Subdural Empyema from Streptococcus suis Infection, South Korea.

In Jeju Island, South Korea, a patient who consumed raw pig products had subdural empyema, which led to meningitis, sepsis, and status epilepticus. We identified Streptococcus suis from blood and the subdural empyema. This case illustrates the importance of considering dietary habits in similar clinical assessments to prevent misdiagnosis.

Severe Human Parainfluenza Virus Community- and Healthcare-Acquired Pneumonia in Adults at Tertiary Hospital, Seoul, South Korea, 2010-2019.

The characteristics of severe human parainfluenza virus (HPIV)-associated pneumonia in adults have not been well evaluated. We investigated epidemiologic and clinical characteristics of 143 patients with severe HPIV-associated pneumonia during 2010-2019. HPIV was the most common cause (25.2%) of severe virus-associated hospital-acquired pneumonia and the third most common cause (15.7%) of severe virus-associated community-acquired pneumonia. Hematologic malignancy (35.0%), diabetes mellitus (23.8%), and structural lung disease (21.0%) were common underlying conditions. Co-infections occurred in 54.5% of patients admitted to an intensive care unit. The 90-day mortality rate for HPIV-associated pneumonia was comparable to that for severe influenza virus-associated pneumonia (55.2% vs. 48.4%; p = 0.22). Ribavirin treatment was not associated with lower mortality rates. Fungal co-infections were associated with 82.4% of deaths. Clinicians should consider the possibility of pathogenic co-infections in patients with HPIV-associated pneumonia. Contact precautions and environmental cleaning are crucial to prevent HPIV transmission in hospital settings.

Evolution and Spread of Highly Pathogenic Avian Influenza A(H5N1) Clade 2.3.4.4b Virus in Wild Birds, South Korea, 2022-2023.

During October 2022-March 2023, highly pathogenic avian influenza (HPAI) A(H5N1) clade 2.3.4.4b virus caused outbreaks in South Korea, including 174 cases in wild birds. To understand the origin and role of wild birds in the evolution and spread of HPAI viruses, we sequenced 113 HPAI isolates from wild birds and performed phylogenetic analysis. We identified 16 different genotypes, indicating extensive genetic reassortment with viruses in wild birds. Phylodynamic analysis showed that the viruses were most likely introduced to the southern Gyeonggi-do/northern Chungcheongnam-do area through whooper swans (Cygnus cygnus) and spread southward. Cross-species transmission occurred between various wild bird species, including waterfowl and raptors, resulting in the persistence of HPAI in wild bird populations and further geographic spread as these birds migrated throughout South Korea. Enhanced genomic surveillance was an integral part of the HPAI outbreak response, aiding in timely understanding of the origin, evolution, and spread of the virus.

Concurrent Infection with Clade 2.3.4.4b Highly Pathogenic Avian Influenza H5N6 and H5N1 Viruses, South Korea, 2023.

Highly pathogenic avian influenza H5N6 and H5N1 viruses of clade 2.3.4.4b were simultaneously introduced into South Korea at the end of 2023. An outbreak at a broiler duck farm consisted of concurrent infection by both viruses. Sharing genetic information and international surveillance of such viruses in wild birds and poultry is critical.

Identifying Contact Time Required for Secondary Transmission of Clostridioides difficile Infections by Using Real-Time Locating System.

Considering patient room shortages and prevalence of other communicable diseases, reassessing the isolation of patients with Clostridioides difficile infection (CDI) is imperative. We conducted a retrospective study to investigate the secondary CDI transmission rate in a hospital in South Korea, where patients with CDI were not isolated. Using data from a real-time locating system and electronic medical records, we investigated patients who had both direct and indirect contact with CDI index patients. The primary outcome was secondary CDI transmission, identified by whole-genome sequencing. Among 909 direct and 2,711 indirect contact cases, 2 instances of secondary transmission were observed (2 [0.05%] of 3,620 cases), 1 transmission via direct contact and 1 via environmental sources. A low level of direct contact (113 minutes) was required for secondary CDI transmission. Our findings support the adoption of exhaustive standard preventive measures, including environmental decontamination, rather than contact isolation of CDI patients in nonoutbreak settings.

Trends in Nationally Notifiable Infectious Diseases in Humans and Animals during COVID-19 Pandemic, South Korea.

