OBJECTIVE: Combined low-risk lifestyle behaviors (LRLBs) have been associated with a reduction in type 2 diabetes risk. This relationship has not been systematically quantified. RESEARCH DESIGN AND METHODS: A systematic review and meta-analysis was conducted to assess the association of combined LRLBs with type 2 diabetes. Databases were searched up to September 2022. Prospective cohort studies reporting the association between a minimum of three combined LRLBs (including healthy diet) with incident type 2 diabetes were included. Independent reviewers extracted data and assessed study quality. Risk estimates of extreme comparisons were pooled using a random-effects model. Global dose-response meta-analysis (DRM) for maximum adherence was estimated using a one-stage linear mixed model. The certainty of the evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluations). RESULTS: Thirty cohort comparisons (n = 1,693,753) involving 75,669 incident type 2 diabetes cases were included. LRLBs, with author-defined ranges, were healthy body weight, healthy diet, regular exercise, smoking abstinence or cessation, and light alcohol consumption. LRLBs were associated with 80% lower risk of type 2 diabetes (relative risk [RR] 0.20; 95% CI 0.17-0.23), comparing the highest with lowest adherence. Global DRM for maximum adherence to all five LRLBs reached 85% protection (RR 0.15; 95% CI 0.12-0.18). The overall certainty of the evidence was graded as high. CONCLUSIONS: There is a very good indication that a combination of LRLBs that includes maintaining a healthy bodyweight, healthy diet, regular exercise, smoking abstinence or cessation, and light alcohol consumption is associated with a lower risk of incident type 2 diabetes.

Catholic University of Croatia School of Medicine Zagreb Croatia

CIBER Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos 3 Madrid Spain

Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto Ontario Canada

College of Pharmacy and Nutrition University of Saskatchewan Saskatoon Saskatchewan Canada

Department of Medicine Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada

Department of Nutritional Sciences Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada

Division of Endocrinology and Metabolism Department of Medicine St Michael's Hospital Toronto Ontario Canada

Human Nutrition Unit Biochemistry and Biotechnology Department Sant Joan University Hospital Institut d'Investigació Sanitària Pere Virgili Universitat Rovira i Virgili Reus Spain

Institute for Clinical and Experimental Medicine Diabetes Centre Prague Czech Republic

Institute of Public Health and Clinical Nutrition School of Medicine University of Eastern Finland Kuopio Finland

Josip Juraj Strossmayer University of Osijek School of Medicine Osijek Croatia

Li KaShing Knowledge Institute St Michael's Hospital Toronto Ontario Canada

Physicians Committee for Responsible Medicine Washington DC

Toronto 3D Knowledge Synthesis and Clinical Trials Unit St Michael's Hospital Toronto Ontario Canada

Vuk Vrhovac University Clinic for Diabetes Endocrinology and Metabolic Diseases Merkur University Hospital Zagreb Croatia

Zobrazit více v PubMed

Saeedi P, Petersohn I, Salpea P, et al. .; IDF Diabetes Atlas Committee . Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract 2019;157:107843. PubMed

Biggs ML, Mukamal KJ, Luchsinger JA, et al. . Association between adiposity in midlife and older age and risk of diabetes in older adults. JAMA 2010;303:2504–2512 PubMed PMC

Schienkiewitz A, Schulze MB, Hoffmann K, Kroke A, Boeing H. Body mass index history and risk of type 2 diabetes: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Am J Clin Nutr 2006;84:427–433 PubMed

Schwingshackl L, Missbach B, König J, Hoffmann G. Adherence to a Mediterranean diet and risk of diabetes: a systematic review and meta-analysis. Public Health Nutr 2015;18:1292–1299 PubMed PMC

Jannasch F, Kröger J, Schulze MB. Dietary patterns and type 2 diabetes: a systematic literature review and meta-analysis of prospective studies. J Nutr 2017;147:1174–1182 PubMed

