Influence of lifestyle on incident cardiovascular disease and mortality in patients with diabetes mellitus
Open accessAbstract
BACKGROUD Evidence is limited regarding the impact of healthy lifestyle practices on the risk of subsequent cardiovascular events among patients with diabetes. OBJECTIVES To examine the associations of an overall healthy lifestyle, defined by eating a high-quality diet (top two fifths of Alternative Healthy Eating Index), non-smoking, engaging in moderate- to vigorous-intensity physical activity (≥150 min/week), and drinking alcohol in moderation (5–15 g/day for women and 5–30 g/day for men), with the risk of developing cardiovascular disease (CVD) and CVD mortality among adults with type 2 diabetes (T2D). METHODS This prospective analysis included 11,527 participants with T2D diagnosed during follow-up (8,970 women from the Nurses’ Health Study and 2,557 men from the Health Professionals Follow-Up Study), who were free of CVD and cancer at the time of diabetes diagnosis. Diet and lifestyle factors before and after T2D diagnosis were repeatedly assessed every 2–4 years. RESULTS There were 2,311 incident CVD cases and 858 CVD deaths during an average of 13.3 years of follow-up. 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 (95% confidence intervals [CIs]) for participants with three or more low-risk lifestyle factors compared with zero was 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, 0.33 (0.21–0.51) for stroke incidence, and 0.32 (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. In addition, greater improvements in healthy lifestyle factors from pre- 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 were a 14% lower risk of incident total CVD, a 12% lower risk of CHD, a 21% lower risk of stroke, and a 27% lower risk of CVD mortality (all P <0.001). Similar results were observed when analyses were stratified by diabetes duration, sex/cohort, body mass index at diabetes diagnosis, smoking status, and lifestyle factors before diabetes diagnosis. CONCLUSIONS Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality among adults with T2D. These findings further support the tremendous benefits of adopting a healthy lifestyle in reducing the subsequent burden of cardiovascular complications in patients with T2D.
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Written from the paper’s full text.
TL;DR
In two large U.S. prospective cohorts of adults with incident type 2 diabetes, greater adherence to an overall healthy lifestyle after diagnosis was associated with substantially lower risk of incident cardiovascular disease and cardiovascular mortality. Improvements in lifestyle from before to after diabetes diagnosis were also associated with lower subsequent CVD risk.
Key findings
- Among 11,527 participants with incident T2D, 2,311 incident CVD cases and 858 CVD deaths occurred over an average 13.3 years of follow-up.
- Comparing ≥3 versus 0 low-risk lifestyle factors after diabetes diagnosis, multivariate-adjusted HRs (95% CIs) were 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, 0.33 (0.21–0.51) for stroke incidence, and 0.32 (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.
- Each increment in low-risk lifestyle factors was associated with 14% lower risk of total CVD, 12% lower CHD, 21% lower stroke, and 27% lower CVD mortality (all P<0.001); improvements from pre- to post-diabetes diagnosis were also associated with lower CVD incidence and mortality.
Methods
- Prospective analysis pooled 8,970 women from the Nurses’ Health Study and 2,557 men from the Health Professionals Follow-Up Study with incident T2D diagnosed during follow-up, free of CVD and cancer at diabetes diagnosis.
- Diet and lifestyle factors were repeatedly assessed every 2–4 years; low-risk factors were high-quality diet (top two fifths of AHEI), non-smoking, moderate- to vigorous-intensity physical activity ≥150 min/week, and moderate alcohol intake (5–15 g/day women; 5–30 g/day men).
- Cox proportional hazards models with time-varying exposures and covariates estimated HRs and 95% CIs for total CVD, CHD, stroke incidence, and CVD mortality; analyses also modeled changes in lifestyle score from pre- to post-diabetes diagnosis and calculated PAR.
