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Original Investigation
July 19, 2021

Association of Cycling With All-Cause and Cardiovascular Disease Mortality Among Persons With Diabetes: The European Prospective Investigation Into Cancer and Nutrition (EPIC) Study

Author Affiliations
  • 1Centre for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
  • 2University of Southern Denmark, Odense, Denmark
  • 3Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
  • 4Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
  • 5Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
  • 6Aarhus University, Aarhus, Denmark
  • 7German Cancer Research Center (DKFZ), Heidelberg, Germany
  • 8Danish Cancer Society, Copenhagen, Denmark
  • 9Imperial College London, London, England, United Kingdom
  • 10University of Ioannina School of Medicine, Ioannina, Greece
  • 11University of Oxford, Oxford, England, United Kingdom
  • 12University Naples Federico II, Naples, Italy
  • 13Prevention and Clinical Network (ISPRO), Florence, Italy
  • 14Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
  • 15International Agency for Research on Cancer, Lyon, France
  • 16German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
  • 17National Institute for Public Health and the Environment, Utrecht, the Netherlands
  • 18Utrecht University, Utrecht, the Netherlands
  • 19Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
  • 20Biomedical Research Institute of Murcia(IMIB-Arrixaca), Murcia, Spain
  • 21CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
  • 22University of Antioquia, Medellín, Colombia
  • 23Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
  • 24German Center for Diabetes Research (DZD), Neuherberg, Germany
  • 25Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany
  • 26Public Health Institute of Navarra, Navarra, Spain
  • 27Navarra Institute for Health Research, Navarra, Spain
  • 28Western Norway University of Applied Sciences, Bergen, Norway
  • 29University of Cambridge, Cambridge, England, United Kingdom
JAMA Intern Med. 2021;181(9):1196-1205. doi:10.1001/jamainternmed.2021.3836
Key Points

Question  Is cycling associated with risk of all-cause and cardiovascular disease mortality among persons with diabetes?

Findings  In this cohort study of 7459 persons with diabetes, cycling was associated with at least a 24% lower all-cause mortality rate when compared with noncyclists, independent of other physical activity and putative confounders. Taking up cycling over a 5-year period was associated with at least a 35% lower risk of all-cause mortality when compared with consistent noncyclists.

Meaning  Cycling could be encouraged as an activity for persons with diabetes to lower the risk of premature mortality.


Importance  Premature death from all causes and cardiovascular disease (CVD) causes is higher among persons with diabetes.

Objective  To investigate the association between time spent cycling and all-cause and CVD mortality among persons with diabetes, as well as to evaluate the association between change in time spent cycling and risk of all-cause and CVD mortality.

Design, Setting, and Participants  This prospective cohort study included 7459 adults with diabetes from the European Prospective Investigation into Cancer and Nutrition study. Questionnaires regarding medical history, sociodemographic, and lifestyle information were administered in 10 Western European countries from 1992 through 2000 (baseline examination) and at a second examination 5 years after baseline. A total of 5423 participants with diabetes completed both examinations. The final updated primary analysis was conducted on November 13, 2020.

Exposures  The primary exposure was self-reported time spent cycling per week at the baseline examination. The secondary exposure was change in cycling status from baseline to the second examination.

Main Outcomes and Measures  The primary and secondary outcomes were all-cause and CVD mortality, respectively, adjusted for other physical activity modalities, diabetes duration, and sociodemographic and lifestyle factors.

Results  Of the 7459 adults with diabetes included in the analysis, the mean (SD) age was 55.9 (7.7) years, and 3924 (52.6%) were female. During 110 944 person-years of follow-up, 1673 deaths from all causes were registered. Compared with the reference group of people who reported no cycling at baseline (0 min/wk), the multivariable-adjusted hazard ratios for all-cause mortality were 0.78 (95% CI, 0.61-0.99), 0.76 (95% CI, 0.65-0.88), 0.68 (95% CI, 0.57-0.82), and 0.76 (95% CI, 0.63-0.91) for cycling 1 to 59, 60 to 149, 150 to 299, and 300 or more min/wk, respectively. In an analysis of change in time spent cycling with 57 802 person-years of follow-up, a total of 975 deaths from all causes were recorded. Compared with people who reported no cycling at both examinations, the multivariable-adjusted hazard ratios for all-cause mortality were 0.90 (95% CI, 0.71-1.14) in those who cycled and then stopped, 0.65 (95% CI, 0.46-0.92) in initial noncyclists who started cycling, and 0.65 (95% CI, 0.53-0.80) for people who reported cycling at both examinations. Similar results were observed for CVD mortality.

Conclusion and Relevance  In this cohort study, cycling was associated with lower all-cause and CVD mortality risk among people with diabetes independent of practicing other types of physical activity. Participants who took up cycling between the baseline and second examination had a considerably lower risk of both all-cause and CVD mortality compared with consistent noncyclists.

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