title: Birth weight and later life adherence to unhealthy lifestyles in predicting type 2 diabetes: prospective cohort study Healthy Behavior Change and Cardiovascular Outcomes in Newly Diagnosed Type 2 Diabetic Patients: A Cohort Analysis of the ADDITION-Cambridge Study Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Mediterranean Diet, Retinopathy, Nephropathy, and Microvascular Diabetes Complications: A Post Hoc Analysis of a Randomized Trial Cumulative Exposure to Ideal Cardiovascular Health and Incident Diabetes in a Chinese Population: The Kailuan Study Lifestyle factors and mortality among adults with diabetes: findings from the European Prospective Investigation into Cancer and Nutrition-Potsdam study*. Lifestyle and the risk of diabetes mellitus in a Japanese population Lifestyle Factors and Risk for New-Onset Diabetes Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Lifestyle factors on the risks of ischemic and hemorrhagic stroke. Lifestyle risk factors and new-onset diabetes mellitus in older adults: the cardiovascular health study. Healthy behaviours and 10-year incidence of diabetes: a population cohort study. Rotating night shift work and adherence to unhealthy lifestyle in predicting risk of type 2 diabetes: results from two large US cohorts of female nurses Lifestyle, Glycosylated Hemoglobin A1c, and Survival Among Patients With Stable Ischemic Heart Disease and Diabetes. Morbidity and mortality after lifestyle intervention for people with impaired glucose tolerance: 30-year results of the Da Qing Diabetes Prevention Outcome Study. Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post-hoc analysis of the Look AHEAD randomised clinical trial. Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients With Diabetes Mellitus. Adherence to healthy lifestyle factors and risk of death in men with diabetes mellitus: The Physicians' Health Study.
abstract: Objectives To prospect ively assess the joint association of birth weight and established lifestyle risk factors in adulthood with incident type 2 diabetes and to quantitatively decompose the attributing effects to birth weight only , to adulthood lifestyle only , and to their interaction . Design Prospect i ve cohort study . Setting Health Professionals Follow-up Study ( 1986 - 2010 ) , Nurses ’ Health Study ( 1980 - 2010 ) , and Nurses ’ Health Study II ( 1991 - 2011 ) . Participants 149 794 men and women without diabetes , cardiovascular disease , or cancer at baseline . Main outcome measure Incident cases of type 2 diabetes , identified through self report and vali date d by a supplementary question naire . Unhealthy lifestyle was defined on the basis of body mass index , smoking , physical activity , alcohol consumption , and the alternate healthy eating index . Results During 20 - 30 years of follow-up , 11 709 new cases of type 2 diabetes were documented . The multivariate adjusted relative risk of type 2 diabetes was 1.45 ( 95 % confidence interval 1.32 to 1.59 ) per kg lower birth weight and 2.10 ( 1.71 to 2.58 ) per unhealthy lifestyle factor . The relative risk of type 2 diabetes associated with a combination of per kg lower birth weight and per unhealthy lifestyle factor was 2.86 ( 2.26 to 3.63 ) , which was more than the addition of the risk associated with each individual factor , indicating a significant interaction on an additive scale ( P for interaction<0.001 ) . The attributable proportions of joint effect were 22 % ( 95 % confidence interval 18.3 % to 26.4 % ) to lower birth weight alone , 59 % ( 57.1 % to 61.5 % ) to unhealthy lifestyle alone , and 18 % ( 13.9 % to 21.3 % ) to their interaction . Conclusion Most cases of type 2 diabetes could be prevented by the adoption of a healthier lifestyle , but simultaneous improvement of both prenatal and postnatal factors could further prevent additional cases OBJECTIVE To examine whether improvements in health behaviors are associated with reduced risk of cardiovascular disease ( CVD ) in individuals with newly diagnosed type 2 diabetes . RESEARCH DESIGN AND METHODS Population -based prospect i ve cohort study of 867 newly diagnosed diabetic patients aged between 40 and 69 years from the treatment phase of the ADDITION-Cambridge study . Because the results for all analyses were similar by trial arm , data were pooled , and results were presented for the whole cohort . Participants were identified via  population -based stepwise screening between 2002 and 2006 , and underwent assessment of physical activity  ( European Prospect i ve Investigation into Cancer-Norfolk Physical Activity Question naire ) , diet ( plasma vitamin C and self-report ) , and alcohol consumption ( self-report ) at baseline and 1 year . A composite primary CVD outcome was examined , comprised of cardiovascular mortality , nonfatal myocardial infa rct ion , nonfatal stroke , and revascularization . RESULTS After a median ( interquartile range ) follow-up period of 5.0 years ( 1.3 years ) , 6 % of the cohort experienced a CVD event ( 12.2 per 1,000 person-years ; 95 % CI 9.3–15.9 ) . CVD risk was inversely related to the number of positive health behaviors changed in the year after diabetes diagnosis . The relative risk for primary CVD event in individuals who did not change any health behavior compared with those who adopted three/four healthy behaviors was 4.17 ( 95 % CI 1.02–17.09 ) , adjusting for age , sex , study group , social class , occupation , and prescription of cardioprotective medication ( P for trend = 0.005 ) . CONCLUSIONS CVD risk was inversely associated with the number of healthy behavior changes adopted in the year after the diagnosis of diabetes . Interventions that promote early achievement of these goals in patients with newly diagnosed diabetes could help reduce the burden of diabetes-related morbidity and mortality IMPORTANCE Short-term studies show that bariatric surgery causes remission of diabetes . The long-term outcomes for remission and diabetes-related complications are not known . OBJECTIVES To determine the long-term diabetes remission rates and the cumulative incidence of microvascular and macrovascular diabetes complications after bariatric surgery . DESIGN , SETTING , AND PARTICIPANTS The Swedish Obese Subjects ( SOS ) is a prospect i ve matched cohort study conducted at 25 surgical departments and 480 primary health care centers in Sweden . Of patients recruited between September 1 , 1987 , and January 31 , 2001 , 260 of 2037 control patients and 343 of 2010 surgery patients had type 2 diabetes at baseline . For the current analysis , diabetes status was determined at SOS health examinations until May 22 , 2013 . Information on diabetes complications was obtained from national health registers until December 31 , 2012 . Participation rates at the 2- , 10- , and 15-year examinations were 81 % , 58 % , and 41 % in the control group and 90 % , 76 % , and 47 % in the surgery group . For diabetes assessment , the median follow-up time was 10 years ( interquartile range [ IQR ] , 2 - 15 ) and 10 years ( IQR , 10 - 15 ) in the control and surgery groups , respectively . For diabetes complications , the median follow-up time was 17.6 years ( IQR , 14.2 - 19.8 ) and 18.1 years ( IQR , 15.2 - 21.1 ) in the control and surgery groups , respectively . INTERVENTIONS Adjustable or nonadjustable b and ing ( n = 61 ) , vertical b and ed gastroplasty ( n = 227 ) , or gastric bypass ( n = 55 ) procedures were performed in the surgery group , and usual obesity and diabetes care was provided to the control group . MAIN OUTCOMES AND MEASURES Diabetes remission , relapse , and diabetes complications . Remission was defined as blood glucose < 110 mg/dL and no diabetes medication . RESULTS The diabetes remission rate 2 years after surgery was 16.4 % ( 95 % CI , 11.7%-22.2 % ; 34/207 ) for control patients and 72.3 % ( 95 % CI , 66.9%-77.2 % ; 219/303 ) for bariatric surgery  patients ( odds ratio [ OR ] , 13.3 ; 95 % CI , 8.5 - 20.7 ; P < .001 ) . At 15 years , the diabetes remission rates decreased to 6.5 % ( 4/62 ) for control patients and to 30.4 % ( 35/115 ) for bariatric surgery patients ( OR , 6.3 ; 95 % CI , 2.1 - 18.9 ; P < .001 ) . With long-term follow-up , the cumulative incidence of microvascular complications was 41.8 per 1000 person-years ( 95 % CI , 35.3 - 49.5 ) for control patients and 20.6 per 1000 person-years ( 95 % CI , 17.0 - 24.9 ) in the surgery group ( hazard ratio [ HR ] , 0.44 ; 95 % CI , 0.34 - 0.56 ; P < .001 ) . Macrovascular complications were observed in 44.2 per 1000 person-years ( 95 % CI , 37.5 - 52.1 ) in control patients and 31.7 per 1000 person-years ( 95 % CI , 27.0 - 37.2 ) for the surgical group ( HR , 0.68 ; 95 % CI , 0.54 - 0.85 ; P = .001 ) . CONCLUSIONS AND RELEVANCE In this very long-term follow-up observational study of obese patients with type 2 diabetes , bariatric surgery was associated with more frequent diabetes remission and fewer complications than usual care . These findings require confirmation in r and omized trials . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01479452 BACKGROUND Our objective was to describe the reduction in relative risk of developing major chronic diseases such as cardiovascular disease , diabetes , and cancer associated with 4 healthy lifestyle factors among German adults . METHODS We used data from 23,153 German participants aged 35 to 65 years from the European Prospect i ve Investigation Into Cancer and Nutrition-Potsdam study . End points included confirmed incident type 2 diabetes mellitus , myocardial infa rct ion , stroke , and cancer . The 4 factors were never smoking , having a body mass index lower than 30 ( calculated as weight in kilograms divided by height in meters squared ) , performing 3.5 h/wk or more of physical activity , and adhering to healthy dietary principles ( high intake of fruits , vegetables , and whole-grain bread and low meat consumption ) . The 4 factors ( healthy , 1 point ; unhealthy , 0 points ) were summed to form an index that ranged from 0 to 4 . RESULTS During a mean follow-up of 7.8 years , 2006 participants developed new-onset diabetes ( 3.7 % ) , myocardial infa rct ion ( 0.9 % ) , stroke ( 0.8 % ) , or cancer ( 3.8 % ) . Fewer than 4 % of participants had zero healthy factors , most had 1 to 3 healthy factors , and approximately 9 % had 4 factors . After adjusting for age , sex , educational status , and occupational status , the hazard ratio for developing a chronic disease decreased progressively as the number of healthy factors increased . Participants with all 4 factors at baseline had a 78 % ( 95 % confidence interval [ CI ] , 72 % to 83 % ) lower risk of developing a chronic disease ( diabetes , 93 % [ 95 % CI , 88 % to 95 % ] ; myocardial infa rct ion , 81 % [ 95 % CI , 47 % to 93 % ] ; stroke , 50 % [ 95 % CI , -18 % to 79 % ] ; and cancer , 36 % [ 95 % CI , 5 % to 57 % ] ) than participants without a healthy factor . CONCLUSION Adhering to 4 simple healthy lifestyle factors can have a strong impact on the prevention of chronic diseases OBJECTIVE To date no clinical trials have evaluated the role of dietary patterns on the incidence of microvascular diabetes complications .  