Limitations
- The paper states participants were all health professionals and mostly Caucasian, limiting generalizability; diabetes diagnoses spanned an extended period since the 1980s; self-reported diet/lifestyle had inevitable measurement error; there were no direct measurements of glycemic control or diabetes severity; PAR assumed causality; and residual confounding or chance could not be excluded.
- The paper also notes the low-risk lifestyle factors considered may not represent all healthy behaviors.
- Evident from the text: this is an observational cohort study, so the reported associations cannot establish causality, and the authors explicitly caution that the PAR calculation depends on a causal assumption.
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- Findingown data
Comparing participants with three or more low-risk lifestyle factors to those with zero, the multivariate-adjusted hazard ratio for coronary heart disease incidence was 0.53 (95% CI 0.42-0.66).
“Comparing participants with zero low-risk lifestyle factor, the participants with three or more low-risk lifestyle factors had HRs (95% CIs) of 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, and 0.33 (0.21–0.51) for stroke incidence (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
Comparing participants with three or more low-risk lifestyle factors to those with zero, the multivariate-adjusted hazard ratio for stroke incidence was 0.33 (95% CI 0.21-0.51).
“Comparing participants with zero low-risk lifestyle factor, the participants with three or more low-risk lifestyle factors had HRs (95% CIs) of 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, and 0.33 (0.21–0.51) for stroke incidence (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
Comparing participants with three or more low-risk lifestyle factors to those with zero, the multivariate-adjusted hazard ratio for total cardiovascular disease incidence was 0.48 (95% CI 0.40-0.59).
“Comparing participants with zero low-risk lifestyle factor, the participants with three or more low-risk lifestyle factors had HRs (95% CIs) of 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, and 0.33 (0.21–0.51) for stroke incidence (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
Comparing participants who adhered to three or more low-risk lifestyle factors with those who adhered to none, the hazard ratio for cardiovascular disease mortality was 0.32 (95% CI 0.22-0.47).
“Comparing participants who adhered to ≥3 low-risk lifestyle factors with those who adhered to none, the HR (95% CI) was 0.32 (0.22–0.47) for CVD mortality (P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
Among adults with type 2 diabetes, greater adherence to an overall healthy lifestyle after diabetes diagnosis is associated with a lower risk of cardiovascular disease incidence and cardiovascular disease mortality.
“Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality among adults with T2D.”
- Also stated in: § Discussion · plain
“we found that an overall healthy lifestyle after diabetes diagnosis, defined as eating a high quality diet, non-smoking, engaging in moderate- to vigorous-intensity physical activity, and drinking alcohol in moderation, was significantly associated with a lower risk of CVD incidence and CVD mortality.”
Quote in the paperSubstantial claim - Also stated in: § Discussion · plain
- Findingown data
When only diet and alcohol consumption were considered in the healthy lifestyle score, comparing participants with at least one versus zero low-risk lifestyle factors, the hazard ratio for cardiovascular disease incidence was 0.91 (95% CI 0.84-1.00).
“When we only considered diet and alcohol consumption in the healthy lifestyle score, comparing ≥1 with 0 low-risk lifestyle factors, the HRs (95% CIs) were 0.91 (0.84, 1.00) for CVD incidence and 0.81 (0.71, 0.94) for CVD mortality.”
Quote in the paperNot a substantial claim - Findingown data
When moderate physical activity was further included in the score, comparing participants with at least two versus zero low-risk factors, the hazard ratio for cardiovascular disease mortality was 0.53 (95% CI 0.42-0.66).
“When moderate physical activity was further included in the score, comparing ≥2 with 0 low-risk factors, the HRs (95% CIs) were 0.85 (0.75, 0.96) for CVD incidence and 0.53 (0.42, 0.66) for CVD mortality.”
Quote in the paperSubstantial claim - Findingown data
Similar results were observed when analyses were stratified by diabetes duration, sex/cohort, body mass index at diabetes diagnosis, smoking status, and lifestyle factors before diabetes diagnosis.
“Similar results were observed when analyses were stratified by diabetes duration, sex/cohort, body mass index at diabetes diagnosis, smoking status, and lifestyle factors before diabetes diagnosis.”
