, Volume 62, Issue 12, pp 2233–2244 | Cite as

Cumulative average dietary pattern scores in young adulthood and risk of incident type 2 diabetes: the CARDIA study

  • Kristin M. Hirahatake
  • David R. JacobsJr
  • James M. Shikany
  • Luohua Jiang
  • Nathan D. Wong
  • Andrew O. OdegaardEmail author



The evidence for the role of contemporary dietary patterns, trends and predominant aspects of energy intake in a typical American diet and in type 2 diabetes risk is limited. Therefore, we examined the association between dietary pattern scores created to reflect the 2015 Dietary Guidelines for Americans (DGA) Scientific Report, a Palaeolithic (Palaeo) diet, a diet high in ‘empty calories’, and the A Priori Diet Quality Score (APDQS) (cohort reference) and type 2 diabetes risk over time.


We carried out a prospective analysis of 4719 young adult black and white men and women from the Coronary Artery Risk Development in Young Adults (CARDIA) study with repeated dietary histories collected at study years 0, 7 and 20. Using multivariable Cox proportional hazards regression models, we examined the association between time-dependent cumulative average dietary pattern scores and incident type 2 diabetes.


During the 30 year follow-up period, 680 (14.4%) incident cases of type 2 diabetes occurred. There was no association between the 2015 DGA, Palaeo or empty calorie scores and type 2 diabetes risk in the overall population. Participants in the fourth quartile of the APDQS, reflecting a more healthful dietary pattern, had a 45% lower risk of type 2 diabetes compared with those in the lowest quartile (HR 0.55 [95% CI 0.41, 0.74]). In stratified analyses there was an inverse association for the 2015 DGA in non-smokers per SD (HR 0.86 [95% CI 0.74, 0.99]) and an inverse association for the empty calorie score in white women (HR 0.76 [95% CI 0.60, 0.96]) as well as in a subgroup analysis of the Palaeo index of participants who maintained a high score over 20 years (per SD, HR 0.59 [95% CI 0.39, 0.88]).


Higher levels of the APDQS, which largely aligns with the 2015 DGA, were strongly inversely associated with 30 year type 2 diabetes risk in the CARDIA cohort; the results from the other patterns were nuanced and need to be considered in the context of the study and potential biases.


Dietary guidelines Dietary patterns Epidemiology Palaeolithic Type 2 diabetes 



A Priori Diet Quality Score


Coronary Artery Risk Development in Young Adults


Dietary Guidelines for Americans


Empty calorie


Exercise units


Nutrition Coordinating Center




Contribution statement

KH and AO are responsible for the concept and design of the study, analysis and interpretation and writing of the manuscript. KH, AO and DJ are responsible for data acquisition. DJ, LJ, NW, and JS contributed to the analysis and interpretation of the data and provided a critical review of the manuscript. All authors have read and approved the final version of the manuscript. KH and AO are the guarantors of this work and, as such, had full access to the data provided by the CARDIA study and take responsibility for the integrity and accuracy of the data analysis.


The CARDIA study is supported by contracts HHSN268201800003I, HHSN268201800004I, HHSN268201800005I, HHSN268201800006I and HHSN268201800007I from the National Heart, Lung, and Blood Institute (NHLBI).

Duality of interest

DJ declares consultancy fees and honoraria received from the California Walnut Commission. All other authors declare no duality of interest associated with their involvement with this manuscript.

Supplementary material

125_2019_4989_MOESM1_ESM.pdf (291 kb)
ESM Tables (PDF 290 kb)