We hypothesized that a nutritional intervention based on the Mediterranean diet ( MedDiet ) would have greater protective effect on diabetic retinopathy and nephropathy than a low-fat control diet . RESEARCH DESIGN AND METHODS This was a post hoc analysis of a cohort of patients with type 2 diabetes participating in the PREvención con DIeta MEDiterránea ( PREDIMED ) study , a multicenter r and omized nutritional intervention trial conducted in a population at high cardiovascular risk . Individuals with type 2 diabetes who were free of microvascular complications at enrollment ( n = 3,614 , aged 55–80 years ) were r and omly assigned to one of three dietary interventions : MedDiet supplemented with extravirgin olive oil ( MedDiet+EVOO ) , MedDiet supplemented with mixed nuts ( MedDiet+Nuts ) , or a low-fat control diet . Two independent outcomes were considered : new onset of diabetic retinopathy and nephropathy . Hazard ratios ( HRs ) were calculated using multivariable-adjusted Cox regression . RESULTS During a median follow-up of 6.0 years , we identified 74 new cases of retinopathy and 168 of nephropathy . Compared with the control diet , multivariable-adjusted HRs for diabetic retinopathy were 0.56 ( 95 % CI 0.32–0.97 ) for the MedDiet+EVOO and 0.63 ( 0.35–1.11 ) for the MedDiet+Nuts . No between-group differences were found for nephropathy . When the yearly up date d information on adherence to the MedDiet was considered , the HR for retinopathy in the highest versus the lowest quintile was 0.34 ( 0.13–0.89 ; P = 0.001 for trend ) . No significant associations were found for nephropathy . CONCLUSIONS A MedDiet enriched with EVOO may protect against diabetic retinopathy but not diabetic nephropathy Background It is unclear whether ideal cardiovascular health ( CVH ) , and particularly cumulative exposure to ideal CVH ( cumCVH ) , is associated with incident diabetes . We aim ed to fill this research gap . Methods and Results The Kailuan Study is a prospect i ve cohort of 101 510 adults aged 18 to 98 years recruited in 2006–2007 and who were subsequently followed up at 2‐ ( Exam 2 ) , 4‐ ( Exam 3 ) , and 6 ( Exam 4)‐year intervals after baseline . The main analysis is restricted to those individuals with complete follow‐up at all 4 examinations and who had no history of diabetes until Exam 3 .  Cumulative exposure to ideal CVH ( cumCVH )  was calculated as the summed CVH score for each examination multiplied by the time between the 2 examinations ( score × year ) . Logistic regression models were used to assess the association between cumCVH and incident diabetes . In fully adjusted models , compared with the lowest quintile of cumCVH , individuals in the highest quintile had ~68 % ( 95 % confidence interval [ CI ] 60‐75 ) lower risk for incident diabetes ( compared with 61 % [ 95 % CI 52‐69 ] lower risk when using baseline CVH ) . Every additional year lived with a 1‐unit increase in ideal CVH was associated with a 24 % ( 95 % CI 21‐28 ) reduction in incident diabetes . Conclusions Ideal CVH is associated with a reduced incidence of diabetes , but the association is likely to be underestimated if baseline measures of CVH exposure are used . Measures of cumulative exposure to ideal CVH are more likely to reflect lifetime risk of diabetes and possibly other health outcomes . Clinical Trial Registration URL : https://www.chictr.org . Unique identifier : ChiCTRTNC‐11001489 BACKGROUND Healthy lifestyle behaviors are among the cornerstones of diabetes self-management , but the extent to which healthy lifestyle factors could potentially prevent premature mortality among people with diabetes remains unknown . The aim of the present study was to estimate the reduction in mortality that could be achieved if people with diabetes did not smoke , had a body mass index < 30 kg/m(2 ) , performed physical activity for ≥3.5 h/week , reported better dietary habits , and consumed alcohol moderately . METHODS A prospect i ve cohort study of 1263 German men and women with diabetes aged 35 - 65 years who were followed for an average of 7.8 years was used and multivariate Cox regression models for all-cause and cause-specific mortality were calculated . RESULTS Approximately 7 % of study participants had no favorable factors , 24 % had one , 35 % had two , and 34 % had three or more . Compared with participants who had no favorable factors , the reduction in risk was 34 % [ 95 % confidence interval ( CI ) 19 % , 63 % ] for those with one favorable factor , 49 % ( 95 % CI 9 % , 71 % ) for those with two , and 63 % ( 95 % CI 31 % , 80 % ) for those with three or more . Furthermore , a competing risk analysis did not show any difference in the inverse associations with mortality due to cardiovascular disease , cancer , or other causes . CONCLUSIONS Favorable lifestyle factors can potentially achieve substantial reductions in premature mortality among people with diabetes . Our results emphasize the importance of helping people with diabetes optimize their lifestyle behaviors The objective was to examine the association between lifestyle and risk for diabetes . For an average of 9.9 years , this study prospect ively followed a cohort of 7,211 ( 2,524 men and 4,687 women ) community residents aged 30–69 years without diabetes at a health check-up conducted between April 1990 and March 1992 until diabetes was confirmed or until the end of 2006 . The subjects were divided into 6 groups according to their total scores of Breslow ’s lifestyle index ( 1–2 , 3 , 4 , 5 , 6 and 7 points ) . The association between lifestyle and diabetes incidence was investigated using Cox proportional hazards regression models . The results showed that the multivariate-adjusted hazard ratios were 0.45 in subjects who scored 5 points , 0.39 in subjects who scored 6 points , and 0.31 in subjects who scored 7 points , compared with subjects who scored 1–2 points . These data indicate that the healthy behaviors prevent the incidence of diabetes BACKGROUND Epidemiologic data on the combined influence of several lifestyle factors on diabetes risk are rare , particularly among older adults . OBJECTIVE To examine how combinations of lifestyle risk factors relate to the 11-year risk for incident diabetes . DESIGN Population -based prospect i ve cohort study . SETTING National Institutes of Health (NIH)-AARP Diet and Health Study . PARTICIPANTS 114,996 men and 92,483 women , aged 50 to 71 years in 1995 to 1996 , without evidence of heart disease , cancer , or diabetes . MEASUREMENTS A comprehensive survey