Smith AD, Crippa A, Woodcock J, Brage S. Physical activity and incident type 2 diabetes mellitus: a systematic review and dose-response meta-analysis of prospective cohort studies. Diabetologia 2016;59:2527–2545 PubMed PMC

Pan A, Wang Y, Talaei M, Hu FB, Wu T. Relation of active, passive, and quitting smoking with incident type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2015;3:958–967 PubMed PMC

Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med 2009;169:1355–1362 PubMed

Long GH, Johansson I, Rolandsson O, et al. . Healthy behaviours and 10-year incidence of diabetes: a population cohort study. Prev Med 2015;71:121–127 PubMed

Lindström J, Peltonen M, Eriksson JG, et al. .; Finnish Diabetes Prevention Study (DPS) . Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia 2013;56:284–293 PubMed

Uusitupa M, Khan TA, Viguiliouk E, et al. . Prevention of type 2 diabetes by lifestyle changes: a systematic review and meta-analysis. Nutrients 2019;11:2611. PubMed PMC

Higgins JPT, Thomas J, Chandler J, et al. . Cochrane Handbook for Systematic Reviews of Interventions. 2nd ed. Chichester: John Wiley & Sons, 2019 PubMed

Stroup DF, Berlin JA, Morton SC, et al. . Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–2012 PubMed

Page MJ, McKenzie JE, Bossuyt PM, et al. . The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 2021;10:89. PubMed PMC

Wells GA, Shea B, O’Connell D, et al. . The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa, The Ottawa Hospital Research Institute, 2000

Zhang Y, Huang L, Wang D, Ren P, Hong Q, Kang D. The ROBINS-I and the NOS had similar reliability but differed in applicability: a random sampling observational studies of systematic reviews/meta-analysis. J Evid Based Med 2021;14:112–122 PubMed

Semnani-Azad Z, Khan TA, Blanco Mejia S, et al. . Association of major food sources of fructose-containing sugars with incident metabolic syndrome: a systematic review and meta-analysis. JAMA Netw Open 2020;3:e209993. PubMed PMC

Lin X, Xu Y, Pan X, et al. . Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Sci Rep 2020;10:14790. PubMed PMC

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177–188 PubMed

Guyatt GH, Oxman AD, Kunz R, et al. .; GRADE Working Group . GRADE guidelines: 7. Rating the quality of evidence--inconsistency. J Clin Epidemiol 2011;64:1294–1302 PubMed

Higgins J, Jackson D, Barrett J, Lu G, Ades A, White IR. Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies. Res Synth Methods 2012;3:98–110 PubMed PMC

Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011;342:d549. PubMed

IntHout J, Ioannidis JP, Rovers MM, Goeman JJ. Plea for routinely presenting prediction intervals in meta-analysis. BMJ Open 2016;6:e010247 PubMed PMC

Higgins J, Thomas J. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3, 2022. Accessed 24 October 2022. Available from https://training.cochrane.org/handbook/current PubMed

Sutton AJ, Higgins JP. Recent developments in meta-analysis. Stat Med 2008;27:625–650 PubMed

VanderWeele TJ, Ding P. Sensitivity analysis in observational research: introducing the E-value. Ann Intern Med 2017;167:268–274 PubMed

Crippa A, Discacciati A, Bottai M, Spiegelman D, Orsini N. One-stage dose-response meta-analysis for aggregated data. Stat Methods Med Res 2019;28:1579–1596 PubMed

Orsini N. Weighted mixed-effects dose–response models for tables of correlated contrasts. Stata J 2021;21:320–347

Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50:1088–1101 PubMed

Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629–634 PubMed PMC

Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000;56:455–463 PubMed

Guyatt G, Oxman AD, Akl EA, et al. . GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64:383–394 PubMed

Schünemann HJ, Higgins JP, Vist GE, et al. .; Cochrane GRADEing Methods Group and the Cochrane Statistical Methods Group . Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In Cochrane Handbook for Systematic Reviews of Interventions. London, Cochrane Collaboration, 2019, pp. 375–402

