The Association Between Dietary Flavonoid and Lignan Intakes and Incident Type 2 Diabetes in European Populations
The EPIC-InterAct Study
- Raul Zamora-Ros, PHD1,2,
- Nita G. Forouhi, FFPH1⇑,
- Stephen J. Sharp, MSC1,
- Carlos A. González, PHD2,
- Brian Buijsse, PHD3,
- Marcela Guevara, MD4,5,
- Yvonne T. van der Schouw, PHD6,
- Pilar Amiano, MSC5,7,
- Heiner Boeing, PHD3,
- Lea Bredsdorff, PHD8,
- Françoise Clavel-Chapelon, PHD9,10,
- Guy Fagherazzi, PHD9,10,
- Edith J. Feskens, PHD11,
- Paul W. Franks, PHD12,
- Sara Grioni, MSC13,
- Verena Katzke, PHD14,
- Timothy J. Key, DPhil15,
- Kay-Tee Khaw, FRCP16,
- Tilman Kühn, MSC14,
- Giovanna Masala, PHD17,
- Amalia Mattiello, PHD18,
- Esther Molina-Montes, PHD5,19,
- Peter M. Nilsson, PHD20,
- Kim Overvad, PHD21,
- Florence Perquier, MSC9,10,
- J. Ramón Quirós, MD22,
- Isabelle Romieu, PHD23,
- Carlotta Sacerdote, PHD24,
- Augustin Scalbert, PHD23,
- Matthias Schulze, DRPH3,
- Nadia Slimani, PHD23,
- Annemieke M.W. Spijkerman, PHD25,
- Anne Tjonneland, PHD26,
- Maria Jose Tormo, PHD5,27,28,
- Rosario Tumino, MD29,
- Daphne L. van der A, PHD27,
- Claudia Langenberg, PHD1,
- Elio Riboli, MD30 and
- Nicholas J. Wareham, FRCP1
- 1Medical Research Council, Epidemiology Unit, Cambridge, U.K.
- 2Unit of Nutrition, Environment and Cancer, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute, Barcelona, Spain
- 3Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany
- 4Navarre Public Health Institute, Pamplona, Spain
- 5CIBER Epidemiología y Salud Pública, Madrid, Spain
- 6Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- 7Public Health Department of Gipuzkoa, BioDonostia Research Institute, Health Department of Basque Region, San Sebastián, Spain
- 8National Food Institute, Technical University of Denmark, Moerkhoej, Denmark
- 9INSERM, Centre for Research in Epidemiology and Population Health, U1018, Nutrition, Hormones and Women's Health, Villejuif, France
- 10Paris South University, Unité Mixte de Recherche 1018, Villejuif, France
- 11Division of Human Nutrition, Section of Nutrition and Epidemiology, University of Wageningen, Wageningen, the Netherlands
- 12Genetic and Molecular Epidemiology Unit, Clinical Research Center, Skåne University Hospital, Lund University, Malmö, Sweden
- 13Nutritional Epidemiology Unit, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy
- 14Department of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany
- 15Cancer Epidemiology Unit, University of Oxford, Oxford, U.K.
- 16Department of Public Health and Primary Care, University of Cambridge, Cambridge, U.K.
- 17Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute, Florence, Italy
- 18Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
- 19Andalusian School of Public Health. Granada, Spain
- 20Department of Clinical Sciences, Lund University, Malmö, Sweden
- 21Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
- 22Public Health Directorate, Asturias, Spain
- 23Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
- 24Center for Cancer Prevention in Piemonte, and Human Genetic Foundation, Torino, Italy
- 25National Institute for Public Health and the Environment, Bilthoven, the Netherlands
- 26Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark
- 27Epidemiology Department, Murcia Regional Health Council, Murcia, Spain
- 28Department of Health and Social Sciences, Universidad de Murcia, Spain
- 29Cancer Registry and Histopathology Unit, “Civile M.P. Arezzo” Hospital, ASP Ragusa, Italy
- 30School of Public Health, Imperial College, London, U.K.
- Corresponding author: Nita G. Forouhi, .
R.Z.-R. and N.G.F. contributed equally to this study.
OBJECTIVE To study the association between dietary flavonoid and lignan intakes, and the risk of development of type 2 diabetes among European populations.
RESEARCH DESIGN AND METHODS The European Prospective Investigation into Cancer and Nutrition-InterAct case-cohort study included 12,403 incident type 2 diabetes cases and a stratified subcohort of 16,154 participants from among 340,234 participants with 3.99 million person-years of follow-up in eight European countries. At baseline, country-specific validated dietary questionnaires were used. A flavonoid and lignan food composition database was developed from the Phenol-Explorer, the U.K. Food Standards Agency, and the U.S. Department of Agriculture databases. Hazard ratios (HRs) from country-specific Prentice-weighted Cox regression models were pooled using random-effects meta-analysis.
RESULTS In multivariable models, a trend for an inverse association between total flavonoid intake and type 2 diabetes was observed (HR for the highest vs. the lowest quintile, 0.90 [95% CI 0.77–1.04]; P value trend = 0.040), but not with lignans (HR 0.88 [95% CI 0.72–1.07]; P value trend = 0.119). Among flavonoid subclasses, flavonols (HR 0.81 [95% CI 0.69–0.95]; P value trend = 0.020) and flavanols (HR 0.82 [95% CI 0.68–0.99]; P value trend = 0.012), including flavan-3-ol monomers (HR 0.73 [95% CI 0.57–0.93]; P value trend = 0.029), were associated with a significantly reduced hazard of diabetes.
CONCLUSIONS Prospective findings in this large European cohort demonstrate inverse associations between flavonoids, particularly flavanols and flavonols, and incident type 2 diabetes. This suggests a potential protective role of eating a diet rich in flavonoids, a dietary pattern based on plant-based foods, in the prevention of type 2 diabetes.
- Received April 15, 2013.
- Accepted July 21, 2013.
- © 2013 by the American Diabetes Association.
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