of demographic characteristics and lifestyle factors  , including dietary intake , body weight and height , physical activity , smoking , and alcohol consumption  at baseline ( 1995 to 1996 ) . Low-risk groups were formed by dichotomizing each lifestyle factor . Incident self-reported , physician-diagnosed diabetes was identified with a follow-up survey in 2004 to 2006 . RESULTS 11,031 men ( 9.6 % ) and 6969 women ( 7.5 % ) developed new-onset diabetes . For each additional lifestyle factor in the low-risk group , the odds for diabetes were 31 % lower ( odds ratio [ OR ] , 0.69 [ 95 % CI , 0.68 to 0.71 ] ) among men and 39 % lower ( OR , 0.61 [ CI , 0.60 to 0.63 ] ) among women . Men and women whose diet score , physical activity level , smoking status , and alcohol use were all in the low-risk group had ORs for diabetes of 0.61 ( CI , 0.56 to 0.66 ) and 0.43 ( CI , 0.34 to 0.55 ) , respectively . When absence of overweight or obesity was added , the respective ORs were 0.28 ( CI , 0.23 to 0.34 ) and 0.16 ( CI , 0.10 to 0.24 ) for men and women . Results did not differ by family history of diabetes or level of adiposity . LIMITATION The study was observational , with potential for residual confounding . CONCLUSION Lifestyle factors , when considered in combination , are associated with a substantial reduction in risk for diabetes . PRIMARY FUNDING SOURCE The NIH-AARP Diet and Health Study was supported by the Intramural Research Program of the NIH BACKGROUND It has been suggested that the inverse association between alcohol and type 2 diabetes could be explained by moderate drinkers ' healthier lifestyles . OBJECTIVE We studied whether moderate alcohol consumption is associated with a lower risk of type 2 diabetes in adults with combined low-risk lifestyle behaviors . DESIGN We prospect ively examined 35,625 adults of the Dutch European Prospect i ve Investigation into Cancer and Nutrition ( EPIC-NL ) cohort aged 20 - 70 y , who were free of diabetes , cardiovascular disease , and cancer at baseline ( 1993 - 1997 ) . In addition to moderate alcohol consumption ( women : 5.0 - 14.9 g/d ; men : 5.0 - 29.9 g/d ) , we defined low-risk categories of 4 lifestyle behaviors : optimal weight [ body mass index ( in kg/m(2 ) ) < 25 ] , physically active ( > or = 30 min of physical activity/d ) , current nonsmoker , and a healthy diet [ upper 2 quintiles of the Dietary Approaches to Stop Hypertension ( DASH ) diet ] . RESULTS During a median of 10.3 y , we identified 796 incident cases of type 2 diabetes . Compared with teetotalers , hazard ratios of moderate alcohol consumers for risk of type 2 diabetes in low-risk lifestyle strata after multivariable adjustments were 0.35 ( 95 % CI : 0.17 , 0.72 ) when of a normal weight , 0.65 ( 95 % CI : 0.46 , 0.91 ) when physically active , 0.54 ( 95 % CI : 0.41 , 0.71 ) when nonsmoking , and 0.57 ( 95 % CI : 0.39 , 0.84 ) when consuming a healthy diet . When > or =3 low-risk lifestyle behaviors were combined , the hazard ratio for incidence of type 2 diabetes in moderate alcohol consumers after multivariable adjustments was 0.56 ( 95 % CI : 0.32 , 1.00 ) . CONCLUSION In subjects already at lower risk of type 2 diabetes on the basis of multiple low-risk lifestyle behaviors , moderate alcohol consumption was associated with an approximately 40 % lower risk compared with abstention BACKGROUND Lifestyle interventions can prevent the deterioration of impaired glucose tolerance to manifest type 2 diabetes , at least as long as the intervention continues . In the extended follow-up of the Finnish Diabetes Prevention Study , we assessed the extent to which the originally-achieved lifestyle changes and risk reduction remain after discontinuation of active counselling . METHODS Overweight , middle-aged men ( n=172 ) and women ( n=350 ) with impaired glucose tolerance were r and omly assigned to intensive lifestyle intervention or control group . After a median of 4 years of active intervention period , participants who were still free of diabetes were further followed up for a median of 3 years , with median total follow-up of 7 years . Diabetes incidence , bodyweight , physical activity , and dietary intakes of fat , saturated fat , and fibre were measured . FINDINGS During the total follow-up , the incidence of type 2 diabetes was 4.3 and 7.4 per 100 person-years in the intervention and control group , respectively ( log-rank test p=0.0001 ) , indicating 43 % reduction in relative risk . The risk reduction was related to the success in achieving the intervention goals of weight loss , reduced intake of total and saturated fat and increased intake of dietary fibre , and increased physical activity . Beneficial lifestyle changes achieved by participants in the intervention group were maintained after the discontinuation of the intervention , and the corresponding incidence rates during the post-intervention follow-up were 4.6 and 7.2 ( p=0.0401 ) , indicating 36 % reduction in relative risk . INTERPRETATION Lifestyle intervention in people at high risk for type 2 diabetes result ed in sustained lifestyle changes and a reduction in diabetes incidence , which remained after the individual lifestyle counselling was stopped BACKGROUND Intensive lifestyle interventions can reduce the incidence of  type 2 diabetes in people with impaired glucose tolerance , but how long these benefits extend beyond the period of active intervention , and whether such interventions reduce the risk of cardiovascular disease ( CVD ) and mortality , is unclear . We aim ed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes , diabetes-related macrovascular and microvascular complications , and mortality . METHODS In 1986 , 577 adults with impaired glucose tolerance from 33 clinics in China were r and omly assigned to either the  control group or to one of three lifestyle intervention groups ( diet , exercise , or diet plus exercise ) . Active intervention took place over 6 years until 1992 . In 2006 , study participants were followed-up to assess the long-term effect of the interventions . The primary outcomes were diabetes incidence , CVD incidence and mortality , and all-cause mortality . FINDINGS Compared with control participants , those in the combined lifestyle intervention groups had a 51 % lower incidence of diabetes ( hazard rate ratio [ HRR ] 0.49 ; 95 % CI 0.33 - 0.73 ) during the active intervention period and a 43 % lower incidence ( 0.57 ; 0.41 - 0.81 ) over the 20 year period , controlled for age and clustering by clinic . The average annual incidence of diabetes was 7 % for intervention participants versus 11 % in control participants , with 20-year cumulative incidence of 80 % in the intervention groups and 93 % in the control group . Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group . There was no significant difference between the intervention and control groups in the rate of first CVD events ( HRR 0.98 ; 95 % CI 0.71 - 1.37 ) , CVD mortality ( 0.83 ; 0.48 - 1.40 ) , and all-cause mortality ( 0.96 ; 0.65 - 1.41 ) , but our study had limited statistical power to detect differences for these outcomes . INTERPRETATION Group-based lifestyle interventions over 6 years can prevent or delay diabetes for up to 14 years after the active intervention . However , whether lifestyle intervention also leads to reduced CVD and mortality remains unclear BACKGROUND Type 2 diabetes affects approximately 8 percent of adults in the United States . Some risk factors -- elevated plasma glucose concentrations in the fasting state and after an oral glucose load , overweight , and a sedentary lifestyle -- are potentially reversible . We hypothesized that modifying these factors with a lifestyle-intervention program or the administration of metformin would prevent or delay the development of diabetes . METHODS We r and omly assigned 3234 nondiabetic persons with elevated fasting and post-load plasma glucose concentrations to placebo , metformin ( 850 mg twice daily ) , or a lifestyle-modification program  with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week . The mean age of the participants was 51 years , and the mean body-mass index ( the weight in kilograms divided by the square of the height in meters ) was 34.0 ; 68 percent were women , and 45 percent were members of minority groups . RESULTS The average follow-up was 2.8 years . The incidence of diabetes was 11.0 , 7.8 , and 4.8 cases per 100 person-years in the placebo , metformin , and lifestyle groups , respectively . The lifestyle intervention reduced the incidence by 58 percent ( 95 percent confidence interval , 48 to 66 percent ) and metformin by 31 percent ( 95 percent confidence interval , 17 to 43 percent ) , as compared with placebo ; the lifestyle intervention was significantly more effective than metformin . To prevent one case of diabetes during a period of three years , 6.9 persons would have to participate in the lifestyle-intervention program , and 13.9 would have to receive metformin . CONCLUSIONS Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk . The lifestyle intervention was more effective than metformin BACKGROUND The joint effects of different lifestyle factors on stroke risk are still to some extent unclear , especially regarding hemorrhagic stroke . METHODS We prospect ively investigated the association of different indicators of lifestyle ( smoking , body mass index , physical activity , and vegetable and alcohol consumption )  with total and type-specific stroke incidence among 36 686 Finnish participants who were 25 to 74 years old and free of coronary heart disease and stroke at baseline . RESULTS During a mean follow-up period of 13.7 years , 1478 people developed an incident stroke event ( 1167 ischemic and 311 hemorrhagic ) . The multivariate-adjusted ( age , sex , education , family history of stroke , history of diabetes mellitus , systolic blood pressure , and serum total cholesterol level ) hazard ratios associated with adherence to 0 to 1 ( reference group ) , 2 , 3 , 4 , and 5 healthy lifestyle indicators were 1 , 0.66 , 0.57 , 0.51 , and 0.33 ( P < .001 for trend ) for total stroke ; 1 , 0.67 , 0.60 , 0.50 , and 0.30 ( P < .001 for trend ) for ischemic stroke ; and 1 , 0.63 , 0.49 , 0.49 , and 0.40 ( P < .001 for trend ) for hemorrhagic stroke , respectively . These inverse associations were similar in both men and women . The partial population attributable risk percentages associated with adherence to 3 , 4 , and 5 healthy lifestyle indicators were 26.3 % , 43.8 % , and 54.6 % for total stroke ; 22.7 % , 45.3 % , and 59.7 % for ischemic stroke ; and 35.0 % , 35.0 % , and 36.1 % for hemorrhagic stroke , respectively . CONCLUSION Healthy lifestyle factors are associated with a lower risk of stroke , and there is a grade d inverse association between the number of healthy lifestyle indicators and the risks of total , ischemic , and hemorrhagic stroke BACKGROUND The combined impact of lifestyle factors on incidence of  diabetes mellitus later in life is not well established . The objective of this study was to determine how lifestyle factors , assessed in combination , relate to new-onset diabetes in a broad and relatively unselected population of older adults . METHODS We prospect ively examined associations of lifestyle factors , measured using repeated assessment s later in life , with incident  diabetes mellitus  during a 10-year period ( 1989 - 1998 ) among 4883 men and women 65 years or older ( mean [ SD ] age at baseline , 73 [ 6 ] years ) enrolled in the Cardiovascular Health Study . Low-risk lifestyle groups were defined by physical activity level ( leisure-time activity and walking pace ) above the median ; dietary score ( higher fiber intake and polyunsaturated to saturated fat ratio , lower trans-fat intake and lower mean glycemic