Quote in the paperNot a substantial claim - Findingown data
When moderate physical activity was further included in the score, comparing participants with at least two versus zero low-risk factors, the hazard ratio for cardiovascular disease incidence was 0.85 (95% CI 0.75-0.96).
“When moderate physical activity was further included in the score, comparing ≥2 with 0 low-risk factors, the HRs (95% CIs) were 0.85 (0.75, 0.96) for CVD incidence and 0.53 (0.42, 0.66) for CVD mortality.”
Quote in the paperSubstantial claim - Findingown data
For each number increment in low-risk lifestyle factors, there was a 27% lower risk of cardiovascular disease mortality.
“For each number increment in low-risk lifestyle factors, there was a 14% lower risk of total CVD incidence, a 12% lower risk of CHD incidence, a 21% lower risk of stroke incidence, and a 27% lower risk of CVD mortality (all P <0.001) (Table 4).”
Quote in the paperSubstantial claim - Findingown data
The population-attributable risk for poor adherence to an overall healthy lifestyle, defined as fewer than three low-risk factors, was 40.9% (95% CI 28.5%-52.0%) for cardiovascular disease mortality.
“The PAR (95% CI) for poor adherence to an overall healthy lifestyle (defined as <3 low-risk factors) was 40.9% (28.5%–52.0%) for CVD mortality.”
Quote in the paperSubstantial claim- The authors state this as an assumption: The population-attributable risk calculation assumes a causal relationship between the low-risk lifestyle factors and cardiovascular disease risk.
- Findingown data
Adherence to a healthy lifestyle is significantly associated with a lower risk of subsequent cardiovascular disease events among diabetic patients with hypertension and/or hypercholesterolemia.
“Online Figure 2 shows that adherence to a healthy lifestyle is significantly associated with a lower risk of subsequent CVD events among diabetic patients with hypertension and/or hypercholesterolemia.”
Quote in the paperSubstantial claim - Findingown data
For each number increment in low-risk lifestyle factors, there was a 21% lower risk of stroke incidence.
“For each number increment in low-risk lifestyle factors, there was a 14% lower risk of total CVD incidence, a 12% lower risk of CHD incidence, a 21% lower risk of stroke incidence, and a 27% lower risk of CVD mortality (all P <0.001) (Table 4).”
Quote in the paperSubstantial claim - Findingown data
Greater improvements in lifestyle factors from pre- to post-diabetes diagnosis were significantly associated with a lower risk of cardiovascular disease incidence and mortality.
“Greater improvements in lifestyle factors from pre- to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and mortality (Table 4).”
Quote in the paperSubstantial claim - Findingown data
Comparing participants without changes in lifestyle, participants who improved their lifestyle had a hazard ratio of 0.80 (95% CI 0.66-0.96) for cardiovascular disease mortality.
“Comparing participants without changes in lifestyle, the participants who improved their lifestyle had an HR (95% CI) of 0.79 (0.70–0.89) for total CVD incidence, 0.82 (0.72–0.94) for CHD incidence, 0.68 (0.52–0.89) for stroke incidence, and 0.80 (0.66–0.96) for CVD mortality (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
Comparing participants without changes in lifestyle, participants who improved their lifestyle had a hazard ratio of 0.79 (95% CI 0.70-0.89) for total cardiovascular disease incidence.
“Comparing participants without changes in lifestyle, the participants who improved their lifestyle had an HR (95% CI) of 0.79 (0.70–0.89) for total CVD incidence, 0.82 (0.72–0.94) for CHD incidence, 0.68 (0.52–0.89) for stroke incidence, and 0.80 (0.66–0.96) for CVD mortality (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
Comparing participants without changes in lifestyle, participants who improved their lifestyle had a hazard ratio of 0.82 (95% CI 0.72-0.94) for coronary heart disease incidence.
