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Dietary diversity, diet cost and incidence of type 2 diabetes in the UK: A prospective cohort study

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Conklin, Annalijn I. 
Monsivais, Pablo 
Khaw, Kay-Tee 
Wareham, Nicholas J. 
Forouhi, Nita G. 


Background: Diet is a key modifiable risk factor for multiple chronic conditions, including type 2 diabetes (T2D). Consuming a range of foods from the five major food groups is advocated as critical to healthy eating, but the association of diversity across major food groups with T2D is not clear and the relationship of within-food group diversity is unknown. In addition, there is a growing price gap between more and less healthy foods which may limit the uptake of varied diets. The current study had two aims: first, to examine the association of reported diversity of intake of food groups as well as their subtypes, with risk of developing type 2 diabetes, and second, to estimate the monetary cost associated with dietary diversity.

Methods and Findings: A prospective study of 23,238 participants in the population-based EPIC-Norfolk cohort completing a baseline Food Frequency Questionnaire in 1993-97 and followed-up for a median of 10 years. We derived a total diet diversity score and additional scores for diversity within each food group (dairy products, fruits, vegetables, meat and alternatives, and grains). We used multivariable Cox regression analyses for incident diabetes (892 new cases), and multivariable linear regression for diet cost. Greater total diet diversity was associated with 30% lower risk of developing type 2 diabetes (Hazard ratio (HR) 0.70 [95%CI 0.51 to 0.95]) comparing diets comprising all five food groups to those with three or fewer, adjusting for confounders including obesity and socioeconomic status. In analyses of diversity within each food group, greater diversity in dairy products (HR 0.61 [0.45 to 0.81]), fruits (HR 0.69 [0.52 to 0.90]), and vegetables (HR 0.67 [0.52 to 0.87]) were each associated with lower incident diabetes. The cost of consuming a diet covering all 5 food groups was 18% higher than one comprising three or fewer groups. Key limitations are the self-reported dietary data and the binary scoring approach whereby some food groups contained both healthy and less healthy food items.

Conclusions: A diet characterized by regular consumption of all five food groups, and by greater variety of dairy, fruit and vegetable subtypes, appears important for a reduced risk of diabetes. However, such a diet is more expensive. Public health efforts to prevent diabetes should include food price policies to promote healthier, more varied diets.


This is the final version of the article. It first appeared from PLOS via


diet diversity, food variety, diet cost, diabetes risk, UK, EPIC-Norfolk

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This work was undertaken by the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research of Excellence which is funded by the British Heart Foundation, Economic and Social Research Council, Medical Research Council, Cancer Research UK, National Institute for Health Research (ES/G007462/1 and MR/K023187/1) and the Wellcome Trust (087636/Z/08/Z), and by the Medical Research Council Epidemiology Unit core support (MC_UU_12015/5 and MC_UU_12015/1). AIC was supported by the Gates Cambridge Trust and by the Canadian Institute for Health Research Postdoctoral Fellowship Award (MFE-135520).