and APC contributed to methods, data interpretation and reviewed/edited the manuscript. JJJ is the guarantor of this work and, as such, had full access to all the data and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors gave final approval of the version to be published.


This research project is supported by a cooperative agreement U01 NS041588 from the National Institute of Neurological Disorders and Stroke, National Institutes of Health and the Department of Health and Human Service. Additional support was provided by U01DP006302 from the Centers for Disease Control and Prevention and K23DK117041 from the National Institute of Diabetes and Digestive and Kidney Diseases. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention, the National Institute of Neurological Disorders and Stroke, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health or the Department of Health and Human Services.

Duality of interest

JJJ and MC are members of the American Heart Association/American Stroke Association 2020 Goal Metrics Committee. APC and MMS report receiving research support from Amgen that is unrelated to the current work. All other authors declare that there is no duality of interest associated with their contribution to this manuscript.

Supplementary material

125_2018_4792_MOESM1_ESM.pdf (198 kb)
ESM (PDF 179 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Joshua J. Joseph
    • 1
    Email author
  • Aleena Bennett
    • 2
  • Justin B. Echouffo Tcheugui
    • 3
  • Valery S. Effoe
    • 4
  • James B. Odei
    • 5
  • Bertha Hidalgo
    • 6
  • Akilah Dulin
    • 7
  • Monika M. Safford
    • 8
  • Doyle M. Cummings
    • 9
  • Mary Cushman
    • 10
  • April P. Carson
    • 6
  1. 1.Division of Endocrinology, Diabetes and MetabolismThe Ohio State University Wexner Medical CenterColumbusUSA
  2. 2.Department of BiostatisticsUniversity of Alabama at Birmingham School of Public HealthBirminghamUSA
  3. 3.Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical SchoolBostonUSA
  4. 4.Department of MedicineMorehouse School of MedicineAtlantaUSA
  5. 5.Division of BiostatisticsThe Ohio State University College of Public HealthColumbusUSA
  6. 6.Department of EpidemiologyUniversity of Alabama at Birmingham School of Public HealthBirminghamUSA
  7. 7.Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceUSA
  8. 8.Division of General Internal MedicineNew York-Presbyterian/Weill Cornell Medical CenterNew YorkUSA
  9. 9.Department of Public Health and Family MedicineEast Carolina University Brody School of MedicineGreenvilleUSA
  10. 10.Department of MedicineUniversity of Vermont College of MedicineBurlingtonUSA

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