index ) in the top 2 quintiles ; never smoked or former smoker more than 20 years ago or for fewer than 5 pack-years ; alcohol use ( predominantly light or moderate ) ; body mass index less than 25 ( calculated as weight in kilograms divided by height in meters squared ) ; and waist circumference of 88 cm for women or 92 cm for men . The main outcome measure was incident diabetes defined annually by new use of insulin or oral hypoglycemic medications . We also evaluated fasting and 2-hour postchallenge glucose levels . RESULTS During 34,539 person-years , 337 new cases of drug-treated diabetes mellitus occurred ( 9.8 per 1000 person-years ) . After adjustment for age , sex , race , educational level , and annual income , each lifestyle factor was independently associated with incident diabetes . Overall , the rate of incident diabetes was 35 % lower ( relative risk , 0.65 ; 95 % confidence interval , 0.59 - 0.71 ) for each 1 additional lifestyle factor in the low-risk group . Participants whose physical activity level and dietary , smoking , and alcohol habits were all in the low-risk group had an 82 % lower incidence of diabetes ( relative risk , 0.18 ; 95 % confidence interval , 0.06 - 0.56 ) compared with all other participants . When absence of adiposity ( either body mass index < 25 or waist circumference < or = 88/92 cm for women/men ) was added to the other 4 low-risk lifestyle factors , incidence of diabetes was 89 % lower ( relative risk , 0.11 ; 95 % confidence interval , 0.01 - 0.76 ) . Overall , 9 of 10 new cases of diabetes appeared to be attributable to these 5 lifestyle factors . Associations were slightly attenuated , but still highly significant , for incident diabetes defined by medication use or glucose level . CONCLUSION Even later in life , combined lifestyle factors are associated with a markedly lower incidence of new-onset diabetes mellitus OBJECTIVE To examine the association between meeting behavioural goals and diabetes incidence over 10 years in a large , representative Swedish population . METHODS Population -based prospect i ve cohort study of 32,120 individuals aged 35 to 55 years participating in a health promotion intervention in Västerbotten County , Sweden ( 1990 to 2013 ) . Participants underwent an oral glucose tolerance test , clinical measures , and completed diet and activity question naires . Poisson regression quantified the association between achieving six behavioural goals at baseline - body mass index ( BMI ) < 25 kg/m(2 ) , moderate physical activity , non-smoker , fat intake < 30 % of energy , fibre intake ≥15 g/4184 kJ and alcohol intake ≤20 g/day - and diabetes incidence over 10 years . RESULTS Median interquartile range ( IQR ) follow-up time was 9.9 ( 0.3 ) years ; 2211 individuals ( 7 % ) developed diabetes . Only 4.4 % of participants met all 6 goals ( n=1245 ) and compared to these individuals , participants meeting 0/1 goals had a 3.74 times higher diabetes incidence ( 95 % confidence interval (CI)=2.50 to 5.59 ) , adjusting for sex , age , calendar period , education , family history of diabetes , history of myocardial infa rct ion and long-term illness . If everyone achieved at least four behavioural goals , 14.1 % ( 95 % CI : 11.7 to 16.5 % ) of incident diabetes cases might be avoided . CONCLUSION Interventions promoting the achievement of behavioural goals in the general population could significantly reduce diabetes incidence Abstract Objectives To prospect ively evaluate the joint association of duration of rotating night shift work and lifestyle factors with risk of type 2 diabetes risk , and to quantitatively decompose this joint association to rotating night shift work only , to lifestyle only , and to their interaction . Design Prospect i ve cohort study . Setting Nurses ’ Health Study ( 1988 - 2012 ) and Nurses ’ Health Study II ( 1991 - 2013 ) . Participants 143 410 women without type 2 diabetes , cardiovascular disease , or cancer at baseline . Exposures Rotating night shift work was defined as at least three night shifts per month in addition to day and evening shifts in that month . Unhealthy lifestyles included current smoking , physical activity levels below 30 minutes per day at moderate to vigorous intensity , diet in the bottom three fifths of the Alternate Healthy Eating Index score , and body mass index of 25 or above . Main outcome measures Incident cases of type 2 diabetes were identified through self report and vali date d by a supplementary question naire . Results During 22 - 24 years of follow-up , 10 915 cases of incident type 2 diabetes occurred . The multivariable adjusted hazard ratios for type 2 diabetes were 1.31 ( 95 % confidence interval 1.19 to 1.44 ) per five year increment of duration of rotating night shift work and 2.30 ( 1.88 to 2.83 ) per unhealthy lifestyle factor ( ever smoking , low diet quality , low physical activity , and overweight or obesity ) . For the joint association of per five year increment rotating night shift work and per unhealthy lifestyle factor with type 2 diabetes , the hazard ratio was 2.83 ( 2.15 to 3.73 ) with a significant additive interaction ( P for interaction < 0.001 ) . The proportions of the joint association were 17.1 % ( 14.0 % to 20.8 % ) for rotating night shift work alone , 71.2 % ( 66.9 % to 75.8 % ) for unhealthy lifestyle alone , and 11.3 % ( 7.3 % to 17.3 % ) for their additive interaction . Conclusions Among female nurses , both rotating night shift work and unhealthy lifestyle were associated with a higher risk of type 2 diabetes . The excess risk of rotating night shift work combined with unhealthy lifestyle was higher than the addition of risk associated with each individual factor . These findings suggest that most cases of type 2 diabetes could be prevented by adhering to a healthy lifestyle , and the benefits could be greater in rotating night shift workers BACKGROUND The importance