We investigated trends in notifiable infectious diseases in both humans and animals during the COVID-19 pandemic in South Korea and compared those data against expected trends had nonpharmaceutical interventions (NPIs) not been implemented. We found that human respiratory infectious diseases other than COVID-19 decreased by an average of 54.7% after NPIs were introduced. On the basis of that trend, we estimated that annual medical expenses associated with respiratory infections other than COVID-19 also decreased by 3.8% in 2020 and 18.9% in 2021. However, human gastrointestinal infectious diseases and livestock diseases exhibited similar or even higher incidence rates after NPIs were instituted. Our investigation revealed that the preventive effect of NPIs varied among diseases and that NPIs might have had limited effectiveness in reducing the spread of certain types of infectious diseases. These findings suggest the need for future, novel public health interventions to compensate for such limitations.

A Prospective Sociocentric Study of 2 Entire Traditional Korean Villages: The Korean Social Life, Health, and Aging Project (KSHAP).

The Korean Social Life, Health, and Aging Project (KSHAP) was a multidisciplinary prospective study conducted in South Korea that measured various health biomarkers from blood, hair, and brain magnetic resonance imaging, and we examined their associations with sociocentric (global) social network data of older adults in 2 entire villages (or cohorts). Cohort K included participants aged 60 years or older, and cohort L included participants aged 65 years or older. We performed a baseline survey involving 814 of the 860 individuals (94.7% response rate) in cohort K in 2012 and 947 of the 1,043 individuals (90.8% response rate) in cohort L in 2017. We gathered longitudinal data for 5 waves in cohort K from 2011 to 2019 and 2 waves in cohort L from 2017 to 2022. Here, we describe for the first time the follow-up design of the KSHAP, the changes in social networks, and various biomarkers over a number of years. The data for cohort K are publicly available via the Korean Social Science Data Archive as well as the project website, and the data for cohort L will be shared soon.

Suicide mortality following the implementation of tobacco packaging and pricing policies in Korea: an interrupted time-series analysis.

BACKGROUND: To prevent tobacco use in Korea, the national quitline number was added to tobacco packages in December 2012, tobacco prices were raised by 80% in January 2015, and graphic health warning labels were placed on tobacco packages in December 2016. This study evaluated the association of these tobacco packaging and pricing policies with suicide mortality in Korea. METHODS: Monthly mortality from suicide was obtained from Cause-of-Death Statistics in Korea from December 2007 to December 2019. Interrupted time-series analysis was performed using segmented Poisson regression models. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated adjusted for suicide prevention strategies. RESULTS: Suicide mortality was 20 per 1,000,000 in December 2007 and showed a downward trend over the study period. After the implementation of tobacco packaging and pricing policies, suicide mortality immediately declined by - 0.09 percent points (95% CI = - 0.19 to 0.01; P > 0.05) for the national quitline number, - 0.22 percent points (95% CI = - 0.35 to - 0.09; P < 0.01) for tobacco prices, and - 0.30 percent points (95% CI = - 0.49 to - 0.11; P < 0.01) for graphic health warning labels. The corresponding RRs for these post-implementation changes compared with the pre-implementation level were 0.91 (95% CI = 0.83 to 1.00), 0.80 (95% CI = 0.70 to 0.91), and 0.74 (95% CI = 0.61 to 0.90), respectively. Significant associations between tobacco control policies and suicide mortality were observed even when stratified by sex and region. CONCLUSIONS: The findings of this study provide new evidence for an association between tobacco control policies and deaths by suicide. An array of effective tobacco control policies should be considered for prevention programs targeting suicide.

Continental scale comparison of mycobiomes in Parmelia and Peltigera lichens from Turkey and South Korea.

