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
A healthy lifestyle has been widely recommended for the prevention and management of type 2 diabetes. However, no systematic review has summarised the relationship between combined lifestyle factors (including, but not limited to, smoking, alcohol drinking, physical activity, diet and being overweight or obese) and incident type 2 diabetes and risk of health outcomes among diabetic individuals.
EMBASE and PubMed were searched up to April 2019 without language restrictions. References included in articles in relevant publications were also screened. Cohort studies investigating the combined associations of at least three lifestyle factors with incident type 2 diabetes and health outcomes among diabetic individuals were included. Reviewers were paired and independently screened studies, extracted data and evaluated study quality. Random-effects models were used to calculate summary HRs. Heterogeneity and publication bias tests were also conducted.
Compared with participants considered to have the least-healthy lifestyle, those with the healthiest lifestyle had a 75% lower risk of incident diabetes (HR 0.25 [95% CI 0.18, 0.35]; 14 studies with approximately 1 million participants). The associations were largely consistent and significant among individuals from different socioeconomic backgrounds and baseline characteristics. Among individuals with type 2 diabetes (10 studies with 34,385 participants), the HRs (95% CIs) were 0.44 (0.33, 0.60) for all-cause death, 0.51 (0.30, 0.86) for cardiovascular death, 0.69 (0.47, 1.00) for cancer death and 0.48 (0.37, 0.63) for incident cardiovascular disease when comparing the healthiest lifestyle with the least-healthy lifestyle.
Adoption of a healthy lifestyle is associated with substantial risk reduction in type 2 diabetes and long-term adverse outcomes among diabetic individuals. Tackling multiple risk factors, instead of concentrating on one certain lifestyle factor, should be the cornerstone for reducing the global burden of type 2 diabetes.
KeywordsCardiovascular disease Lifestyle Meta-analysis Mortality Systematic review Type 2 diabetes
Life’s Simple 7
The authors cordially acknowledge Y. Li (Department of Nutrition, Harvard T.H. Chan School of Public Health, USA) for providing additional data and information pertinent to original reports.
YbZ, XFP and AP designed the research. YbZ and JC did the literature search. YbZ, JC, LX, AC, YgZ, JW and HL reviewed studies for inclusion and performed data extraction and checking. YbZ and JC performed meta-analyses. YbZ, KY, KG, MH and AP contributed to the interpretation of data. YbZ drafted the article. XFP, JC, LX, AC, YgZ, JW, HL, KY, KG, MH and AP contributed to the critical revision of the manuscript for important intellectual content. All authors approved the final manuscript. AP is the guarantor of this work.
AP was supported by the National Key Research and Development Program of China (2017YFC0907500 and 2017YFC0907504), National Nature Science Foundation of China (81773517) and Hubei Province Science Fund for Distinguished Young Scholars (2018CFA033). XFP was supported by the China Postdoctoral Science Foundation (176596) and International Postdoctoral Exchange Fellowship of the China Postdoctoral Council (20180062). MH was supported by the National Nature Science Foundation of China (81522040) and the National Key Research and Development Program of China (2017YFC0907501). The study sponsor was not involved in the design of the study, the collection, analysis and interpretation of data, writing the report or the decision to submit the report for publication.
Duality of interest
The authors declare that there is no duality of interest associated with this manuscript.
- 1.James SL, Abate D, Abate KH et al (2018) Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392(10159):1789–1858. https://doi.org/10.1016/S0140-6736(18)32279-7 CrossRefGoogle Scholar
- 5.World Health Organization (2017) ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Available from http://www.who.int/iris/handle/10665/259232. Accessed 5 May 2019
- 6.Gong Q, Zhang P, Wang J et al (2019) Morbidity and mortality after lifestyle intervention for people with impaired glucose tolerance: 30-year results of the Da Qing Diabetes Prevention Outcome Study. Lancet Diabetes Endocrinol 7(6):452–461. https://doi.org/10.1016/S2213-8587(19)30093-2 CrossRefGoogle Scholar
- 11.Reis JP, Loria CM, Sorlie PD, Park Y, Hollenbeck A, Schatzkin A (2011) Lifestyle factors and risk for new-onset diabetes a population-based cohort study. Ann Intern Med 155(5):292–299. https://doi.org/10.7326/0003-4819-155-5-201109060-00006 CrossRefGoogle Scholar
- 13.Lloyd-Jones DM, Hong Y, Labarthe D et al (2010) Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Associationʼs strategic Impact Goal through 2020 and beyond. Circulation 121(4):586–613. https://doi.org/10.1161/CIRCULATIONAHA.109.192703 CrossRefGoogle Scholar
- 15.Higgins JPT, Green S (2006) Cochrane handbook for systematic reviews of interventions. John Wiley, ChichesterGoogle Scholar
- 19.Ford ES, Bergmann MM, Kroger J, Schienkiewitz A, Weikert C, Boeing H (2009) Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med 169(15):1355–1362. https://doi.org/10.1001/archinternmed.2009.237 CrossRefGoogle Scholar
- 43.International Diabetes Federation (2017) IDF Diabetes Atlas, 8th edn. International Diabetes Federation, BrusselsGoogle Scholar
- 44.World Health Organization (2016) Global report on diabetes. Available from https://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf?sequence=1. Accessed 28 April 2019
- 49.Cloostermans L, Wendelvos W, Doornbos G et al (2015) Independent and combined effects of physical activity and body mass index on the development of type 2 diabetes – a meta-analysis of 9 prospective cohort studies. Int J Behav Nutr Phys Act 12(1):147. https://doi.org/10.1186/s12966-015-0304-3 CrossRefGoogle Scholar
- 51.de Walque D (2010) Education, information, and smoking decisions: evidence from smoking histories in the United States, 1940–2000. J Hum Resour 45(3):682–717Google Scholar
- 55.World Health Organization (2017) Noncommunicable diseases progress monitor, 2017. Available from https://www.who.int/nmh/publications/ncd-progress-monitor-2017/en/. Accessed 5 May 2019
- 57.Gregg EW, Jakicic JM, Blackburn G et al (2016) Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post-hoc analysis of the Look AHEAD randomised clinical trial. Lancet Diabetes Endocrinol 4(11):913–921CrossRefGoogle Scholar
- 62.Zhu P, Pan X-F, Sheng L, Chen H, Pan A (2017) Cigarette smoking, diabetes, and diabetes complications: call for urgent action. Curr Diab Rep 17(9):78Google Scholar