  1. 1.
    World Health Organization (2016) Global report on diabetes. WHO, GenevaGoogle Scholar
  2. 2.
    Centers for Disease Control and Prevention (2017) National Diabetes Statistics Report, 2017. Centers for Disease Control and PreventionUS Department of Health and Human Services, AtlantaGoogle Scholar
  3. 3.
    Alhazmi A, Stojanovski E, McEvoy M, Garg ML (2014) The association between dietary patterns and type 2 diabetes: a systematic review and meta-analysis of cohort studies. J Hum Nutr Diet 27(3):251–260. CrossRefPubMedGoogle Scholar
  4. 4.
    Jannasch F, Kröger J, Schulze MB (2017) Dietary patterns and type 2 diabetes: a systematic literature review and meta-analysis of prospective studies. J Nutr 147(6):1174–1182. CrossRefPubMedGoogle Scholar
  5. 5.
    Dietary Guidelines Advisory Committee (2015) Scientific report of the 2015 Dietary Guidelines Advisory Committee: advisory report to the secretary of health and human services and the secretary of agriculture. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC. CrossRefGoogle Scholar
  6. 6.
    Meyer KA, Sijtsma FP, Nettleton JA et al (2013) Dietary patterns are associated with plasma F(2)-isoprostanes in an observational cohort study of adults. Free Radic Biol Med 57:201–209. CrossRefPubMedGoogle Scholar
  7. 7.
    Shikany JM, Jacobs DR Jr, Lewis CE et al (2013) Associations between food groups, dietary patterns, and cardiorespiratory fitness in the Coronary Artery Risk Development in Young Adults study. Am J Clin Nutr 98(6):1402–1409. CrossRefGoogle Scholar
  8. 8.
    Sijtsma FPC, Meyer KA, Steffen LM et al (2014) Diet quality and markers of endothelial function: the CARDIA study. Nutr Metab Cardiovasc Dis 24(6):632–638. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Buijsse B, Jacobs DR Jr, Steffen LM, Kromhout D, Gross MD (2015) Plasma ascorbic acid, a priori diet quality score, and incident hypertension: a prospective cohort study. PLoS One 10(12):e0144920. CrossRefGoogle Scholar
  10. 10.
    Friedman GD, Cutter GR, Donahue RP et al (1988) CARDIA: study design, recruitment, and some characteristics of the examined subjects. J Clin Epidemiol 41(11):1105–1116. CrossRefPubMedGoogle Scholar
  11. 11.
    McDonald A, Van Horn L, Slattery M et al (1991) The CARDIA dietary history: development, implementation, and evaluation. J Am Diet Assoc 91(9):1104–1112PubMedGoogle Scholar
  12. 12.
    Liu K, Slattery M, Jacobs D Jr et al (1994) A study of the reliability and comparative validity of the cardia dietary history. Ethn Dis 4(1):15–27Google Scholar
  13. 13.
    Sijtsma FP, Meyer KA, Steffen LM et al (2012) Longitudinal trends in diet and effects of sex, race, and education on dietary quality score change: the Coronary Artery Risk Development in Young Adults study. Am J Clin Nutr 95(3):580–586. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Jacobs DR Jr, Sluik D, Rokling-Andersen MH, Anderssen SA, Drevon CA (2009) Association of 1-y changes in diet pattern with cardiovascular disease risk factors and adipokines: results from the 1-y randomized Oslo Diet and Exercise Study. Am J Clin Nutr 89(2):509–517. CrossRefPubMedGoogle Scholar
  15. 15.
    Lockheart MS, Steffen LM, Rebnord HM et al (2007) Dietary patterns, food groups and myocardial infarction: a case-control study. Br J Nutr 98(2):380–387. CrossRefPubMedGoogle Scholar
  16. 16.
    Nettleton JA, Schulze MB, Jiang R, Jenny NS, Burke GL, Jacobs DR Jr (2008) A priori-defined dietary patterns and markers of cardiovascular disease risk in the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Clin Nutr 88(1):185–194. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Jönsson T, Granfeldt Y, Ahrén B et al (2009) Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol 8(1):35. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Whalen KA, McCullough M, Flanders WD, Hartman TJ, Judd S, Bostick RM (2014) Paleolithic and Mediterranean diet pattern scores and risk of incident, sporadic colorectal adenomas. Am J Epidemiol 180(11):1088–1097. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Eaton SB, Konner M (1985) Paleolithic nutrition - a consideration of its nature and current implications. N Engl J Med 312(5):283–289. CrossRefPubMedGoogle Scholar
  20. 20.
    Jacobs DR Jr, Hahn LP, Haskell WL, Pirie P, Sidney S (1989) Validity and reliability of a short physical activity history: CARDIA and the Minnesota Heart Health Program. J Cardiopulm Rehabil 9(12):448–459Google Scholar
  21. 21.
    Parker ED, Schmitz KH, Jacobs DR Jr, Dengel DR, Schreiner PJ, Schreiner PJ (2007) Physical activity in young adults and incident hypertension over 15 years of follow-up: the CARDIA study. Am J Public Health 97(4):703–709. CrossRefGoogle Scholar
  22. 22.
    Cutter GR, Burke GL, Dyer AR et al (1991) Cardiovascular risk factors in young adults. The CARDIA baseline monograph. Control Clin Trials 12:1S–77SCrossRefGoogle Scholar
  23. 23.