BACKGROUND: Lichens, traditionally considered as a simple partnership primarily between mycobiont and photobiont, are, in reality, complex holobionts comprised of a multitude of microorganisms. Lichen mycobiome represents fungal community residing within lichen thalli. While it is acknowledged that factors like the host lichen species and environmental conditions influence the structure of the lichen mycobiome, the existing research remains insufficient. To investigate which factor, host genus or location, has a greater impact on the lichen mycobiome, we conducted a comparative analysis of mycobiomes within Parmelia and Peltigera collected from both Turkey and South Korea, using high-throughput sequencing based on internal transcribed spacer region amplification. RESULTS: Overall, the lichen mycobiome was dominated by Capnodiales (Dothideomycetes), regardless of host or location. At the order level, the taxonomic composition was not significantly different according to lichen genus host or geographical distance. Hierarchical clustering of the top 100 abundant ASVs did not clearly indicate whether the lichen mycobiome was more influenced by host genus or location. Analyses of community similarity and partitioning variables revealed that the structure of the lichen mycobiome is more significantly influenced by location than by host genus. When analyzing the core mycobiome by host genus, the Peltigera mycobiome contained more ASV members than the Parmelia mycobiome. These two core mycobiomes also share common fungal strains, including basidiomycete yeast. Additionally, we used chi-squared tests to identify host genus-specialists and location-specialists. CONCLUSIONS: By comparing lichen mycobiomes of the same genera across different countries, our study advances our comprehension of these microbial communities. Our study elucidates that, although host species play a contributory role, geographic distance exerts a more pronounced impact on the structure of lichen mycobiome. We have made foundational contributions to understanding the lichen mycobiome occupying ecologically crucial niches. We anticipate that broader global-scale investigations into the fungal community structures will provide more detailed insights into fungal residents within lichens.

Identification of a novel orthonairovirus from ticks and serological survey in animals near China-North korea border.

Emerging pathogenic tick-borne viruses (TBVs) have attracted a great deal of attention due to their significant impact on human and animal health. A novel orthonairovirus named Dadong virus (DDV) was isolated from Haemaphysalis concinna ticks in the Changbai Mountain region on the China-North Korea border. DDV can induce cytopathic effects in mammalian and human cell lines. Phylogenetic analysis showed that it belongs to the genus Orthonairovirus, family Nairoviridae, exhibiting 72.4%-81.3% nucleic acid identity to Tofla orthonairovirus, known to cause lethal infection in IFNAR KO mice. The first serological evidence of DDV circulating in cattle and mice was also obtained, with 4.0% (1/25) of cattle and 2.27% (1/44) of mice seropositive for DDV. Further investigations, including serological surveys using human samples, are required to assess the public health risk posed by DDV.

Association of Soda Drinks and Fast Food with Allergic Diseases in Korean Adolescents: A Nationwide Representative Study.

INTRODUCTION: A high consumption of carbonated soft drinks (i.e., soda drinks) and fast food is potentially associated with the observed global rise in adolescent allergic diseases. Thus, our study aimed to examine the potential associations between the consumption of soda drinks and fast food and allergic conditions, identifying specific relationships across subgroups and each allergic condition (asthma, allergic rhinitis, and atopic dermatitis). METHODS: This study uses large-scale data from the Korea Youth Risk Behavior Web-Based Survey (total n = 865,614). Soda drinks and fast food were defined by a self-reported questionnaire and allergic conditions by physician-diagnosed within 1 year. Multivariable logistic regression was used to analyze the weighted odds ratios (ORs), along with 95% confidence intervals (CIs), for allergic diseases associated with the intake of soda drinks and fast food. RESULTS: Among 865,614 adolescents in grades 7-12 (male, 51.40%), patients with asthma, allergic rhinitis, and atopic dermatitis were 18,568 (2.15%), 153,536 (17.74%), and 59,014 (6.82%), respectively. Current asthma was associated with soda drinks (OR, 1.07; 95% CI, 1.03-1.12) and fast food consumption (1.25; 1.17-1.33). Interestingly, stronger associations were observed for female high schoolers, compared to male high schoolers and middle schoolers, in relation to the consumption of soda drinks (1.31; 1.19-1.44) and fast food (1.46; 1.26-1.69) with asthma. Current allergic rhinitis and atopic dermatitis had no significant association with fast food consumption and soda drinks. CONCLUSION: This first large-scale study suggests that fast food and soda drinks consumption are potentially associated with current asthma, with stronger associations observed in females than males, underscoring the need for sex-specific allergy prevention programs.

National Trends and Prevalence of Atopic Dermatitis and Pandemic-Related Factors among Korean Adults, 2007-2021.

