摘要Background:Type 2 diabetes(T2D)is a global epidemic that reduces life expectancy.Evidence is limited on the benefits of achieving multiple guideline-recommended targets and cross-country differences.This study aimed to quantify the associations of risk factor control with mortality and life expectancy among individuals with T2D using nationwide cohorts from China,the USA,and the UK.Methods:We included 46,351 adults with T2D at baseline from China Chronic Disease and Risk Factors Surveillance(CCDRFS;2013,follow-up until 2021),USA National Health and Nutrition Examination Survey(USA NHANES;1999-2018,follow-up until 2019),and UK Biobank(2006-2010,follow-up until 2022).Patients with T2D were matched to controls without T2D using propensity score matching based on key demographic factors.Cox regression estimated mortality associated with lifestyle and metabolic factors outside target ranges[physical inactivity,smoking,unhealthy diet,elevated hemoglobin A1c(HbA1c),dyslipidemia,high blood pressure].Results:Only a small proportion of participants achieved≥5 combined targets:16.0%in CCDRFS,9.9%in USA NHANES,and 6.8%in UK Biobank.During 470,369 person-years of follow-up,7650 deaths(16.5%)occurred among individuals with T2D,and 9349 deaths(10.2%)occurred among controls over 965,249 person-years.At age 50,individuals with≤1 risk factor outside the target lived 6-9 years longer than those with≥5,and their life expectancy was comparable to that of controls without T2D.The association was independent of genetic predisposition to shorter lifespan in the UK Biobank.Additionally,individuals with T2D who failed to achieve optimal metabolic control but maintained a healthy lifestyle had a longer life expectancy compared with those who achieved optimal metabolic control but had an unhealthy lifestyle across all cohorts,with life expectancy gains ranging from 1.5 to 3.4 years depending on sex and cohort.Among individuals with T2D,healthy lifestyle behaviors(physical activity,non-smoking,a healthy diet)and HbA1c control contributed most to gains in life expectancy.Variations in multiple risk factor control and their associations with all-cause mortality were observed across different population subgroups.Conclusions:Achievement of guideline targets for multiple risk factors was low among individuals with T2D in China,the USA,and the UK.Comprehensive management of multiple risk factors,particularly lifestyle factors,was associated with a substantial reduction in the life expectancy gap between those with and without T2D,underscoring the importance of guideline-based care and individualized management.