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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

  • Yanbo Zhang
  • Xiong-Fei Pan
  • Junxiang Chen
  • Lu Xia
  • Anlan Cao
  • Yuge Zhang
  • Jing Wang
  • Huiqi Li
  • Kun Yang
  • Kunquan Guo
  • Meian He
  • An PanEmail author



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.


Cardiovascular disease Lifestyle Meta-analysis Mortality Systematic review Type 2 diabetes 



Cardiovascular disease


Interquartile range


Life’s Simple 7


Newcastle–Ottawa Scale



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.

Contribution statement

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.

Supplementary material

125_2019_4985_MOESM1_ESM.pdf (418 kb)
ESM (PDF 417 kb)


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Copyright information

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

Authors and Affiliations

  • Yanbo Zhang
    • 1
    • 2
  • Xiong-Fei Pan
    • 1
    • 2
  • Junxiang Chen
    • 1
    • 2
  • Lu Xia
    • 1
    • 2
  • Anlan Cao
    • 1
    • 2
  • Yuge Zhang
    • 1
    • 2
  • Jing Wang
    • 3
  • Huiqi Li
    • 1
    • 2
  • Kun Yang
    • 4
  • Kunquan Guo
    • 4
  • Meian He
    • 2
    • 5
  • An Pan
    • 1
    • 2
    Email author
  1. 1.Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
  2. 2.Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
  3. 3.Department of Forensic Medicine, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
  4. 4.Department of EndocrinologyAffiliated Dongfeng Hospital, Hubei University of MedicineShiyanChina
  5. 5.Department of Occupational and Environmental Health, School of Public Health, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina

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