Adherence to a Healthy Lifestyle and the Risk of All-Cause Mortality and Cardiovascular Events in Individuals With Diabetes: The ARIC Study

Objective: The relationship between combined healthy lifestyle and cardiovascular (CV) events in diabetes is unclear. We aim to investigate the association between a healthy lifestyle score (HLS) and the risk of mortality and CV events in diabetes. Methods: We examined the associations of six lifestyle factors scores (including healthy diet, moderate alcohol and regular coffee intakes, never smoking, physical activity, and normal weight) with diabetes in the Atherosclerosis Risk in Communities (ARIC) study of 3,804 participants with diabetes from the United States at baseline. Primary outcomes included all-cause mortality, CV mortality, and composite CV events (heart failure hospitalizations, myocardial infarction, fatal coronary heart disease, and stroke). Results: Among these diabetic participants, 1,881 (49.4%), 683 (18.0%), and 1,600 (42.0%) cases of all-cause mortality, CV mortality, and CV events were documented, respectively, during the 26 years of follow-up. Further, the prevalence of these adverse events became lower with the increase of HLS (all P < 0.001). In the risk-factors adjusted Cox regression model, compared to participants with HLS of 0, participants with HLS of 2 had significant lower risk of all-cause mortality (HR = 0.811, 95% CI: 0.687-0.957, P = 0.013), CV mortality (HR = 0.744, 95% CI: 0.576-0.962, P = 0.024), and CV events (HR = 0.789, 95% CI: 0.661-0.943, P = 0.009). The association of HLS with CV events was stronger for women than men (P for interaction <0.05). Conclusion: Adherence to a healthy lifestyle was associated with a lower risk of CV events and mortality in diabetics. Our findings suggest that the promotion of a healthy lifestyle would help reduce the increasing healthcare burden of diabetes.