“Comparing participants without changes in lifestyle, the participants who improved their lifestyle had an HR (95% CI) of 0.79 (0.70–0.89) for total CVD incidence, 0.82 (0.72–0.94) for CHD incidence, 0.68 (0.52–0.89) for stroke incidence, and 0.80 (0.66–0.96) for CVD mortality (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
When only diet and alcohol consumption were considered in the healthy lifestyle score, comparing participants with at least one versus zero low-risk lifestyle factors, the hazard ratio for cardiovascular disease mortality was 0.81 (95% CI 0.71-0.94).
“When we only considered diet and alcohol consumption in the healthy lifestyle score, comparing ≥1 with 0 low-risk lifestyle factors, the HRs (95% CIs) were 0.91 (0.84, 1.00) for CVD incidence and 0.81 (0.71, 0.94) for CVD mortality.”
Quote in the paperNot a substantial claim - Findingown data
Comparing participants without changes in lifestyle, participants who improved their lifestyle had a hazard ratio of 0.68 (95% CI 0.52-0.89) for stroke incidence.
“Comparing participants without changes in lifestyle, the participants who improved their lifestyle had an HR (95% CI) of 0.79 (0.70–0.89) for total CVD incidence, 0.82 (0.72–0.94) for CHD incidence, 0.68 (0.52–0.89) for stroke incidence, and 0.80 (0.66–0.96) for CVD mortality (all P trend<0.001).”
Quote in the paperSubstantial claim - Findingown data
When healthy body weight (18.5≤BMI<25.0 kg/m2) at diabetes diagnosis was also included in the low-risk lifestyle score, the results did not change materially.
“When 18.5≤BMI<25.0 kg/m2 at diabetes diagnosis was also included in the low-risk lifestyle score, the results did not change materially (Online Table 3).”
Quote in the paperNot a substantial claim - Findingown data
In secondary analyses, similar results were observed when cumulative averages of AHEI score, physical activity, and alcohol consumption were used to compute the overall healthy lifestyle score.
“In secondary analyses, similar results were observed when we used cumulative averages of AHEI score, physical activity, and alcohol consumption to compute the overall healthy lifestyle score.”
Quote in the paperNot a substantial claim - Findingown data
For each number increment in low-risk lifestyle factors, there was a 12% lower risk of coronary heart disease incidence.
“For each number increment in low-risk lifestyle factors, there was a 14% lower risk of total CVD incidence, a 12% lower risk of CHD incidence, a 21% lower risk of stroke incidence, and a 27% lower risk of CVD mortality (all P <0.001) (Table 4).”
Quote in the paperSubstantial claim - Findingown data
The results were largely unchanged with further adjustment for presence of hypertension or hypercholesterolemia and use of antihypertensive or cholesterol-lowering drugs.
“The results were largely unchanged with further adjustment of presence of hypertension or hypercholesterolemia and use of antihypertensive or cholesterol-lowering drugs (Online Table 1).”
Quote in the paperSubstantial claim - Findingown data
For the associations of lifestyle factors before diabetes diagnosis with cardiovascular disease incidence and mortality, similar results were observed.
“For the associations of the lifestyle factors before diabetes diagnosis with CVD incidence and mortality, similar results were observed (Online Table 5).”
Quote in the paperNot a substantial claim - Findingown data
The results did not materially change when diabetes medication use and HbA1c levels were further controlled for in a subset of the study participants.
“In addition, the results did not materially change when diabetes medication use and HbA1c levels were further controlled for in a subset of the study participants (Online Table 2).”
Quote in the paperNot a substantial claim - Findingown data
Further adding non-smoking to the lifestyle score yielded the same estimates of associations as in Tables 2 and 3.
“Further adding non-smoking to the lifestyle score yielded the same estimates of associations as in Tables 2 and 3.”
Quote in the paperNot a substantial claim - Findingown data
No significant interactions were detected between the stratifying variables and the low-risk lifestyle score (all P interaction > 0.1).
