| ObjectivesWith the rapid increase of prevalence,diabetes has become the major cause of premature illness and deaths worldwide.This study analyzed the diabetes mortality in Jiangsu Province from 2013 to 2017 in order to understand the characteristics of diabetes deaths and mortality trends.Meanwhile,prospective follow-up data of 20053community-based type 2 diabetic patients in Jiangsu Province were used to explore the associations and dose-response relationships of physical activity,sedentary behavior and sleep duration with the risk of all-cause and cause specific mortality,which will provide scientific basis for the prevention and treatment of type 2 diabetes in the community.Methods1.Deaths primarily due to diabetes were retrieved from the Death Registration and Reporting System of Jiangsu Province from January 1st,2013 to December 31st,2017.The age standardized mortality was calculated using the 2010 national census data.Data were collated and analyzed using Excel and SPSS online version software to calculate crude mortality and age standardized rate,the chi-squared(χ~2)test was used to examine the difference in mortality rate,the estimated annual change percentage(EAPC)was used to assess the annual change trend of diabetes mortality.2.A total of 20,053 type 2 diabetic patients who were included in National Basic Public Health Service in Changshu County of Suzhou city,Qinghe District and Huai’an District in Huai’an City of Jiangsu Province were recruited as participants,and 17,666 subjects with complete physical activity data were followed.Diabetes mortality data from January 1,2014 to June 30,2018 were obtained by matching with Death Registration and Reporting System of Jiangsu Province.Cox proportional hazards regression models and restricted cubic spline model were employed to estimate the association and dose-response relationship between physical activity and all-cause as well as cause specific mortality in patients with type 2 diabetes.3.After excluding those who had missing values for sedentary behavior,sleep duration and other study variables,a total of 18,202 eligible subjects were included in the analysis.Cox proportional hazards regression models and restricted cubic spline model were employed to estimate the association and dose-response relationship of sedentary behavior and sleep duration with all-cause and cause specific mortality in patients with type 2 diabetes.Results1.From 2013 to 2017,a total of 61,554(male:25,785 and female:35,769)cases died from diabetes in Jiangsu Province,the annual average mortality was16.36/100,000(male:13.57/100,000 and female:19.22/100,000).The annual average mortality of diabetes among urban residents was 14.60/100,000(male:18.06/100 000and female:19.32/100,000),and was 15.93/100,000(male:12.86/100,000 and female:19.10/100,000)among rural residents.Mortality of female was significant higher than that of male from 2013 to 2017.Crude death rates of diabetes were found increased significantly in total residents(EAPC=6.66%,P<0.01),male(EAPC=7.48%,P=0.02),female(EAPC=6.00%,P<0.001)and urban residents(EAPC=7.05%,P=0.03)during the study period.2.Among 77,644.75 person-years of the fo1low-up,the median of follow-up time was 4 years,and 1,282 deaths occurred during the follow-up period(male:634and female:648),with a death density of 16.50/1000 person-years.Among them,396deaths were from cardiovascular disease(CVD),385 deaths from cancer.Compared to patients with physical activity<2 h/d,physical activity≥12 MET-h/d was associated with 44%reduced all-cause mortality(HR=0.56,95%CI:0.48-0.65),43%reduced CVD mortality(HR=0.57,95%CI:0.43-0.76)and 40%reduced cancer mortality(HR=0.60,95%CI:0.47-0.78).We also found different types and strength of physical activity can decrease the risk of mortality in type 2 diabetes patients.An apparent non-linear association of physical activity with all-cause(Non-linear test,c~2=45.58,P>0.05),CVD(Non-linear test,c~2=11.47,P=0.003)and cancer mortality(Non-linear test,c~2=11.00,P=0.007)was observed.The HRs between physical activity and mortality showed a J-shape,which suggesting that low levels of physical activity can also reduce the risk of mortality in patients with type 2 diabetes.3.Among 76,806.33 person-years of the fo1low-up,the median of follow-up time was 4 years,and 1,260 deaths occurred during the follow-up period(males:627and females:633),with a death density of 16.40/1000 person-years.Among them,392deaths were from CVD,382 deaths from cancer.Compared to patients with sedentary behavior≤2 h/d,the adjusted hazard ratio of all-cause mortality associated with sedentary behavior levels of 3-4,5-6 and≥7 h/d was 1.06(95%CI:0.92-1.21),1.18(95%CI:1.01-1.39)and 1.41(95%CI:1.19-1.68),respectively.A 1-h/day increase in sedentary behavior was associated with 4%increased hazard both for all-cause and CVD mortality However,no significant association between sedentary behavior and cancer mortality was found.The results of restrictive cubic spline analysis showed that the continuous change of sedentary behavior had a linear dose-response relationship with all-cause mortality(Non-linear test,c~2=0.67,P=0.714)and CVD mortality(Non-linear test,c~2=0.95,P=0.622).Compared to patients with sleep duration of 7 h/d,the adjusted hazard ratio of all-cause mortality associated with sleep duration levels of≤6,8,9 and≥10h/d was1.13(95%CI:0.94-1.34),1.13(95%CI:0.94-1.32),1.24(95%CI:0.99-1.54),and 1.54(95%CI:1.24-1.84),respectively.A 1-h/day increase in sleep duration among patients which sleep duration level≥7 h/d was associated with 6%increased hazard of all-cause mortality(HR=1.06,95%CI:1.03-1.09)and 11%of cancer death(HR=1.11,95%CI:1.05-1.18).However,no significant association between sleep duration and CVD mortality was found.The results of restrictive cubic spline analysis showed that the continuous change of sedentary behavior had a non-linear dose-response relationship with all-cause mortality(Non-linear test,c~2=7.55,P=0.023).Longer sleep duration(≥10 h/d)was positively associated with all-cause mortality,however,no significant association between shorter sleep duration and all-cause mortality was found.Conclusions1.In recent years,an increasing trend of diabetes mortality in Jiangsu Province was observed.Community-based prevention and treatment measures should be taken to strengthen behavioral intervention and management of diabetic patients to reduce population diabetes mortality.2.Physical activity is an independent factor in reducing all-cause,CVD and cancer mortality in type 2 diabetic patients.We found different types and strength physical activity can reduce the risk of mortality in type 2 diabetes patients.Given high burden of mortality and low level of physical activity in type 2 diabetes in China,increasing physical activity level should be an essential component for preventing deaths among type 2 diabetic patients.3.Sedentary behavior and sleep duration are independent factors of mortality in type2 diabetic patients.Longer sedentary behavior and sleep duration was associated with increasing all-cause,CVD and cancer mortality in type 2 diabetic patients.Lifestyle interventions should be strengthened to reduce risk of mortality in type 2 diabetic patients,including improving physical activity levels,reducing sedentary behavior and keeping good sleep habits. |
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