Physical Activity, Cardiovascular Risk Factors, and Mortality Among Finnish Adults With Diabetes GANG HU, MD, PHD 1,2 PEKKA JOUSILAHTI, MD, PHD 1,2 NO¨ EL C. BARENGO, MD, MPH 3 QING QIAO, MD, PHD 1,2 TIMO A. LAKKA, MD, PHD 4,5 JAAKKO TUOMILEHTO, MD, PHD 1,2 OBJECTIVE — The aim of this study was to examine both single and joint associations of physical activity and conventional cardiovascular risk factors with total and cardiovascular mortality among patients with diabetes. RESEARCH DESIGN AND METHODS — We prospectively followed 3,708 Finnish patients with type 2 diabetes aged 25–74 years. Physical activity, smoking status, blood pressure, height, weight, and serum cholesterol level were determined at baseline. Cox proportional hazard models were used to estimate single and joint effects of physical activity and other cardiovascular risk factors on the risk of mortality. RESULTS — During a mean follow-up of 18.7 years, 1,423 deaths were recorded, 906 of which were due to cardiovascular disease. Moderate or high levels of physical activity were associated with decreased total and cardiovascular mortality, whereas higher levels of BMI and blood pressure and current smoking were associated with increased total and cardiovascular mortality. High serum cholesterol levels also increased cardiovascular mortality. The protective effect of physical activity was consistent in diabetic patients with any levels of BMI, blood pressure, total cholesterol, and smoking. CONCLUSIONS — A moderate or high level of physical activity was associated with a reduced risk of total and cardiovascular mortality among patients with type 2 diabetes. The favorable association of physical activity with longevity was observed regardless of the levels of BMI, blood pressure, total cholesterol, and smoking. Diabetes Care 28:799 – 805, 2005 T ype 2 diabetes is one of the fastest growing public health problems in both developed and developing countries. It is estimated that the number of diabetic people in the world will dou- ble from 171 million in 2000 to 366 mil- lion in 2030 (1). Cardiovascular disease (CVD) accounts for 75% of total mor- tality among patients with type 2 diabetes (2). Obesity, hypertension, and dyslipi- demia not only are very common in pa- tients with diabetes but also exacerbate all of the vascular complications of diabetes (3–7). Several studies have indicated that high leisure-time physical activity is asso- ciated with reduced total and CVD mor- tality among patients with diabetes or impaired glucose tolerance (8 –13). How- ever, no previous studies have examined the joint association of physical activity and all conventional CVD risk factors, in- cluding obesity, blood pressure, serum cholesterol level, and smoking, with CVD or total mortality among patients with di- abetes. The aim of this study was to ex- amine both single and joint associations of physical activity, BMI, blood pressure, serum total cholesterol level, and smok- ing with total and CVD mortality among Finnish patients with type 2 diabetes par- ticipating in population-based surveys. RESEARCH DESIGN AND METHODS — Six independent cross- sectional population surveys were per- formed in the Kuopio and North Karelia provinces in eastern Finland in 1972, 1977, 1982, 1987, 1992, and 1997 (14). The survey was expanded to the Turku- Loimaa region in southwestern Finland in 1982, the Helsinki capital area in 1992, and the northern province of Oulu in 1997. In 1972 and 1977, a randomly se- lected sample (6.6%) of the population born between 1913 and 1947 was drawn. Since 1982, the sample was stratified by area, sex, and 10-year age-group accord- ing to the World Health Organization MONICA (Monitoring Trends and Deter- minants in Cardiovascular Disease) pro- tocol (15). In the six surveys, the subjects included were 25– 64 years of age, and in the 1997 survey, subjects between 65 and 74 years of age were also included. Sub- jects who participated in more than one survey were included only in the first sur- vey cohort. The total sample size of the six surveys was 53,166. The participation rate varied by year from 74 to 88% (14). These surveys were conducted according to the ethical rules of the National Public Health Institute, and the investigations were carried out in accordance with the Declaration of Helsinki. Patients who participated in any of ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Department of Epidemiology and Health Promotion, National Public Health Institute, Helsinki, Finland; the 2 Department of Public Health, University of Helsinki, Helsinki, Finland; the 3 Department of Public Health and General Practice, University of Kuopio, Kuopio, Finland; the 4 Department of Physiology, University of Kuopio, Kuopio, Finland; and the 5 Kuopio Research Institute of Exercise Medicine, Kuopio, Finland. Address correspondence and reprint requests to Dr. Gang Hu, Diabetes and Genetic Epidemiology Unit, Department of Epidemiology and Health Promotion, National Public Health Institute, Mannerheimintie 166, FIN-00300 Helsinki, Finland. E-mail: hu.gang@ktl.fi. Received for publication 27 September 2004 and accepted in revised form 31 December 2004. Abbreviations: CHD, coronary heart disease; CVD, cardiovascular disease. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2005 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E DIABETES CARE, VOLUME 28, NUMBER 4, APRIL 2005 799