“No significant interactions were detected between these stratifying variables and the low-risk lifestyle score (all P interaction>0.1).”
Quote in the paperSubstantial claim - Findingown data
For each number increment in low-risk lifestyle factors, there was a 14% lower risk of total cardiovascular disease incidence.
“For each number increment in low-risk lifestyle factors, there was a 14% lower risk of total CVD incidence, a 12% lower risk of CHD incidence, a 21% lower risk of stroke incidence, and a 27% lower risk of CVD mortality (all P <0.001) (Table 4).”
Quote in the paperSubstantial claim - Findingown data
No significant interaction was observed between lifestyle factors and HbA1c levels.
“No significant interaction was observed between lifestyle factors and HbA1c levels.”
Quote in the paperNot a substantial claim - Study design and conductnone given
The study did not have direct measurements of glycemic control and severity of diabetes.
“Fourth, our study did not have direct measurements of glycemic control and severity of diabetes.”
Quote in the paperNot a substantial claim - Interpretationown data
The association between an overall healthy lifestyle and lower cardiovascular disease risk was independent of established cardiovascular disease risk factors, including diabetes duration, body mass index, medication use, and lifestyle before diabetes diagnosis.
“This association was independent of established CVD risk factors, including diabetes duration, BMI, medication use, and lifestyle before diabetes diagnosis.”
Quote in the paperSubstantial claim - Study design and conductown data
The proportional hazards assumption was tested and no evidence of violation was found.
“In the current study, the proportional hazards assumption was tested by using a likelihood ratio test comparing models with and without multiplicative interaction terms between exposure and calendar year, and we did not find evidence of violation of the proportional hazards assumption.”
Quote in the paperSubstantial claim - Premisecitation
Evidence is limited regarding the impact of an overall healthy lifestyle after diabetes diagnosis on the risk of subsequent cardiovascular events.
“but the evidence regarding the impact of an overall healthy lifestyle after diabetes diagnosis on the risk of subsequent cardiovascular events is limited (6).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6] Schellenberg, 2013, Lifestyle interventions for patients with and at risk for type 2 diabetes: a systematic review and meta-analysis, Ann Intern Med source
Not checked in the free run.
- May combine two claims. 9
- Classified as probably not a substantial claim. 7
May combine two claims.
Findingown dataThe results remained similar when further adjusted for duration of diabetes, use of insulin and hypoglycemic medications, and self-reported HbA1c levels, suggesting that the findings are unlikely explained by confounding due to severity of diabetes.
“However, the results remained similar when we further adjusted for duration of diabetes, use of insulin and hypoglycemic medications, and self-reported HbA1c levels, suggesting that our findings are unlikely explained by confounding due to the severity of diabetes.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe results remained similar when analyses were stratified before/after 1998, when complete data were used, or when deaths that occurred within 4 years of diabetes diagnosis were excluded.
“The results remained similar when analyses were stratified before/after 1998, when complete data were used, or when deaths occurred within 4 years of diabetes diagnosis were excluded.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe follow-up rate for death in the Nurses' Health Study and Health Professionals Follow-Up Study was over 98%.
“The follow-up rate for death in the NHS and HPFS was over 98%.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationProspective observational studies among diabetic patients have largely focused on associations between healthy lifestyle practices and total mortality, but data specific for cardiovascular disease risk are lacking.
“Prospective observational studies among diabetic patients thus far largely focused on associations between healthy lifestyle practices and total mortality (13–15), but data specific for CVD risk are lacking.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [13] Lin, 2012, Impact of lifestyle-related factors on all-cause and cause-specific mortality in patients with type 2 diabetes: the Taichung Diabetes Study, Diabetes Care source
Not checked in the free run.
- cites [14] Patel, 2018, Adherence to healthy lifestyle factors and risk of death in men with diabetes mellitus: The Physicians' Health Study, Clin Nutr source
Not checked in the free run.