    Wagenknecht LE, Burke GL, Perkins LL, Haley NJ, Friedman GD (1992) Misclassification of smoking status in the CARDIA study: a comparison of self-report with serum cotinine levels. Am J Public Health 82(1):33–36. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Zamora D, Gordon-Larsen P, He K, Jacobs DR Jr, Shikany JM, Popkin BM (2011) Are the 2005 Dietary Guidelines for Americans associated with reduced risk of type 2 diabetes and cardiometabolic risk factors? Twenty-year findings from the CARDIA study. Diabetes Care 34(5):1183–1185. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Jacobs S, Harmon BE, Boushey CJ et al (2015) A priori-defined diet quality indexes and risk of type 2 diabetes: the multiethnic cohort. Diabetologia 58(1):98–112. CrossRefPubMedGoogle Scholar
  26. 26.
    de Koning L, Chiuve SE, Fung TT, Willett WC, Rimm EB, Hu FB (2011) Diet-quality scores and the risk of type 2 diabetes in men. Diabetes Care 34(5):1150–1156. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    McCullough ML, Feskanich D, Stampfer MJ et al (2002) Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr 76(6):1261–1271. CrossRefPubMedGoogle Scholar
  28. 28.
    Chiuve SE, Fung TT, Rimm EB et al (2012) Alternative dietary indices both strongly predict risk of chronic disease. J Nutr 142(6):1009–1018. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    InterAct Consortium (2014) Adherence to predefined dietary patterns and incident type 2 diabetes in European populations: EPIC-InterAct Study. Diabetologia 57(2):321–333. CrossRefGoogle Scholar
  30. 30.
    Eaton SB, Cordain L, Lindeberg S (2002) Evolutionary health promotion: a consideration of common counterarguments. Prev Med (Baltim) 34(2):119–123. CrossRefGoogle Scholar
  31. 31.
    Hallfrisch J, Facn BKM (2000) Mechanisms of the effects of grains on insulin and glucose responses. J Am Coll Nutr 19(sup3):320S–325S. CrossRefPubMedGoogle Scholar
  32. 32.
    Higgins JA (2012) Whole grains, legumes, and the subsequent meal effect: implications for blood glucose control and the role of fermentation. J Nutr Metab 2012:829238–829237. CrossRefPubMedGoogle Scholar
  33. 33.
    Bjørnshave A, Hermansen K (2014) Effects of dairy protein and fat on the metabolic syndrome and type 2 diabetes. Rev Diabet Stud 11(2):153–166. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Barnard N, Levin S, Trapp C (2014) Meat consumption as a risk factor for type 2 diabetes. Nutrients 6(2):897–910. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    McRae MP (2018) Dietary fiber intake and type 2 diabetes mellitus: an umbrella review of meta-analyses. J Chiropr Med 17(1):44–53. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Jacobs DR Jr, Steffen LM (2003) Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr 78(3):508S–513S. CrossRefPubMedGoogle Scholar
  37. 37.
    Willi C, Bodenmann P, Ghali WA, Faris PD, Cornuz J (2007) Active smoking and the risk of type 2 diabetes. JAMA 298(22):2654–2664. CrossRefPubMedGoogle Scholar
  38. 38.
    Sargeant LA, Khaw K-T, Bingham S et al (2001) Cigarette smoking and glycaemia: the EPIC-Norfolk Study. Int J Epidemiol 30(3):547–554. CrossRefPubMedGoogle Scholar
  39. 39.
    Odegaard AO, Koh WP, Butler LM et al (2011) Dietary patterns and incident type 2 diabetes in Chinese men and women: the Singapore Chinese health study. Diabetes Care 34(4):880–885. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Hozawa A, Jacobs DR Jr, Steffes MW, Gross MD, Steffen LM, Lee DH (2006) Associations of serum carotenoid concentrations with the development of diabetes and with insulin concentration: interaction with smoking: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Epidemiol 163(10):929–937. CrossRefPubMedGoogle Scholar
  41. 41.
    Dietrich M, Block G, Norkus EP et al (2003) Smoking and exposure to environmental tobacco smoke decrease some plasma antioxidants and increase γ-tocopherol in vivo after adjustment for dietary antioxidant intakes. Am J Clin Nutr 77(1):160–166. CrossRefPubMedGoogle Scholar
  42. 42.
    Li N, Frigerio F, Maechler P (2008) The sensitivity of pancreatic β-cells to mitochondrial injuries triggered by lipotoxicity and oxidative stress. Biochem Soc Trans 36(5):930–934. CrossRefPubMedGoogle Scholar
  43. 43.
    Chiolero A, Faeh D, Paccaud F, Cornuz J (2008) Consequences of smoking for body weight, body fat distribution, and insulin resistance. Am J Clin Nutr 87(4):801–809. CrossRefPubMedGoogle Scholar
  44. 44.
    Janzon L, Berntorp K, Hanson M, Lindell SE, Trell E (1983) Glucose tolerance and smoking: a population study of oral and intravenous glucose tolerance tests in middle-aged men. Diabetologia 25(2):86–88. CrossRefPubMedGoogle Scholar
  45. 45.
    Willett WC (2013) Nutritional epidemiology, 3rd edn. Oxford University Press, New YorkGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Kristin M. Hirahatake
    • 1
  • David R. JacobsJr
    • 2
  • James M. Shikany
    • 3
  • Luohua Jiang
    • 1
  • Nathan D. Wong
    • 1
  • Andrew O. Odegaard
    • 1
    Email author
  1. 1.Department of Epidemiology, School of MedicineUniversity of CaliforniaIrvineUSA
  2. 2.Division of Epidemiology and Community Health, School of Public HealthUniversity of MinnesotaMinneapolisUSA
  3. 3.Division of Preventive Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamUSA

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