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?


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.


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.


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.


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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