Tuomilehto J, Wang Y, Hu G, Jousilahti P. Poster Sessions: Avoidance of type 2 diabetes (T2D) depends on adherence with multiple concomitant healthy lifestyle traits: a prospective real-life population-based observation in Finland. J Diabetes 2013;5:52

Rajaobelina K, Dow C, Romana Mancini F, et al. . Population attributable fractions of the main type 2 diabetes mellitus risk factors in women: findings from the French E3N cohort. J Diabetes 2019;11:242–253 PubMed

Lv J, Yu C, Guo Y, et al. .; China Kadoorie Biobank Collaborative Group . Adherence to a healthy lifestyle and the risk of type 2 diabetes in Chinese adults. Int J Epidemiol 2017;46:1410–1420 PubMed PMC

Djoussé L, Driver JA, Gaziano JM, Buring JE, Lee IM. Association between modifiable lifestyle factors and residual lifetime risk of diabetes. Nutr Metab Cardiovasc Dis 2013;23:17–22 PubMed PMC

Li Y, Ley SH, Tobias DK, et al. . Birth weight and later life adherence to unhealthy lifestyles in predicting type 2 diabetes: prospective cohort study. BMJ 2015;351:h3672. PubMed PMC

Joosten MM, Grobbee DE, van der A DL, Verschuren WM, Hendriks HF, Beulens JW. Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Am J Clin Nutr 2010;91:1777–1783 PubMed

Reis JP, Loria CM, Sorlie PD, Park Y, Hollenbeck A, Schatzkin A. Lifestyle factors and risk for new-onset diabetes: a population-based cohort study. Ann Intern Med 2011;155:292–299 PubMed PMC

Mozaffarian D, Kamineni A, Carnethon M, Djoussé L, Mukamal KJ, Siscovick D. Lifestyle risk factors and new-onset diabetes mellitus in older adults: the cardiovascular health study. Arch Intern Med 2009;169:798–807 PubMed PMC

Dow C, Balkau B, Bonnet F, et al. . Strong adherence to dietary and lifestyle recommendations is associated with decreased type 2 diabetes risk in the AusDiab cohort study. Prev Med 2019;123:208–216 PubMed

Steinbrecher A, Morimoto Y, Heak S, et al. . The preventable proportion of type 2 diabetes by ethnicity: the multiethnic cohort. Ann Epidemiol 2011;21:526–535 PubMed PMC

Simmons RK, Harding A-H, Jakes RW, Welch A, Wareham NJ, Griffin SJ. How much might achievement of diabetes prevention behaviour goals reduce the incidence of diabetes if implemented at the population level? Diabetologia 2006;49:905–911 PubMed

Han X, Wei Y, Hu H, et al. . Genetic risk, a healthy lifestyle, and type 2 diabetes: the Dongfeng-Tongji Cohort Study. J Clin Endocrinol Metab 2020;105:dgz325. PubMed

Li Y, Schoufour J, Wang DD, et al. . Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study. BMJ 2020;368:l6669. PubMed PMC

Shen QM, Li HL, Li ZY, et al. . Joint impact of BMI, physical activity and diet on type 2 diabetes: Findings from two population-based cohorts in China. Diabet Med 2022;39:e14762. PubMed

Delgado-Velandia M, Gonzalez-Marrachelli V, Domingo-Relloso A, et al. . Healthy lifestyle, metabolomics and incident type 2 diabetes in a population-based cohort from Spain. Int J Behav Nutr Phys Act 2022;19:8. PubMed PMC

Wang W, Lv J, Yu C, et al. .; China Kadoorie Biobank Collaborative Group . Lifestyle factors and fetal and childhood origins of type 2 diabetes: a prospective study of Chinese and European adults. Am J Clin Nutr 2022;115:749–758 PubMed

Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280:1690–1691 PubMed

Shor E, Roelfs D, Vang ZM. The “Hispanic mortality paradox” revisited: meta-analysis and meta-regression of life-course differentials in Latin American and Caribbean immigrants’ mortality. Soc Sci Med 2017;186:20–33 PubMed

Miettinen OS. Proportion of disease caused or prevented by a given exposure, trait or intervention. Am J Epidemiol 1974;99:325–332 PubMed

Zhang Y, Pan XF, Chen J, et al. . Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies. Diabetologia 2020;63:21–33 PubMed

Schlesinger S, Neuenschwander M, Ballon A, Nöthlings U, Barbaresko J. Adherence to healthy lifestyles and incidence of diabetes and mortality among individuals with diabetes: a systematic review and meta-analysis of prospective studies. J Epidemiol Community Health 2020;74:481–487 PubMed

Tuomilehto J, Lindström J, Eriksson JG, et al. .; Finnish Diabetes Prevention Study Group . Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343–1350 PubMed

Lindström J, Peltonen M, Eriksson JG, et al. . High-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish Diabetes Prevention Study. Diabetologia 2006;49:912–920 PubMed

Penn L, White M, Lindström J, et al. . Importance of weight loss maintenance and risk prediction in the prevention of type 2 diabetes: analysis of European Diabetes Prevention Study RCT. PLoS One 2013;8:e57143. PubMed PMC

Knowler WC, Barrett-Connor E, Fowler SE, et al. .; Diabetes Prevention Program Research Group . Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403 PubMed PMC

Kodama S, Horikawa C, Fujihara K, et al. . Comparisons of the strength of associations with future type 2 diabetes risk among anthropometric obesity indicators, including waist-to-height ratio: a meta-analysis. Am J Epidemiol 2012;176:959–969 PubMed

Lean ME, Leslie WS, Barnes AC, et al. . Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 2018;391:541–551 PubMed

Salas-Salvadó J, Guasch-Ferré M, Lee C-H, Estruch R, Clish CB, Ros E. Protective effects of the Mediterranean diet on type 2 diabetes and metabolic syndrome. J Nutr 2015;146:920S–927S PubMed PMC

Aune D, Norat T, Leitzmann M, Tonstad S, Vatten LJ. Physical activity and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis. Eur J Epidemiol 2015;30:529–542 PubMed

Knott C, Bell S, Britton A. Alcohol consumption and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis of more than 1.9 million individuals from 38 observational studies. Diabetes Care 2015;38:1804–1812 PubMed

Li X-H, Yu FF, Zhou YH, He J. Association between alcohol consumption and the risk of incident type 2 diabetes: a systematic review and dose-response meta-analysis. Am J Clin Nutr 2016;103:818–829 PubMed

Holst C, Becker U, Jørgensen ME, Grønbæk M, Tolstrup JS. Alcohol drinking patterns and risk of diabetes: a cohort study of 70,551 men and women from the general Danish population. Diabetologia 2017;60:1941–1950 PubMed

Fernández-Solà J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. Nat Rev Cardiol 2015;12:576–587 PubMed

Holmes MV, Asselbergs FW, Palmer TM, et al. .; UCLEB consortium . Mendelian randomization of blood lipids for coronary heart disease. Eur Heart J 2015;36:539–550 PubMed PMC

Chiavaroli L, Viguiliouk E, Nishi SK, et al. . DASH dietary pattern and cardiometabolic outcomes: an umbrella review of systematic reviews and meta-analyses. Nutrients 2019;11:338. PubMed PMC

Cespedes EM, Hu FB. Dietary prevention of obesity and cardiometabolic disease. Nat Rev Endocrinol 2015;11:448–449 PubMed PMC

Wang Y, Xu D. Effects of aerobic exercise on lipids and lipoproteins. Lipids Health Dis 2017;16:132. PubMed PMC