INTRODUCTION: Previous studies have variably reported inconclusive trends in the prevalence of atopic dermatitis (AD) among adults, and there are limited data on the impact of the COVID-19 pandemic. We aimed to investigate the national trends and age-stratified prevalence of AD among adults from 2007 to 2021 in South Korea, focusing mainly on the impact of the COVID-19 pandemic-related factors. METHODS: A nationwide cross-sectional study was conducted using the Korea National Health and Nutrition Examination Survey data from 2007 to 2021. Overall and age-stratified prevalence for AD were assessed using weighted beta coefficients or odds ratios. RESULTS: A total of 83,566 adults over 20 years (male, 49.40%) were included. During the observation period, the prevalence of AD was stable in the overall population from 2.61% (95% CI, 2.29-2.93) in 2007-2009 to 2.15% (1.68-2.63) in 2020 and 2.38% (1.81-2.95) in 2021. However, the weighted prevalence of AD in adults aged 40-59 years old decreased during the pre-pandemic era, and the prevalence of AD in adults aged above 60 years significantly decreased during the pandemic, with a significant decline observed after the initial outbreak. From age-stratification analysis, the adults aged 40-59 years showed a significant increase after the pandemic outbreak which was evident in specific variables: individuals with rural residence, lower education, and lower household income quartiles. Adults aged above 60 years showed a significant decrease in the slope after the outbreak, evident in specific variables: individuals of female, rural residence, lower education, and lower household income quartiles. CONCLUSION: We observed a stable overall prevalence of AD throughout the 15-year observation period. However, the age-stratified analysis suggested significantly different trends according to age-stratified groups and the impact of the COVID-19 pandemic on the prevalence of AD.

Cumulative effect of unemployment on suicide mortality in South Korean workers (2018-2019).

BACKGROUND: While unemployment is known to increase the risk of suicide, its cumulative effect remains underexplored. This study investigates how unemployment affects suicide mortality and whether the effect varies based on the number of unemployment spells using two years of nationwide data. METHODS: Using the data from the National Statistical Office and Employment Insurance Database for 2018 and 2019, we identified an average of 2365 cases of suicide over two years among 7.76 million workers aged 25-64 years who had been employed within one year before their suicide. The number of unemployment spells was counted using the employment history of the past five years. We calculated crude suicide mortality rates per 100 000 population, age- and sex- standardized mortality rates (SMRs), and proportionate mortality rates (PMRs) for suicide. RESULTS: Over the two years, the crude suicide rate was 30.0 per 100 000 among the general population and 30.5 among workers. Workers with no unemployment spells in the past five years had a significantly lower SMR (0.44; 0.42-0.46), while those with four or more unemployment spells had a significantly higher SMR (3.13; 2.92-3.35) than the general population. These findings were consistent across all sex and age groups. Additionally, workers with four or more unemployment spells had a significantly higher PMR than the general population. CONCLUSION: The impact of unemployment on suicide mortality intensifies as the number of unemployment spells increases. These results underscore the necessity for additional social and psychological support along with economic assistance for individuals facing recurrent unemployment.

Do later school start times improve adolescents' sleep and substance use? A quasi-experimental study.

OBJECTIVE: A later school start time policy has been recommended as a solution to adolescents' sleep deprivation. We estimated the impacts of later school start times on adolescents' sleep and substance use by leveraging a quasi-experiment in which school start time was delayed in some regions in South Korea. METHODS: A later school start time policy was implemented in 2014 and 2015, which delayed school start times by approximately 30-90 minutes. We applied difference-in-differences and event-study designs to longitudinal data on a nationally representative cohort of adolescents from 2010 to 2015, which annually tracked sleep and substance use of 1133 adolescents from grade 7 through grade 12. RESULTS: The adoption of a later school start time policy was initially associated with a 19-minute increase in sleep duration (95% CI, 5.52 to 32.04), driven by a delayed wake time and consistent bedtime. The policy was also associated with statistically significant reductions in monthly smoking and drinking frequencies. However, approximately a year after implementation, the observed increase in sleep duration shrank to 7  minutes (95% CI, -12.60 to 25.86) and became statistically nonsignificant. Similarly, the observed reduction in smoking and drinking was attenuated a year after. CONCLUSIONS: Our findings suggest that policies that increase sleep in adolescents may have positive effects on health behaviors, but additional efforts may be required to sustain positive impacts over time. Physicians and education and health policymakers should consider the long-term effects of later school start times on adolescent health and well-being.

Association between seaweed intake and risk of type 2 diabetes mellitus: a prospective cohort study.

