Association of cardiovascular health with diabetic complications, all-cause mortality, and life expectancy among people with type 2 diabetes

Abstract

Background: We aimed to assess the impact of healthy cardiovascular health (CVH) on diabetic complications, mortality, and life expectancy among people with type 2 diabetes and to explore whether inflammation marker mediate these associations.

Methods: This prospective cohort study included 33,236 participants (aged 40-72) with type 2 diabetes from the UK Biobank with annual follow-up from 2006 to 2010 to 2020. Type 2 diabetes was ascertained from self-report, glycated hemoglobin ≥ 6.5%, hospital inpatient registry, or glucose-lowering medication use. Information on mortality was derived from the national death registry. Favorable CVH metrics consisted of non-smoker, regular physical activity, a healthy diet, non-overweight, untreated resting blood pressure < 120/<80 mm Hg, and untreated total cholesterol < 200 mg/dL. Participants were categorized into three groups according to the number of favorable CVH metrics: unfavorable (0 or 1); intermediate (any 2 or 3); and favorable (4 or more). Inflammation marker, as measured by C-reactive protein (CRP), was assessed at baseline and categorized as low (≤ 3 mg/L) and high (> 3 mg/L). Data were analyzed using Cox regression models, flexible parametric survival models, and mediation models.

Results: During the follow-up (median: 11.7 years), 3133 (9.4%) cases of diabetes complications and 4701 (14.1%) deaths occurred. Compared to unfavorable CVH, favorable CVH was associated with a reduced risk of diabetes complications (HR, 0.35; 95% CI, 0.26-0.47) and all-cause mortality (HR, 0.53; 95% CI, 0.43-0.65). In participants with unfavorable CVH, life expectancy at age 45 had a significantly reduction of 7.20 (95% CI, 5.48-8.92) years compared to those with a favorable CVH. Among people with type 2 diabetes, the proportions of diabetes complications and all-cause mortality that would be reduced by promoting the favorable CVH was 61.5% and 39.1%, respectively. CRP level mediated 14.3% and 29.7% of the associations between CVH and diabetic complication and all-cause mortality, respectively.

Conclusion: A favorable CVH was associated with lower risk of diabetes complications and mortality risk, and was associated with a longer life expectancy among people with type 2 diabetes. This association may be in part accounted for by inflammatory processes. Our findings highlight the importance of favorable CVH for the prevention of diabetic complications and all-cause mortality among people with type 2 diabetes, and underscores the need to monitor inflammation among people with unfavorable CVH.

Keywords: Cardiovascular health; Diabetic complications; Inflammation marker; Life expectancy; Mortality; Type 2 diabetes.

Fig. 1

Years of life expectancy lost by cardiovascular health (CVH) metrics among people with type 2 diabetes. A Years of life lost were estimated as the difference in residual life expectancy between participants with intermediate CVH and participants with unfavorable CVH; B Box plots of the distributions of years of life expectancy lost by intermediate and unfavorable CVH. Model was adjusted for sex, age, education level, socioeconomic status, ethnicity background, alcohol consumption, sugar-sweetened beverages, family history of diabetes, triglyceride, serum creatinine, and C-reactive protein

Fig. 2

Mediation analysis of inflammation marker, as measured by C-reactive protein level, on the associations of cardiovascular health (CVH) metrics with diabetic complications A and all-cause mortality (B). The mediation analyses were adjusted for sex, age, education level, socioeconomic status, ethnicity background, alcohol consumption, sugar-sweetened beverages, family history of diabetes, triglyceride, serum creatinine. ^*P < 0.05