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

Mathias Ried-Larsen, PhD1,2Martin Gillies Rasmussen, PhD2Kim Blond, MSc3; et alThure F. Overvad, PhD4,5Kim Overvad, PhD4,6Karen Steindorf, PhD7Verena Katzke, PhD7Julie L. M. Andersen, MSc8Kristina E. N. Petersen, MSc8Dagfinn Aune, PhD9Kostas K. Tsilidis, PhD9,10Alicia K. Heath, PhD9Keren Papier, PhD11Salvatore Panico, PhD12Giovanna Masala, PhD13Valeria Pala, ScD14Elisabete Weiderpass, PhD15Heinz Freisling, PhD15Manuela M. Bergmann, PhD16W. M. Monique Verschuren, PhD17,18Raul Zamora-Ros, PhD19Sandra M. Colorado-Yohar, PhD20,21,22Annemieke M. W. Spijkerman, PhD17Matthias B. Schulze, DrPH23,24,25Eva M. A. Ardanaz, PhD21,26,27Lars Bo Andersen, DrMed28Nick Wareham, PhD29Søren Brage, PhD29Anders Grøntved, PhD2

Author Affiliations

JAMA Intern Med. Published online July 19, 2021. 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.




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


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.


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.


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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