This study aimed to identify the longitudinal association between seaweed and type 2 diabetes mellitus (T2DM) in the Korean population. Data from 148 404 Korean adults aged 40 years and older without a history of T2DM, cardiovascular disease or cancer at baseline were obtained from the Korean Genome and Epidemiology Study data. The participants' seaweed intake was obtained using a validated semi-quantitative food frequency questionnaire, and the diagnosis of T2DM was surveyed through a self-reported questionnaire during follow-up. The hazard ratio (HR) and 95 % confidence interval (CI) for T2DM were calculated using the Cox proportional hazard regression, and the dose-response relationship was analysed using a restricted cubic spline regression. Participants had a mean follow-up period of 5 years. Participants with the highest seaweed intake had a 7 % lower risk of T2DM compared with the group with the lowest intake (95 % CI (0·87, 0·99)). Interestingly, this association was stronger in those with normal weight (HR: 0·88, 95 % CI (0·81, 0·95)), while no association was observed in participants with obesity. Spline regression revealed an inverse linear relationship between seaweed intake and T2DM risk in participants with normal weight, showing a trend where increased seaweed intake is related to lower instances of T2DM (Pfor nonlinearity = 0·48). Seaweed intake is inversely associated with the onset of T2DM in Korean adults with normal weight.

The association of diet-dependent acid load with colorectal cancer risk: a case-control study in Korea.

Acid-base disequilibrium is a contributor to cancer development because it affects molecular activities such as insulin-like growth factor 1 levels and adiponectin production. However, evidence of an association of diet-induced acid-base imbalance with colorectal cancer (CRC) is limited. We examined whether colorectal carcinogenesis is attributable to a diet with a high acid load. We recruited a total of 923 CRC cases and 1846 controls at the National Cancer Center in Korea for inclusion in a case-control study. We collected information on nutrient intake and specific clinical parameters of CRC by using a semiquantitative FFQ and medical records, respectively. Potential renal acid load (PRAL) and net endogenous acid production (NEAP) were used to estimate diet-dependent acid load. We used an unconditional logistic regression model to analyse the association. Dietary acid load scores had a positive association with the odds of CRC (OR = 2·31 (95 % CI 1·79, 2·99) and OR = 2·14 (95 % CI 1·66, 2·76) for PRAL and NEAP, respectively, Pfor trend < 0·001). A stronger positive association was observed for females (OR = 3·09, 95 % CI 1·93, 4·94) than for males (OR = 1·71, 95 % CI 1·27, 2·31). Furthermore, acidogenic diets appeared to affect rectal cancer more strongly than colon cancer in females. Our study contributes to reinforcing epidemiological evidence regarding a detrimental effect of acidogenic diets on colorectal carcinogenesis. Thus, it is important to pay attention to the balance of acidogenic (e.g. poultry and red meat) and alkalinogenic foods (e.g. fruits and vegetables) in CRC prevention, especially for females.

The interaction effect of dietary selenium intake and the IL10 rs1800871 polymorphism on the risk of colorectal cancer: a case-control study in Korea.

The importance of Se in human health has received much attention due to its antioxidant properties when it is consumed at an appropriate level. However, the existing evidence is limited to obtain an effective conclusion for colorectal cancer (CRC). Notably, an adequate intake of Se was reported for Koreans. Furthermore, cytokine secretion and immune function may be affected by dietary Se. Our study aimed to explore whether Se potentially reduces CRC risk and whether the IL10 rs1800871 polymorphism has an effect on this association. We designed a case-control study with 1420 cases and 2840 controls. A semi-quantitative FFQ was used to obtain information on Se intake. We determined IL10 rs1800871 through genetic analysis. Different models were developed to explore Se intake related to CRC risk by calculating OR and 95 % CI using unconditional logistic regression. A reduced risk of CRC was found as Se intake increased, with an OR (95 % CI) of 0·44 (0·35, 0·55) (Pfor trend < 0·001). However, this association seems to be allele-specific and only present among risk variant allele carriers (GA/GG) with a significant interaction between dietary Se and IL10 rs1800871 (Pfor interaction = 0·043). We emphasised that a reduction in CRC risk is associated with appropriate Se intake. However, the IL10 rs1800871 polymorphism has an impact on this reduction, with a greater effect on variant allele carriers. These findings suggest the importance of considering an individual's genetic characteristics when developing nutritional strategies for CRC prevention.

Should we ignore SARS-CoV-2 disease?

