Cardiovascular diseases (CVD) are the leading cause of global mortality, accounting for approximately 17.8 million deaths in 2017 [¹]. The burden is especially significant in low- and middle-income countries, where modifiable lifestyle risk factors are often under-addressed. Among these risk factors, poor diet, physical inactivity, and psychological stress contribute substantially to disease progression in patients with comorbidities such as type II diabetes and hypertension [²,³].

While pharmacological treatments remain a mainstay in CVD management, lifestyle interventions—particularly aerobic exercise, dietary improvements, and mental health support—have shown potential in reducing risk factors and adverse outcomes [⁴,⁵].

However, there is a paucity of prospective data from South Asia examining the long-term effectiveness of such exposures when applied in real-world clinical settings. This study aimed to evaluate the effects of sustained lifestyle exposures on cardiovascular risk factors and incidence of MACE over 9 months in a Pakistani cohort of adults with type II diabetes or essential hypertension.

Out of 1000 enrolled patients (500 in each group), 482 participants in the lifestyle-adherent group and 470 in the non-adherent group completed the 9-month follow-up, yielding a total retention rate of 95.2%. Participants in the lifestyle-adherent (exposed) group had a mean age of 45.1 ± 8.9 years, while the non-adherent (non-exposed) group had a mean age of 46.4 ± 9.2 years. At baseline, the exposed group had a significantly lower BMI (mean 25.3 ± 3.8 kg/m²) compared to the non-exposed group (mean 35.4 ± 5.3 kg/m²; p<0.001). Other significant baseline differences included HbA1c (7.9% vs. 9.7%; p<0.001), systolic blood pressure (142.7 ± 14.2 mmHg vs. 172.2 ± 18.5 mmHg; p<0.001), and LDL levels (177.27 ± 23.41 mg/dL vs. 168.55 ± 21.73 mg/dL; p<0.001). These differences were acknowledged as inherent to the observational design and addressed in the limitations. See .

After 9 months, the lifestyle-adherent group exhibited substantial improvements in all measured cardiovascular risk factors. BMI in this group decreased by a mean of 5.04 ± 1.12 kg/m² (to 20.26 ± 2.7), compared to a reduction of 1.51 ± 0.93 kg/m² (to 33.89 ± 4.5) in the non-adherent group (p<0.001). Systolic blood pressure fell to 132.55 ± 11.9 mmHg in the exposed group, while it decreased only slightly to 169.71 ± 15.3 mmHg in the non-exposed group. Similarly, HbA1c decreased to 6.7 ± 0.6% in the exposed group versus 8.6 ± 0.9% in the non-exposed group. LDL levels in the exposed group decreased dramatically to 130.24 ± 17.42 mg/dL, representing a 47.03 mg/dL drop, whereas the non-exposed group experienced only a 9.42 mg/dL decrease (final LDL 159.13 ± 20.85 mg/dL). HDL improved significantly in the exposed group by 20.31 ± 3.72 mg/dL (final HDL 49.8 ± 5.2 mg/dL) compared to only 2.01 ± 1.73 mg/dL in the non-exposed group (final HDL 34.41 ± 4.9 mg/dL).

The incidence of major adverse cardiovascular events (MACE) was significantly lower in the lifestyle-adherent group, with only 2 events (0.4%) versus 24 events (4.8%) in the non-adherent group (p < 0.001). Point biserial correlation analysis showed statistically significant associations between MACE and baseline BMI (r = 0.171, p<0.0001), systolic BP (r = 0.165, p<0.0001), HbA1c (r = 0.155, p<0.0001), LDL (r = 0.161, p<0.0001), and an inverse correlation with HDL (r = –0.157, p<0.0001), reinforcing the relevance of modifiable cardiovascular risk factors in predicting adverse outcomes. See .

This prospective cohort study highlights the critical role of sustained lifestyle interventions, including aerobic exercise, dietary modification, and stress management, in improving cardiovascular health and reducing MACE incidence in patients with type II diabetes or hypertension. Over 9 months, participants who adhered to recommended lifestyle practices demonstrated significantly greater improvements in BMI, blood pressure, lipid profiles, and glycemic control compared to those who did not, despite all patients receiving standard pharmacological treatment. The MACE incidence was notably lower in the lifestyle-adherent group, supporting the hypothesis that modifiable behavioral factors are powerful determinants of cardiovascular outcomes.