- cites [15] Nöthlings, 2010, Lifestyle factors and mortality among adults with diabetes: findings from the European Prospective Investigation into Cancer and Nutrition–Potsdam study, J Diabetes
Not checked in the free run.
May combine two claims.
Study design and conductcitationIn validation studies, 98% (61/62 cases) of diabetes cases confirmed by the supplementary questionnaire were re-confirmed by medical record review in the Nurses' Health Study, and 97% (57/59 cases) were re-confirmed in the Health Professionals Follow-Up Study.
“In our validation studies, 98% (61/62 cases) of diabetes cases confirmed by the supplementary questionnaire were re-confirmed by medical record review in the NHS, and 97% (57/59 cases) were re-confirmed in the HPFS (28,29).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [28] Hu, 2001, Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men, Arch Intern Med source
Not checked in the free run.
- cites [29] Manson, 1991, Physical activity and incidence of non-insulin-dependent diabetes mellitus in women, Lancet source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe diabetic patients in the study were diagnosed during an extended period of time since the 1980s.
“Second, the diabetic patients in our study were diagnosed during an extended period of time since 1980s.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationSeveral trials of multi-component lifestyle interventions demonstrated benefits on reducing type 2 diabetes risk and improving cardiovascular health among high-risk individuals, although long-term benefits on reducing cardiovascular disease events among diabetic patients were less established.
“Several trials that examined the efficacy of multi-component lifestyle interventions have demonstrated tremendous benefits on reducing T2D risk and improving cardiovascular health among high-risk individuals (7–12), although the long-term benefits on reducing CVD events among diabetic patients were less established (6).”
Quote in the paperSubstantial claim0 of 7 sources checked- cites [7] Knowler, 2009, 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study, Lancet source
Not checked in the free run.
- cites [8] Lindstrom, 2006, Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study, Lancet source
Not checked in the free run.
- cites [9] Li, 2008, The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study, Lancet source
Not checked in the free run.
- cites [10] Li, 2014, Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study, Lancet Diabetes Endocrinol source
Not checked in the free run.
- cites [11] Estruch, 2013, Primary prevention of cardiovascular disease with a Mediterranean diet, N Engl J Med source
Not checked in the free run.
- cites [12] 2015, Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study, Lancet Diabetes Endocrinol source
Not checked in the free run.
- cites [6] Schellenberg, 2013, Lifestyle interventions for patients with and at risk for type 2 diabetes: a systematic review and meta-analysis, Ann Intern Med source
Not checked in the free run.
May combine two claims.
Study design and conductreasoningMeasurement errors in self-reported assessments of dietary and lifestyle factors were likely non-differential in this prospective study and would be more likely to bias the associations toward the null.
“In addition, such measurement errors were likely to be non-differential in this prospective study and thus would be more likely to bias the associations toward the null.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductnone givenThe study could not exclude the role of confounding by genetic susceptibility, medication use, or psychosocial stress, residual confounding due to measurement errors of covariates, or chance.
“In particular, we could not exclude the role of confounding by genetic susceptibility, medication use, or psychosocial stress, residual confounding due to measurement errors of covariates, or chance in the current study.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe cumulative response rate was over 90% for both cohorts.
“The cumulative response rate was over 90% for both cohorts.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductown dataParticipants from the two cohorts were pooled in the absence of heterogeneity of results to increase statistical power.
“To increase statistical power, we pooled the participants from the two cohorts in the absence of heterogeneity of results.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Interpretationnone givenThe risk profile of diabetic patients might significantly change over time due to better control of blood lipids and other risk factors in recent years.
“The risk profile of diabetic patients might significantly change over time due to better control of blood lipids and other risk factors in recent years, although similar results were found in analyses stratified before/after 1998.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationBody mass index may no longer serve as a valid measure of adiposity after diabetes diagnosis, so it was not included in the lifestyle score to minimize reverse causation bias.
