Diabetes Risk Plummets by 75% When Multiple Risk Factors Tackled

Nancy A. Melville

September 10, 2019

Healthy behaviors — such as physical activity, eating a balanced diet, and reducing alcohol intake — are well-established as key to type 2 diabetes prevention, but a new meta-analysis shows just how dramatic the combined effect of adopting all of these behaviors can be, reducing the risk of developing the disease by as much as 75% and substantially reducing poor outcomes among those who have diabetes.

"Our study is the first systematic review and meta-analysis to summarize the relationship between combined lifestyle factors and incident type 2 diabetes as well as the risk of mortality and incident cardiovascular disease among diabetic individuals," write Yanbo Zhang of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, and colleagues in their systemic review and analysis published online September 4 in Diabetologia.

The considerably lower risk of diabetes was observed even with significant variation between studies in everything from the definition of healthy lifestyle factors to population characteristics and calculation methods, senior author An Pan, PhD, professor and assistant dean of the School of Public Health at the same institution, told Medscape Medical News.

"Therefore, we think that lifestyle modification should be the cornerstone and should be promoted for all people [around the world] to prevent diabetes as well as diabetes complications and premature deaths among diabetic patients," Pan said.

And, given that the proportion of individuals with the healthiest lifestyle was found to be low in most populations, the key is "promotion of an overall healthy lifestyle, instead of tackling one particular lifestyle factor," say the researchers, noting that this approach "should be a public health priority for all countries."

Louis H. Philipson, MD, PhD, president, medicine & science, at the American Diabetes Association (ADA), agrees, telling Medscape Medical News that these new findings support the current best practice recommendations of the ADA.

"Given that most of the people in the world with type 2 diabetes are in fact Asian, it is reassuring that similar advice may apply to people everywhere," said Philipson, who is also director of the Kovler Diabetes Center at the University of Chicago, Illinois.

"[And] given the differences in Asian people of different ancestry, it will be important to follow this up in yet other populations." But, he added, "it is hard to imagine why this would not be the case."

Behaviors Influence Diabetes Incidence as Well as Outcomes

For the review, Zhang and colleagues identified cohort studies that reported relations of combined lifestyle factors, including physical activity, diet, being overweight or obese, smoking or alcohol use, and predetermined outcomes. The studies had to have at least 1 year of follow-up. 

In the main analysis, they identified 14 studies including 1,116,248 participants in the United States, Asia, Europe, and Oceania that showed participants with the healthiest lifestyles had a 75% lower risk of incident diabetes compared to those with the least healthy lifestyles (hazard ratio [HR], 0.25). Participants were a mean age of 38 to 73 years and had a mean follow-up of 2.7 to 20.8 years.

At the individual level, people are encouraged to maintain optimal weight, avoid smoking and heavy drinking, adopt a healthy diet, and increase physical activity levels, the authors reiterate.

"At the population level, governments and organizations should incorporate encouragement of healthy lifestyles into all health-related policies and guidelines and should facilitate the environmental change needed to make healthy lifestyle choices accessible, affordable, and sustainable."

A further analysis focusing specifically on patients with type 2 diabetes identified 10 studies involving 34,385 participants in the United States, Asia, Europe, and one global study. Participants were a mean age of 46 to 69 years.

With a mean follow-up of 4 to 21 years, compared to those with the least healthy lifestyle, those with the healthiest lifestyles had significantly lower rates of all-cause mortality (HR, 0.44), cardiovascular death (HR, 0.51), cancer death (HR, 0.69), and incident cardiovascular disease (HR, 0.48).

These findings suggest "that future studies should focus on the associations between combined lifestyle factors and microvascular complications and long-term outcomes among diabetic individuals to provide important evidence for diabetes management," the authors note.

Strategies to Revive Message in Latest ADA Guidelines

The dramatic effect of combined lifestyle interventions in preventing diabetes is supported by prior evidence from across the globe, Zhang and colleagues add, including from the Da Qing Diabetes Prevention Outcome Study and US Diabetes Prevention Program (DPP). And lifestyle interventions are among the four key methods proposed for diabetes prevention in people with prediabetes (along with pharmacologic interventions, prevention of cardiovascular disease, and diabetes self-management education and support) in the ADA's Standards in Medical Care in Diabetes 2019.

With the ubiquitous recommendations of improving diet and exercise prone to losing their impact on patients and clinicians alike, these latest ADA guidelines feature strategies to revive the message, Philipson stressed.

"Programs such as 'Diabetes is Primary' and 'Know Diabetes by Heart' were created to address therapeutic inertia and to encourage doctors of all kinds to be more aggressive in promoting lifestyle modifications in their patients at risk," he explained.

"In addition, the [US] Centers for Disease Control and Prevention and other diabetes organizations have been supporting the DPP for several years, which takes proven diabetes prevention programs that focus on healthy lifestyle activities into community-based programs," he continued.

Healthy Behaviors Message Needs to Begin in Childhood

Pan also underscored the pressing need to communicate messages about healthy behaviors to individuals earlier in life, as troubling emerging evidence shows increasing rates of type 2 diabetes in adolescents and young adults.

"At this moment, we do not have a lot of studies looking at combined healthy lifestyles in adolescents and young adults and risk of [type 2] diabetes in later life, [and] we are calling for more studies on this issue," Pan noted.

Although healthy lifestyles for youth are promoted in most countries, "there are still a lot of gaps [such as] lack of sufficient physical activity in school and a junk food environment," Pan said.

Philipson echoed these concerns.

"These efforts have to start with the youngest children [and] not wait until high school or college — that is already too late. It should continue for young adults, but it needs to start much earlier."

But "food 'deserts' and unsafe neighborhoods make this very difficult in many cities," he observed.  

"Governments need constant reminders to support these programs that are well supported by a large body of research and have such a huge payoff in preventing diabetes," he concluded.

Pan has reported receiving support from the National Key Research and Development Program of China, National Nature Science Foundation of China, and Hubei Province Science Fund for Distinguished Young Scholars. The authors and Philipson have reported no relevant financial relationships.

Diabetologia. Published September 4, 2019. Abstract

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