Results:

A total of 11,537 adults with T2D were included in the present analysis (8,970 women from NHS and 2,557 from HPFUS). The proportions of participants with 0, 1, 2, and ≥3 low-risk lifestyle factors at diabetes diagnosis were 6.6%, 45.9%, 34.6%, and 12.9% in women and 3.0%, 31.7%, 37.8%, and 27.4% in men, respectively. Over 13.3 years of follow-up, 2,311 incident CVD cases and 858 CVD deaths occurred. After multivariate adjustment of covariates, the low-risk lifestyle factors after diabetes diagnosis were each associated with a lower risk of CVD incidence and CVD mortality. The multivariate-adjusted hazard ratios for participants with ≥3 low-risk lifestyle factors compared with 0 were 0.48 (95% confidence interval [CI], 0.40-0.59) for total CVD incidence, 0.53 (95% CI, 0.42-0.66) for incidence of coronary heart disease, 0.33 (95% CI, 0.21-0.51) for stroke incidence, and 0.32 (95% CI, 0.22-0.47) for CVD mortality (all p trend < 0.001). The population-attributable risk for poor adherence to the overall healthy lifestyle (<3 low-risk factors) was 40.9% (95% CI, 28.5%-52.0%) for CVD mortality. Greater improvements in healthy lifestyle factors from prediabetes to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and CVD mortality. For each number increment in low-risk lifestyle factors, there was a 14% lower risk of incident total CVD, a 12% lower risk of coronary heart disease, a 21% lower risk of stroke, and a 27% lower risk of CVD mortality (all p < 0.001).