Abstract
BackgroundObservational studies implicate higher dietary energy density (DED) as a potential risk factor for weight gain and obesity. It has been hypothesized that DED may also be associated with risk of type 2 diabetes (T2D), but limited evidence exists. Therefore, we investigated the association between DED and risk of T2D in a large prospective study with heterogeneity of dietary intake.Methodology/Principal FindingsA case-cohort study was nested within the European Prospective Investigation into Cancer (EPIC) study of 340,234 participants contributing 3.99 million person years of follow-up, identifying 12,403 incident diabetes cases and a random subcohort of 16,835 individuals from 8 European countries. DED was calculated as energy (kcal) from foods (except beverages) divided by the weight (gram) of foods estimated from dietary questionnaires. Prentice-weighted Cox proportional hazard regression models were fitted by country. Risk estimates were pooled by random effects meta-analysis and heterogeneity was evaluated. Estimated mean (sd) DED was 1.5 (0.3) kcal/g among cases and subcohort members, varying across countries (range 1.4–1.7 kcal/g). After adjustment for age, sex, smoking, physical activity, alcohol intake, energy intake from beverages and misreporting of dietary intake, no association was observed between DED and T2D (HR 1.02 (95% CI: 0.93–1.13), which was consistent across countries (I 2 = 2.9%).Conclusions/SignificanceIn this large European case-cohort study no association between DED of solid and semi-solid foods and risk of T2D was observed. However, despite the fact that there currently is no conclusive evidence for an association between DED and T2DM risk, choosing low energy dense foods should be promoted as they support current WHO recommendations to prevent chronic diseases.
Highlights
Over the past decades the prevalence of type 2 diabetes (T2D) has increased dramatically, and it is estimated that the global prevalence of diabetes will continue to rise, with an estimated 489 million cases in the year 2030, increased from an estimated 285 million in 2010 [1]
The highest mean dietary energy density (DED) was observed in Germany (1.7 kcal/g) whereas the lowest DED was found in France, Spain and the UK (1.4 kcal/g)
After adjustment for sex and age an inverse association between DED and T2D was found, which became statistically significant following adjustment for known risk factors of diabetes
Summary
Over the past decades the prevalence of type 2 diabetes (T2D) has increased dramatically, and it is estimated that the global prevalence of diabetes will continue to rise, with an estimated 489 million cases in the year 2030, increased from an estimated 285 million in 2010 [1]. Major non-genetic risk factors for T2D such as obesity, smoking, physical inactivity and diets high in (saturated) fat and low in dietary fiber are potentially modifiable [2]. Targeting those risk factors by lifestyle intervention among high risk individuals has shown to be effective in the prevention of T2D [3,4,5]. Several observational studies have observed a positive association between dietary energy density (DED) and subsequent weight or waist circumference gain [8,9,10]. Observational studies implicate higher dietary energy density (DED) as a potential risk factor for weight gain and obesity. We investigated the association between DED and risk of T2D in a large prospective study with heterogeneity of dietary intake
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