of glycosylated hemoglobin A1c ( A1c ) control as part of comprehensive risk factor management in patients with stable ischemic heart disease ( SIHD ) and diabetes mellitus ( DM ) is controversial . OBJECTIVES The purpose of this study was to determine whether a greater number of controlled risk factors at 1 year , including A1c , affects survival in patients with DM and SIHD . METHODS Of 690 patients with DM followed in the COURAGE ( Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation ) trial , 592 ( 86 % ) had complete ascertainment of 7 pre-specified risk factors at baseline and after 1 year : systolic blood pressure , low-density lipoprotein cholesterol , nonsmoking , physical activity , diet adherence , body mass index , and A1c . The primary outcome measure was mortality beyond 1 year after r and omization . RESULTS During a mean follow-up of 7.0 ± 4.2 years beyond 1 year after r and omization , 186 subjects  died ( 31.4 % overall , 4.5%/year ) . The greater the number of risk factors controlled at 1 year , the higher the probability of survival ( unadjusted log rank p = 0.002 ) . Compared with 0 to 1 controlled risk factors , attaining 3 to 7 goals predicted progressively lower mortality ( hazard ratio for control of 6 or 7 risk factors was 0.13 ; 95 % confidence interval : 0.05 to 0.40 ) . Importantly , only 10.3 % of subjects achieved control of 6 or 7 risk factors . In multivariate analysis , the strongest predictors of improved survival were no smoking , regular physical activity , dietary adherence , and A1c < 7 % . CONCLUSIONS In this high-risk subset of SIHD patients with DM , the number of controlled risk factors , particularly lifestyle behaviors and A1c , were associated with improved survival . ( Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation ; NCT00007657 ) BACKGROUND Lifestyle interventions can delay the onset of type 2 diabetes in people with impaired glucose tolerance , but whether this leads subsequently to fewer complications or to increased longevity is uncertain . We aim ed to assess the long-term effects of lifestyle interventions in people with impaired glucose tolerance on the incidence of diabetes , its complications , and mortality . METHODS The original study was a cluster r and omised trial , started in 1986 , in which 33 clinics in Da Qing , China , were r and omly assigned to either be a control clinic or provide one of three interventions ( diet , exercise , or diet plus exercise ) for 6 years for 577 adults with impaired glucose tolerance who usually receive their medical care from the clinics . Subsequently , participants were followed for up to 30 years to assess the effects of intervention on the incidence of diabetes , cardiovascular disease events , composite microvascular complications , cardiovascular disease death , all-cause mortality , and life expectancy . FINDINGS Of the 577 participants , 438 were assigned to an intervention group and 138 to the control group  ( one refused baseline examination ) . After 30 years of follow-up , 540 ( 94 % ) of 576 participants were assessed for outcomes ( 135 in the control group , 405 in the intervention group ) . During the 30-year follow-up , compared with control , the combined intervention group had a median delay in diabetes onset of 3·96 years ( 95 % CI 1·25 to 6·67 ; p=0·0042 ) , fewer cardiovascular disease events ( hazard ratio 0·74 , 95 % CI 0·59 - 0·92 ; p=0·0060 ) , a lower incidence of microvascular complications ( 0·65 , 0·45 - 0·95 ; p=0·025 ) , fewer cardiovascular disease deaths ( 0·67 , 0·48 - 0·94 ; p=0·022 ) , fewer all-cause deaths ( 0·74 , 0·61 - 0·89 ; p=0·0015 ) , and an average increase in life expectancy of 1·44 years ( 95 % CI 0·20 - 2·68 ; p=0·023 ) . INTERPRETATION Lifestyle intervention in people with impaired glucose tolerance delayed the onset of type 2 diabetes and reduced the incidence of cardiovascular events , microvascular complications , and cardiovascular and all-cause mortality , and increased life expectancy . These findings provide strong justification to continue to implement and exp and the use of such interventions to curb the global epidemic of type 2 diabetes and its consequences . FUNDING US Centers for Disease Control and Prevention , WHO , Chinese Center for Disease Control and Prevention , World Bank , Ministry of Public Health of the People 's Republic of China , Da Qing First Hospital , China-Japan Friendship Hospital , and National Center for Cardiovascular Diseases & Fuwai Hospital BACKGROUND Findings from the Look AHEAD trial showed no significant reductions in the primary outcome of cardiovascular disease incidence in adults with type 2 diabetes r and omly assigned to an intensive lifestyle intervention for weight loss compared with those r and omly assigned to diabetes support and education ( control ) . We examined whether the incidence of cardiovascular disease in Look AHEAD varied by changes in weight or fitness . METHODS Look AHEAD was a r and omised clinical trial done at 16 clinical sites in the USA , recruiting patients from Aug 22 , 2001 , to April 30 , 2004 . In the trial , 5145 overweight or obese adults aged 45 - 76 years with type 2 diabetes were assigned ( 1:1 ) to an intensive lifestyle intervention or diabetes support and education . In this observational , post-hoc analysis , we examined the association of magnitude of weight loss and fitness change over the first year with incidence of cardiovascular disease . The primary outcome of the trial and of this analysis was a composite of death from cardiovascular causes , non-fatal acute myocardial infa rct ion , non-fatal stroke , or admission to hospital for angina . The secondary outcome included the same indices plus coronary artery bypass grafting , carotid endartectomy , percutaneous coronary intervention , hospitalisation for congestive heart failure , peripheral vascular disease , or total mortality . We adjusted analyses for baseline differences in weight or fitness , demographic characteristics , and risk factors for cardiovascular disease . The Look AHEAD trial is registered with Clinical Trials.gov , number NCT00017953 . FINDINGS For the analyses related to weight change , we excluded 311 ineligible participants , leaving a population of 4834 ; for the analyses related to fitness change , we excluded 739 participants , leaving a population of 4406 . In analyses of the full cohort ( ie , combining both study groups ) , over a median 10·2 years of follow-up ( IQR 9·5 - 10·7 ) , individuals who lost at least 10 % of their bodyweight in the first year of the study had a 21 % lower risk of the primary outcome ( adjusted hazard ratio [ HR ] 0·79 , 95 % CI 0·64 - 0·98 ; p=0·034 ) and a 24 % reduced risk of the secondary outcome ( adjusted HR 0·76 , 95 % CI 0·63 - 0·91 ; p=0·003 ) compared with individuals with stable weight or weight gain . Achieving an increase of at least 2 metabolic equivalents in fitness change was associated with a significant reduction in the secondary outcome ( adjusted HR 0·77 , 95 % CI 0·61 - 0·96 ; p=0·023 ) but not the primary outcome ( adjusted HR 0·78 , 0·60 - 1·03 ; p=0·079 ) . In analyses treating the control group as the reference group , participants in the intensive lifestyle intervention group who lost at least 10 % of their bodyweight had a 20 % lower risk of the primary outcome ( adjusted HR 0·80 , 95 % CI 0·65 - 0·99 ; p=0·039 ) , and a 21 % lower risk of the secondary outcome ( adjusted HR 0·79 , 95 % CI 0·66 - 0·95 ; p=0·011 ) ; however , change in fitness was not significantly associated with a change in the primary outcome . INTERPRETATION The results of this post-hoc analysis of Look AHEAD suggest an association between the magnitude of weight loss and incidence of cardiovascular disease in people with type 2 diabetes . These findings suggest a need to continue to refine approaches to identify individuals who are most likely to benefit from lifestyle interventions and to develop strategies to improve the magnitude of sustained weight loss with lifestyle interventions . FUNDING US National Institute of Diabetes and Digestive and Kidney Diseases BACKGROUND Evidence is limited regarding the impact of healthy lifestyle practice s on the risk of subsequent cardiovascular events among patients with diabetes . OBJECTIVES The purpose of this study was to examine the associations of an overall healthy lifestyle , defined by eating a high- quality diet ( top two-fifths of Alternative Healthy Eating Index ) , nonsmoking , engaging in moderate- to vigorous-intensity physical activity ( ≥150 min/week ) , and drinking alcohol in moderation ( 5 to 15 g/day for women and 5 to 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 prospect i ve 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 to 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 for participants with 3 or more low-risk lifestyle factors compared with 0 were 0.48 ( 95 % confidence interval [ CI ] : 0.40 to 0.59 ) for total CVD incidence , 0.53 ( 95 % CI : 0.42 to 0.66 ) for incidence of coronary heart disease , 0.33 ( 95 % CI : 0.21 to 0.51 ) for stroke incidence , and 0.32 ( 95 % CI : 0.22 to 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 % to 52.0 % ) for CVD mortality . In addition , greater improvements in healthy lifestyle factors from pre-diabetes 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 ) . 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 BACKGROUND & AIMS The relationship between healthy lifestyle factors and mortality in people with type 2 diabetes is unclear . The purpose of this study was to examine whether healthy lifestyle factors are associated with mortality in people with type 2 diabetes . METHODS We prospect ively studied 1163 men with type 2 diabetes from the Physicians ' Health Study . Lifestyle factors consisted of currently not smoking , moderate drinking ( 1 - 2 drinks/day ) , vigorous exercise ( 1+/week ) , BMI < 25 kg/m2 , and being in the top 2 quintiles of the alternate healthy eating index-2010 ( AHEI-2010 ) . Multivariate Cox regression models were used to estimate hazard ratios ( 95 % confidence intervals ) of mortality . RESULTS At baseline , average age was 69 years and mean follow up was 9 years . About 22 % of study participants had ≤1 healthy lifestyle factor , 37 % had two , 29 % had three , and 12 % had four or more healthy lifestyle factors . An inverse relationship was found between the number of lifestyle factors and total mortality . Compared with participants who had ≤1 healthy lifestyle factor , the risk of death was 42 % ( 95 % CI ; 19%-58 % ) lower for those with two healthy lifestyle factors , 41 % ( 95 % CI ; 18%-58 % ) lower for those with three , and 44 % ( 95 % CI ; 12%-64 % ) lower for those with 4 or more healthy lifestyle factors . CONCLUSION Adherence to modifiable healthy lifestyle factors is associated with a lower risk of death among adult men with type 2 diabetes . Our study emphasizes the importance of educating individuals with diabetes to adhere to healthy lifestyle factors
target: The associations were largely consistent and significant among individuals from different socioeconomic background s and baseline characteristics .
  Conclusions /interpretationAdoption of a healthy lifestyle is associated with substantial risk reduction in type 2 diabetes and long-term adverse outcomes among diabetic individuals .
background: Aims /hypothesisA healthy lifestyle has been widely recommended for the prevention and management of type 2 diabetes .
  However , no systematic review has summarised the relationship between combined lifestyle factors ( including , but not limited to , smoking , alcohol drinking , physical activity , diet and being overweight or obese ) and  incident type 2 diabetes and risk of health outcomes among diabetic individuals .