Is "Perfect" the Enemy of the "Good?": Insights from the Lifestyle Behaviors and Health Status of Americans with Type 2 Diabetes.

Persons with Type 2 diabetes mellitus (T2DM, ~ 38.1 million Americans) are at risk of poor health, cardiovascular disease (CVD) and chronic kidney disease (CKD) if their disease is poorly controlled. T2DM control requires disease self-management through adequate physical activity and optimum diet. We evaluated the physical activity and diet patterns of the US T2DM population against the American Diabetes Association and clinical practice guideline norms, and their associations with health outcomes. Using a cross-sectional, observational study design, we studied the US T2DM population's physical activity and fruit/vegetable intake (independent variables), and their associations with three health outcomes, self-rated health (from the SF-36 question on experienced health status, categorized as excellent/very good/good vs. fair/poor), CVD-free status, and CKD-free status. We used pooled data from the Behavioral Risk Factor Surveillance Surveys (2015, 2017 and 2019) on adults aged 30-75 years with T2DM (defined as diabetes mellitus diagnosed after age 30). Physical activity categories were inactive, insufficiently active, sufficiently active, highly active, and fruit/vegetable intake categories, ≤ 2, 3-4, and ≥ 5 daily servings. We used hierarchical logistic regression, adjusting for demographic variables (age, sex, race), and potentially confounding factors, diabetes severity (disease duration, insulin use), chronic comorbidity, overweight/obese, smoking, alcohol overuse, having a regular healthcare provider, and having health insurance. Missing data were coded as a separate category. We conducted a subgroup analysis of those with ≥ 10 years of disease duration. Among 119,298 respondents with T2DM (52.1% female, mean age 62.1 years, 94% insured), 36.9% were physically inactive and 16.2% insufficiently active, 52.6% consumed ≤ 2 daily servings of fruit/vegetables, 57% reported excellent-good health, 24.7% had CVD, and 9.7% had CKD. Physical activity showed a dose-dependent association with self-rated health (reference group, physically inactive; adjusted OR for insufficiently active 1.77 (95%CI 1.71-1.83), sufficiently active, 2.33 (2.24-2.43), highly active, 2.63 (2.54-2.72)), as did fruit/vegetable intake [reference group ≤ 2 daily servings; OR for 3-4 servings, 1.12 (1.09-1.16), and ≥ 5 servings, 1.13 (1.08-1.17)]. Physical activity was associated with being CKD-free (ORs, 1.29 (1.22-1.37), 1.50 (1.40-1.60), 1.52 (1.44-1.60, respectively), and being CVD-free (1.31 (1.25-1.37), 1.34 (1.28-1.41, and 1.37(1.31-1.42), respectively). Fruit/vegetable intake was not associated with CVD. CKD outcome was not studied due to dietary restrictions of CKD patients. Subgroup analyses (53,925 respondents) showed similar results. Over a third of the US T2DM population and the subgroup with long-term T2DM were physically inactive, a sixth were insufficiently active, and over half had negligible fruit/vegetable intake. On the positive side, even limited physical activity and fruit-vegetable intake were associated with substantial health benefits including subjective quality of life (self-rated health) compared to physically inactive/negligible fruit-vegetable intake. Our findings call for disease self-management research focused on physician communication for patient empowerment to enable incremental improvements, however modest.