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Exercise can reduce the risk of cardiovascular disease in people with type 2 diabetes

An article from the e-journal of the ESC Council for Cardiology Practice

Regular physical activity can reduce risk of cardiovascular mortality among patients with type 2 diabetes whether or not they have other known cardiovascular risk factors. Thus, the American Diabetes Association, the National Cholesterol Education Program Export Panel and the International Diabetes Federation (European Region) have recommended physical activity for the primary and second prevention of cardiovascular complications among patients with type 2 diabetes (1-3).


 There is good evidence that regular physical activity reduces the risk of cardiovascular disease in the general population (4, 5).
Recently, several studies have assessed the association between physical activity or physical fitness and the risk of cardiovascular mortality among patients with type 2 diabetes (6-12).

The results from the Aerobic Center Longitudinal Study (6), the Nurses’ Health Study (7), the Whitehall Study (8), the National Health Interview Survey (9), and the Health Professionals’ Follow-up Study (10) have indicated that regular leisure-time physical activity is associated with reduced cardiovascular and total mortality among patients with diabetes or impaired glucose tolerance. Walking has a similar inverse association with the risk of cardiovascular and total mortality to that of vigorous leisure-time physical activity (7-10).
In the Aerobic Center Longitudinal Study, physical fitness had a strong and independent inverse association with total mortality in men with diabetes, and this association was seen in all body mass index and body fatness group (6, 11).

The analyses from the FINMONICA study also evaluated whether other types of physical activities, such as occupational and daily commuting physical activity on foot or by bicycle, are related to reduced cardiovascular mortality among diabetic patients (12).
We reviewed data on 3316 patients aged 25 to 74 with history of type 2 diabetes who participated in surveys of randomly selected samples from the Finnish population conducted between 1972 and 1997. The data included questionnaires on the level of physical activity on the job; on the way to and from work; and during their leisure time.
During an average follow-up of 18.4 years, 1410 of the subjects died, 903 (64%) from cardiovascular disease. After adjusting for age, gender, body mass index, systolic blood pressure, total cholesterol, smoking and the other two categories of physical activity, we found that moderately active work was associated with a 9% reduction in cardiovascular mortality and active work was associated with a 40% reduction (Table).
High level of leisure-time physical activity was associated with a 33% drop and moderate activity was linked to a 17% drop in cardiovascular mortality compared with the most sedentary group. Daily walking or cycling to and from work decreased cardiovascular mortality, but this relation was no longer significant after additional adjustment for occupational and leisure-time physical activity.

We further merged and regrouped these three types of physical activity into three categories: low was defined as subjects who reported light levels of occupational, commuting (<1 minute) and leisure-time physical activity; moderate was defined as subjects who reported only one of the all three types of moderate to high physical activity; high was defined as subjects who reported two or three types of moderate to high physical activity.
We found that those who were moderately active reduced their risk of dying from cardiovascular disease by 39 percent, while those who were highly active reduced the risk by 48 percent (13). The protective benefits of physical activity were consistent regardless of body mass index, blood pressure or cholesterol levels or whether or not the person smoked (13).



Deaths, n



Hazard ratios

Model 1

(95% CIs)*

Model 2

Occupation physical activity         
Light 517 25549 1.00 1.00
Moderate 161 13216 0.84 (0.70-1.01) 0.91 (0.75-1.10)
Active 225 22305 0.59 (0.50-0.69) 0.60 (0.50-0.71)
P for trend      <0.001  <0.001
Walking or cycling to and from work        
0 minute 609 33530 1.00 1.00
1-29 minutes 165 15581 0.81 (0.67-0.96) 0.89 (0.75-1.07)
> or equal to 30 minutes 129 11959 0.74 (0.61-0.90) 0.86 (0.70-1.06)
P for trend      0.002 0.27
Leisure-time physical activity         
Low 480 27974 1.00 1.00
Moderate  381 28072 0.85 (0.74-0.98) 0.83 (0.72-0.95)
High 42 5024 0.70 (0.51-0.96) 0.67 (0.49-0.93)
P for trend     0.016 0.005

*Model 1: adjusted for age, sex, study year, body mass index, systolic blood pressure, cholesterol and smoking; model 2, adjusted also for other two physical activity;

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


1. National Institute of Health. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). Jama 2001;285:2486-97.
2. American Diabetes Association. Physical activity/exercise and diabetes mellitus. Diabetes Care 2003;26:S73-77.
3. Working Party of the international Diabetes Federation (European Region). Hypertension in people with Type 2 diabetes: knowledge-based diabetes-specific guidelines. Diabet Med 2003;20:972-87.
4. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Jama 1995;273:402-7.
5. Wannamethee SG, Shaper AG. Physical activity in the prevention of cardiovascular disease: an epidemiological perspective. Sports Med 2001;31:101-14.
6. Wei M, Gibbons LW, Kampert JB, Nichaman MZ, Blair SN. Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. Ann Intern Med 2000;132:605-11.
7. Hu FB, Stampfer MJ, Solomon C, et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med 2001;134:96-105.
8. Batty GD, Shipley MJ, Marmot M, Smith GD. Physical activity and cause-specific mortality in men with Type 2 diabetes/impaired glucose tolerance: evidence from the Whitehall study. Diabet Med 2002;19:580-8.
9. Gregg EW, Gerzoff RB, Caspersen CJ, Williamson DF, Narayan KM. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med 2003;163:1440-7.
10. Tanasescu M, Leitzmann MF, Rimm EB, Hu FB. Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation 2003;107:2435-9.
11. Church TS, Cheng YJ, Earnest CP, et al. Exercise capacity and body composition as predictors of mortality among men with diabetes. Diabetes Care 2004;27:83-8.
12. Hu G, Eriksson J, Barengo NC, et al. Occupational, commuting, and leisure-time physical activity in relation to total and cardiovascular mortality among Finnish subjects with type 2 diabetes. Circulation 2004;110:666-73.
13. Hu G, Jousilahti P, Barengo NC, Qiao Q, Lakka TA, Tuomilehto J. Physical activity, cardiovascular risk factors, and mortality among finnish adults with diabetes. Diabetes Care 2005;28:799-805.


Vol3 N°31

Notes to editor

Gang Hu, MD, MPH, PhD, Senior Researcher
Pekka Jousilahti, MD, MSc, PhD, Professor
Jaakko Tuomilehto, MD, MPolSc, PhD, Professor

Department of Epidemiology and Health Promotion
National Public Health Institute
Department of Public Health
University of Helsinki

Mannerheimintie 166
00300 Helsinki, Finland

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.