“Given that weight change is one of the typical symptoms of diabetes, and treatment could result in weight change after diagnosis as well, BMI may no longer serve as a valid measure of adiposity and thus was not included in the lifestyle score to minimize reverse causation bias (21).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [21] Tobias, 2014, Body-mass index and mortality among adults with incident type 2 diabetes, N Engl J Med source
Not checked in the free run.
- Rests on an assumption: Weight change is a typical symptom of diabetes, and treatment can result in weight change after diagnosis.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe low-risk lifestyle factors considered in the analysis may not necessarily represent all healthy behaviors.
“Lastly, the low-risk lifestyle factors considered in the current analysis may not necessarily represent all healthy behaviors.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductnone givenThe study participants were all health professionals, and most were Caucasians.
“First, the study participants were all health professionals, and most were Caucasians.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductnone givenPhysicians blinded to the participant questionnaire data reviewed all medical records.
“Physicians blinded to the participant questionnaire data reviewed all medical records.”
Quote in the paperSubstantial claim
The authors state this as an assumption.
The population-attributable risk calculation assumes a causal relationship between the low-risk lifestyle factors and cardiovascular disease risk.
“Fifth, the PAR calculation was based on the assumption of a causal relationship between the low-risk lifestyle factors and CVD risk, which may not hold true in observational studies.”
The paper relies on this without support.
Little is known regarding whether improvements in lifestyle from pre- to post-diabetes diagnosis may yield cardiovascular benefits.
“Importantly, little is known regarding whether improvements in lifestyle from pre- to post-diabetes diagnosis may yield cardiovascular benefits.”
The paper relies on this without support.
Weight change is a typical symptom of diabetes, and treatment can result in weight change after diagnosis.
“Given that weight change is one of the typical symptoms of diabetes, and treatment could result in weight change after diagnosis as well, BMI may no longer serve as a valid measure of adiposity and thus was not included in the lifestyle score to minimize reverse causation bias (21).”
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The magnitude of the association between moderate-to-vigorous physical activity and vascular events was generally larger than that previously reported by studies using self-reported moderate-to-vigorous physical activity data.
“The magnitude of this association was generally larger than that previously reported by studies using self-reported MVPA data.38,39”
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Compendium of Physical Activities: Classification of energy costs of human physical activities
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- Authors
- Liu, G., Li, Y., Hu, Y., Zong, G., Li, S., Rimm, E. B., Hu, F. B., Manson, J. E., Rexrode, K. M., Shin, H. J., & Sun, Q.
- Affiliations
- Harvard University (US)
- Chinese Academy of Sciences (CN)
- Boston University (US)
- Brigham and Women's Hospital (US)
- Corresponding author
- Sun, Qi
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2018-06
- Volume
- 71
- Issue
- 25
- Pages
- 2867-2876
- ISSN
- 0735-1097 (ISSN-L)
- PMC
- PMC6052788
- OpenAlex
- W2807965683
- Semantic Scholar
- 6317bba6e88e84f03622e634f93a9b1eb3725492
- Cited by
- 221
- References
- 47
- Citations by year
- 2026: 18 · 2025: 33 · 2024: 35 · 2023: 30 · 2022: 33 · 2021: 26 · 2020: 19 · 2019: 22 · 2018: 5
- FWCI
- 14.31
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (R01HL035464, R01HL034594, R01HL088521)
- National Cancer Institute (UM1CA176726, UM1CA186107, UM1CA167552, U01CA176726, U01CA167552)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK058845, R01DK082486)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Keywords
- healthy lifestyle, type 2 diabetes, cardiovascular disease incidence, cardiovascular mortality, Alternative Healthy Eating Index, diet quality, physical activity, alcohol consumption, smoking, coronary artery disease, stroke, prediabetes, lifestyle adherence, population attributable risk, Nurses' Health Study, Health Professionals Follow-up Study, cardiovascular risk reduction
- MeSH terms
- Aged, Cardiovascular Diseases, Diabetes Mellitus, Type 2, Female, Humans, Life Style, Male, Middle Aged, Prospective Studies, United States, Incidence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.
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