Current World Health Organization (WHO) reports claim a decline in COVID-19 testing and reporting of new infections. To discuss the consequences of ignoring severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, the endemic characteristics of the disease in 2023 with the ones estimated before using 2022 data sets are compared. The accumulated numbers of cases and deaths reported to the WHO by the 10 most infected countries and global figures were used to calculate the average daily numbers of cases DCC and deaths DDC per capita and case fatality rates (CFRs = DDC/DCC) for two periods in 2023. In some countries, the DDC values can be higher than the upper 2022 limit and exceed the seasonal influenza mortality. The increase in CFR in 2023 shows that SARS-CoV-2 infection is still dangerous. The numbers of COVID-19 cases and deaths per capita in 2022 and 2023 do not demonstrate downward trends with the increase in the percentages of fully vaccinated people and boosters. The reasons may be both rapid mutations of the coronavirus, which reduced the effectiveness of vaccines and led to a large number of re-infections, and inappropriate management.

Migrant well-being and undocumented status in South Korea: a cross-sectional assessment of physical, psychological, social well-being, and health behaviors.

BACKGROUND: A high burden of physical, mental, and occupational health problems among migrant workers has been well-documented, but data on undocumented migrant workers are limited and their well-being has rarely been compared to that of the general population. METHODS: Using data from a cross-sectional survey of non-professional migrant workers in South Korea in early 2021, we described their physical, psychological, social well-being and health behaviors across a wide range of outcomes, including self-rated health, occupational injury, cigarette smoking, heavy alcohol consumption, meal pattern, happiness, mental illness, social support, and social participation. The outcomes were first compared between documented and undocumented migrant workers in generalized linear regressions adjusting for potential confounders. Then, the well-being of the migrant workers was compared against that of the general population using data from the Korean Happiness Survey, which is a nationally representative survey of the South Korean general population conducted in late 2020. The parametric g-formula was performed to adjust for potential confounders. RESULTS: After adjusting for potential confounders, the undocumented migrant workers were less likely to be happy or participate in social communities, and much more likely to have anxiety or depression, smoke cigarettes, or engage in heavy alcohol consumption than the documented migrant workers. When compared to the general South Korean population, an evident social gradient emerged for happiness and mental illness; the undocumented experienced the worst outcome, followed by the documented, and then the general population. Also, the undocumented migrant workers were more likely to smoke cigarettes than the general population. CONCLUSION: The undocumented migrant workers face considerably greater challenges in terms of mental health and happiness, demonstrate higher rates of risky health behaviors such as smoking and heavy drinking, and experience a lack of social support and community integration. A stark social gradient in happiness, mental illness, and cigarette smoking exists among the documented, undocumented migrant workers and the general population in South Korea. Socio-structural factors are likely to play a crucial role in contributing to the suboptimal level of overall well-being of undocumented migrant workers. Policy-level interventions as well as interpersonal efforts are in urgent need.

The association of dietary total flavonoids and their subclasses with the risk of type 2 diabetes: a prospective cohort study.

BACKGROUND: Data from mechanistic studies suggest flavonoids may benefit glucose metabolism, but their associations with type 2 diabetes (T2D) remain unclear. This study examined the prospective associations of dietary intake of total, classes, and individual flavonoids, as well as their source foods, with T2D in the CArdioVascular disease Association Study (CAVAS). METHODS: A total of 16,666 Korean men and women were enrolled at baseline, and 953 were newly diagnosed with T2D over a median follow-up of 5.96 years. Intake of flavonoids was cumulatively averaged using all food frequency questionnaires before the censoring events. A Poisson regression model was used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: Women with higher total flavonoid, flavonol, isoflavone, and proanthocyanidin intake had a lower risk of T2D (fourth vs. first quartile, IRR 0.62; 95% CI 0.44-0.89; P for linearity and non-linearity < 0.05 for total flavonoids), while in men, flavanones, anthocyanins, and proanthocyanidins, but not total flavonoids, were inversely associated with T2D risk (all P interaction for sex > 0.05). The key source foods contributing to flavonoid intake were also different between men and women, except for apples: tangerines and strawberries in men and green leafy vegetables and soy products in women. CONCLUSIONS: A higher intake of total flavonoids, particularly from vegetables, soybeans, and apples, may be associated with lower risk of T2D in women. However, flavonoids from fruits, rather than total flavonoids, may be inversely associated in men. The association between flavonoid intake and the risk of T2D may be contingent upon the dietary sources of flavonoids consumed.