Lifestyle Factors and Mortality Risk in Individuals With Diabetes Mellitus: Are the Associations Different From Those in Individuals Without Diabetes?

Study Questions:

Do lifestyle factors and related mortality risk differ between adults with diabetes mellitus and those without diabetes?

Methods:

Data from EPIC (European Prospective Investigation into Cancer and Nutrition), an ongoing multicenter prospective study, were used for the present analysis. EPIC is a cohort study including 519,978 participants, ages 35-70 years, from 23 centers in 10 European countries, who were recruited from 1992 to 2000. Participants were predominantly recruited from the general population residing in a certain geographic area (town, province, or country). The cohort comprised 6,412 individuals with confirmed diabetes at study entry, and, after exclusion of participants without follow-up information on vital status (n = 28), the analytical sample included 6,384 individuals with diabetes. Subsequently, 258,911 participants without a verified or a self-reported diabetes diagnosis at baseline from the same EPIC study centers were selected as the group without diabetes. Lifestyle factors included diet (26 food groups), alcohol consumption, leisure-time physical activity, and smoking. Body mass index and waist/height ratio were also measured. The primary outcome of interest was all-cause mortality.

Results:

A total of 6,384 diabetic adults and 258,911 participants without known diabetes were included. After a median follow-up of 9.9 years, 830 (13%) participants with diabetes and 12,135 (5%) participants without known diabetes had died. Compared with participants without diabetes, those with diabetes were older, more likely to be male, and had a higher body mass index (BMI) and waist/height ratio. Those with diabetes had lower alcohol consumption and were more likely to be physically inactive and educated to a lower standard than their nondiabetic counterparts. Prevalence of hypertension and heart disease were higher among those with diabetes. All-cause mortality risk among those with diabetes was hazard ratio 1.62 (95% confidence interval, 1.51-1.75) compared to nondiabetics, after adjustment for age, sex, prevalent diseases, educational status, BMI, waist/height ratio, diet, alcohol consumption, physical activity, and smoking. A higher consumption of fruit, legumes, nuts and seeds, pasta, poultry, and vegetable oil was associated with a lower mortality risk in individuals with diabetes. A higher consumption of butter and margarine was related to a higher mortality risk in individuals with diabetes. These associations were significantly different in magnitude from those in diabetes-free individuals, but directions were similar. Diabetes status did not substantially affect the associations between mortality risk and adiposity, physical activity, smoking, and alcohol consumption.

Conclusions:

The investigators concluded that diabetes status did not substantially influence the associations between lifestyle and mortality risk. People with diabetes may benefit more from a healthy diet, but the directions of association were similar. Lifestyle advice with respect to mortality for patients with diabetes should not differ from recommendations for the general population.

Perspective:

This large-scale study suggests that adults with diabetes benefit from a healthy lifestyle. The benefits of a healthy diet and regular exercise are important components of treatment plans for both diabetic and nondiabetic adults.

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism, Diet, Hypertension, Smoking

Keywords: Risk, Neoplasms, Life Style, Follow-Up Studies, Butter, Poultry, Europe, Smoking, Heart Diseases, Fruit, Seeds, Body Mass Index, Vegetables, Cardiovascular Diseases, Motor Activity, Adiposity, Nuts, Nutritional Status, Obesity, Diet, Hypertension, Diabetes Mellitus


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