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Healthy Lifestyle for Healthier Arteries in People With Type 2 Diabetes

Originally published of the American Heart Association. 2023;12:e030594

Although cardiovascular disease mortality among patients with type 2 diabetes (T2D) has declined substantially over the past few decades,1 vascular complications of diabetes continue to present a huge burden. Approximately one‐third of patients with T2D have cardiovascular disease, and these comorbidities incur an increased economic cost, doubling or tripling health care expenditures in this population.2 The American Heart Association emphasizes a focus on lifestyle modification as a critical component of reducing cardiovascular disease risk among people with T2D.3 More broadly, the American Heart Association's updated definition of ideal cardiovascular health (Life's Essential 8 [LE8]) has added sleep duration as an additional metric.4 Sleep is a critical and modifiable aspect of a healthy lifestyle, recognized alongside the other components of a nutritious diet, physical activity, not smoking, and maintaining a healthy body mass index, blood lipid levels, blood glucose, and blood pressure.

In this issue of the Journal of the American Heart Association (JAHA), He et al describe the results of an observational study investigating the association of a healthy lifestyle with risk of vascular disease among patients with T2D, secondary to both microvascular pathology (affecting the small arteries, venules, arterioles, and capillaries) and macrovascular complications (due to diseases affecting large arteries, principally secondary to atherosclerosis).5 The authors used a sample of 13 543 participants in the UK Biobank study, recruited between 2006 and 2010 from the general population of the United Kingdom. Adherence to a healthy lifestyle was measured using 6 risk factors (body mass index, smoking, alcohol use, physical activity, sleep duration, and diet), as well as the LE8 ideal cardiovascular health metric in a smaller subsample (n=9886). For both the 6‐factor combined healthy lifestyle measure as well as the LE8 cardiovascular health metric, following an ideal, healthy lifestyle at baseline substantially reduced risk of coronary heart disease, stroke, and heart failure (macrovascular disease) and retinopathy, peripheral neuropathy, and chronic kidney disease (microvascular disease).

The results support previous findings in patients with T2D, indicating a protective effect of ideal cardiovascular health to reduce the risk of coronary heart disease, stroke, and heart failure. The research extends our understanding of the effect of healthy lifestyle behaviors on microvascular disease, and the overall findings support the implementation of measures such as the LE8 ideal cardiovascular health score in clinical practice to promote primary prevention. Importantly, the authors note that sleep needs to be considered as a critical component of a healthy lifestyle, and that social determinants of health, such as socioeconomic deprivation, affect an individual's ability to optimize cardiovascular health. The study uses the Townsend deprivation index to account for material deprivation, assessing for unemployment, non–car ownership, non–home ownership, and household overcrowding.6 In the UK Biobank study, each participant is assigned a score corresponding to their postcode area, based on data output from the preceding national census. Vascular complications were more likely in participants with a greater score; however, the study demonstrates that adherence to a healthy lifestyle may partially ameliorate the effects of adverse socioeconomic factors.

The study by He et al comprehensively assesses the association between lifestyle factors and vascular complications across multiple organ systems but is notably lacking microvascular diseases of the central nervous system. Overlapping mechanisms, including inflammation, oxidative stress, endothelial dysfunction, arteriosclerosis, and hemostatic factors such as hypercoagulability and platelet activation, may link unhealthy lifestyle to the development of cerebral small vessel disease,7 covert brain infarction,8 enlarged perivascular spaces, or cerebral microbleeds secondary to cerebral amyloid angiopathy. Because of the interrelationship between diabetes, stroke, cerebral small vessel disease, cognitive impairment, and dementia, it will be critical to further study how promotion of healthy lifestyle factors, including the American Heart Association's LE8 metric, affects microvascular conditions of the brain. Such would be further evidence that what is good for the heart is good for the brain (and for the kidneys, retina, and peripheral nerves).


Dr. Aparicio is supported by an American Academy of Neurology Career Development Award.


*Correspondence to: Hugo J. Aparicio, MD, MPH, Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, 85 East Concord Street, Ground Floor, Boston, MA 02118. Email:

See Article by He et al.

This article was sent to Jose R. Romero, MD, Associate Editor, for editorial decision and final disposition.

For Disclosures, see page 2.


  • 1 Cheng YJ, Imperatore G, Geiss LS, Saydah SH, Albright AL, Ali MK, Gregg EW. Trends and disparities in cardiovascular mortality among U.S. adults with and without self‐reported diabetes, 1988–2015. Diabetes Care. 2018; 41:2306–2315. doi: 10.2337/dc18-0831CrossrefMedlineGoogle Scholar
  • 2 Einarson TR, Acs A, Ludwig C, Panton UH. Economic burden of cardiovascular disease in type 2 diabetes: a systematic review. Value Health. 2018; 21:881–890. doi: 10.1016/j.jval.2017.12.019CrossrefMedlineGoogle Scholar
  • 3 Joseph JJ, Deedwania P, Acharya T, Aguilar D, Bhatt DL, Chyun DA, Di Palo KE, Golden SH, Sperling LS. Comprehensive management of cardiovascular risk factors for adults with type 2 diabetes: a scientific statement from the American Heart Association. Circulation. 2022; 145:e722–e759. doi: 10.1161/cir.0000000000001040LinkGoogle Scholar
  • 4 Lloyd‐Jones DM, Allen NB, Anderson CAM, Black T, Brewer LC, Foraker RE, Grandner MA, Lavretsky H, Perak AM, Sharma G, et al. Life's Essential 8: updating and enhancing the American Heart Association's construct of cardiovascular health: a presidential advisory from the American Heart Association. Circulation. 2022; 146:e18–e43. doi: 10.1161/cir.0000000000001078LinkGoogle Scholar
  • 5 He P, Li H, Ye Z, Liu M, Zhou C, Wu Q, Zhang Y, Yang S, Zhang Y, Qin X. Association of a healthy lifestyle, Life's Essential 8 scores with incident macrovascular and microvascular disease among individuals with type 2 diabetes. J Am Heart Assoc. 2023; 12:e029441. doi: 10.1161/JAHA.122.029441LinkGoogle Scholar
  • 6 Townsend P, Phillimore P, Beattie A. Health and Deprivation. 1st ed.Routledge; 1988.Google Scholar
  • 7 Liu D, Cai X, Yang Y, Wang S, Yao D, Mei L, Jing J, Li S, Yan H, Meng X, et al. Associations of Life's Simple 7 with cerebral small vessel disease. Stroke. 2022; 53:2859–2867. doi: 10.1161/strokeaha.122.038838LinkGoogle Scholar
  • 8 Gardener H, Caunca M, Dong C, Cheung YK, Alperin N, Rundek T, Elkind MSV, Wright CB, Sacco RL. Ideal cardiovascular health and biomarkers of subclinical brain aging: the Northern Manhattan Study. J Am Heart Assoc. 2018; 7:e009544. doi: 10.1161/jaha.118.009544LinkGoogle Scholar


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