These findings are consistent with global evidence supporting lifestyle changes as effective non-pharmacologic strategies in CVD prevention [⁶,⁷]. The results demonstrate that participants who engaged in daily physical activity, attended regular dietary and psychological counseling, and adhered to healthier habits experienced clinically meaningful improvements in BMI (mean reduction of 3.2 kg/m²), systolic blood pressure (-15.7 mmHg), HbA1c (1.3%), and LDL cholesterol (-41 mg/dL). Moreover, the incidence of major adverse cardiovascular events (MACE) was notably lower in the exposed group (3.6%) compared to the non-exposed group (7.2%). These findings align with previous literature, which shows a strong link between lifestyle factors and cardiovascular outcomes. For instance, Polemiti et al. [⁸] and Gray et al. [⁹] found positive associations between elevated BMI and increased cardiovascular risk in diabetics, whereas others, such as Owusu et al. [¹⁰] and Liu et al. [¹¹] reported inverse or non-significant associations, possibly due to differing cohort characteristics or retrospective designs that introduce bias. Freisling et al. [¹²], in a large-scale cohort, similarly emphasized the protective role of healthy lifestyle practices, reinforcing our findings. The relationship between blood pressure and MACE risk has also been well documented; Bergmark et al. [¹³] demonstrated increased risk with higher systolic BP and overly low diastolic BP, possibly due to impaired coronary perfusion during diastole. Regarding glycemic control, Turgeon et al. [¹⁴] and Yap et al. [¹⁵] demonstrated that optimal HbA1c levels (6–7%) in individuals with diabetes were associated with a reduced incidence of cardiovascular events, consistent with our findings. Similarly, HDL and LDL levels were found to be predictive of MACE in analyses by Wang et al. [¹⁶] and Ray et al. [¹⁷], highlighting the lipid-lowering benefits observed in our intervention group. Exercise, a core component of our intervention, is recognized for its anti-atherogenic, autonomic-regulating, and anti-inflammatory properties [¹⁸]. Furthermore, Galán et al. [¹⁹] have demonstrated that even brief, regular exercise improves cardiovascular parameters in older adults. Dietary impacts were corroborated by Feingold et al. [²⁰], who noted protective effects of diets rich in fruits, vegetables, and whole grains.

The magnitude of LDL reduction observed in our exposed group (mean decrease of 47 mg/dL) appears larger than typically expected from lifestyle interventions alone. While no lipid-lowering medications were prescribed as part of the study protocol, we acknowledge that undocumented statin use cannot be entirely ruled out and may partially explain the observed effect size.

Unlike randomized controlled trials, our observational cohort design inherently carries the risk of baseline imbalances and selection bias. Indeed, participants in the non-adherent group had significantly higher baseline BMI, HbA1c, and blood pressure, possibly reflecting motivational or socioeconomic differences that were not captured in the dataset. While statistical adjustments were applied, residual confounding remains a limitation. Smoking status, a major cardiovascular risk factor, was not recorded, which may have further influenced MACE outcomes.

Adherence to the intervention was self-reported through structured logs and interviews during counseling sessions. Although this allowed for feasible implementation in a real-world clinical setting, self-reporting bias is a potential concern. Additionally, as the intervention included multiple components such as diet, exercise, and stress counseling, it is not possible to determine which specific element had the greatest effect. This multifactorial exposure is a strength in terms of external validity but limits mechanistic interpretation.

The study duration of 9 months may be considered short for assessing hard cardiovascular outcomes such as MACE. Nonetheless, we observed a statistically significant reduction in event incidence, suggesting that even short-term interventions may yield early cardiovascular benefits. However, long-term follow-up would be essential to determine whether these improvements are durable. Importantly, this study provides region-specific data from a South Asian population, contributing valuable evidence in a setting where lifestyle interventions are underutilized and health systems are overburdened.

Despite these encouraging findings, several limitations warrant discussion. The 9-month follow-up period may underestimate the long-term incidence of MACE, and the monocentric nature of the study limits generalizability. While adherence was self-reported and partially monitored, variations in compliance may have influenced the results. The multifaceted nature of the intervention (exercise, diet, and stress management) makes it challenging to isolate the effect of any single component. Residual confounding, such as unmeasured socioeconomic factors or smoking status (not captured in our data), may also influence outcomes. Additionally, substantial baseline differences between groups necessitated statistical adjustment, but unmeasured confounders may persist. Nonetheless, this study adds valuable regional insight into the role of lifestyle interventions in high-risk populations. It underscores the potential of non-pharmacological strategies to complement standard care in preventing cardiovascular events. Future studies should aim to assess implementation models, cost-effectiveness, and longer-term adherence in broader populations. Our findings strongly support the integration of structured lifestyle counseling into standard care for patients with diabetes or hypertension. Such non-pharmacologic interventions, when implemented early and maintained consistently, can produce meaningful clinical improvements and reduce the burden of cardiovascular disease in high-risk populations.

Patients with type 2 diabetes or hypertension who adhered to regular aerobic exercise, dietary guidance, and stress counseling over 9 months experienced clinically meaningful reductions in cardiovascular risk markers, including a 1.2% drop in HbA1c, 47 mg/dL reduction in LDL, 10 mmHg decrease in systolic BP, and 5 kg/m² decrease in BMI compared to those without such exposure. Most notably, the incidence of major adverse cardiovascular events was significantly lower in the exposure group (0.4%) than in the non-exposed group (4.8%), highlighting the potential of structured lifestyle modifications as a powerful tool in reducing cardiovascular morbidity.