Palmefors H, DuttaRoy S, Rundqvist B, Börjesson M. The effect of physical activity or exercise on key biomarkers in atherosclerosis–a systematic review. Atherosclerosis 2014;235:150–161 PubMed

Snowling NJ, Hopkins WG. Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes Care 2006;29:2518–2527 PubMed

Vina J, Sanchis-Gomar F, Martinez-Bello V, Gomez-Cabrera MC. Exercise acts as a drug; the pharmacological benefits of exercise. Br J Pharmacol 2012;167:1–12 PubMed PMC

Colberg SR, Sigal RJ, Yardley JE, et al. . Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2065–2079 PubMed PMC

Chang SA. Smoking and type 2 diabetes mellitus. Diabetes Metab J 2012;36:399–403 PubMed PMC

Yeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Ann Intern Med 2010;152:10–17 PubMed PMC

Griswold MG, Fullman N, Hawley C, et al. .; GBD 2016 Alcohol Collaborators . Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2018;392:1015–1035 PubMed PMC

Marlatt GA, Witkiewitz K. Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addict Behav 2002;27:867–886 PubMed

Nutt DJ, Rehm J. Doing it by numbers: a simple approach to reducing the harms of alcohol. J Psychopharmacol 2014;28:3–7 PubMed

Rücker G, Schwarzer G, Carpenter JR, Schumacher M. Undue reliance on I(2) in assessing heterogeneity may mislead. BMC Med Res Methodol 2008;8:79. PubMed PMC

Haneuse S, VanderWeele TJ, Arterburn D. Using the E-value to assess the potential effect of unmeasured confounding in observational studies. JAMA 2019;321:602–603 PubMed

Shan Z, Ma H, Xie M, et al. . Sleep duration and risk of type 2 diabetes: a meta-analysis of prospective studies. Diabetes Care 2015;38:529–537 PubMed

D’Aiuto F, Gkranias N, Bhowruth D, et al. .; TASTE Group . Systemic effects of periodontitis treatment in patients with type 2 diabetes: a 12 month, single-centre, investigator-masked, randomised trial. Lancet Diabetes Endocrinol 2018;6:954–965 PubMed

White J, Greene G, Kivimaki M, Batty GD. Association between changes in lifestyle and all-cause mortality: the Health and Lifestyle Survey. J Epidemiol Community Health 2018;72:711–714 PubMed

Möller H, Dherani M, Harwood C, Kinsella T, Pope D. Health planning for the future: comparative risk assessment of five major lifestyle risk factors: evidence from the Wirral, UK. J Public Health (Oxf) 2012;34:430–437 PubMed

Truthmann J, Busch MA, Scheidt-Nave C, et al. . Modifiable cardiovascular risk factors in adults aged 40-79 years in Germany with and without prior coronary heart disease or stroke. BMC Public Health 2015;15:701. PubMed PMC

Wirth T, Kozak A, Schedlbauer G, Nienhaus A. Health behaviour, health status and occupational prospects of apprentice nurses and kindergarten teachers in Germany: a cross-sectional study. J Occup Med Toxicol 2016;11:26. PubMed PMC

Kotseva K, Wood D, De Bacquer D, et al. .; EUROASPIRE Investigators . EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol 2016;23:636–648 PubMed

De Cocker K, Ottevaere C, Sjöström M, et al. .; HELENA Study Group . Self-reported physical activity in European adolescents: results from the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) study. Public Health Nutr 2011;14:246–254 PubMed

Moreno LA, Gottrand F, Huybrechts I, Ruiz JR, González-Gross M; HELENA Study Group . Nutrition and lifestyle in european adolescents: the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) study. Adv Nutr 2014;5:615S–623S PubMed PMC

Johnson SS, Paiva AL, Cummins CO, et al. . Transtheoretical model-based multiple behavior intervention for weight management: effectiveness on a population basis. Prev Med 2008;46:238–246 PubMed PMC