Clusters of carbohydrate-rich foods and associations with type 2 diabetes incidence: a prospective cohort study.

BACKGROUND: About one in ten adults are living with diabetes worldwide. Intake of carbohydrates and carbohydrate-rich foods are often identified as modifiable risk factors for incident type 2 diabetes. However, strong correlation between food variables can make it difficult to identify true associations. The purpose of this study was to identify clusters of carbohydrate-rich foods and analyse their associations with type 2 diabetes incidence in the Malmö Diet and Cancer Study cohort in southern Sweden. METHODS: Dietary intake of 26 622 participants was assessed using a validated three-part diet history method: a 7-day food diary, a 168-item food frequency questionnaire, and a 60-minute interview. K-means clustering analysis identified five clusters from 21 food variables. The Cox proportional hazard regression model was applied to calculate hazard ratios (HR) and 95% confidence intervals (CI) of the association between clusters and incident type 2 diabetes. RESULTS: The cluster analysis resulted in five clusters; high vegetables/low added sugar, high sugar-sweetened beverages, high juice, high fruit, and high refined carbohydrates/low fruit & vegetables (reference). During mean follow-up of 18 years, 4046 type 2 diabetes cases were identified. After adjustment for potential confounding (including lifestyle, body mass index, and diet), a high fruit cluster (HR 0.86; 95% CI 0.78, 0.94) was inversely associated with type 2 diabetes compared to the reference cluster. No other significant associations were identified. CONCLUSIONS: A dietary pattern defined by a high intake of fruits was associated with a lower incidence of type 2 diabetes. The findings provide additional evidence of a potential protective effect from fruit intake in reducing type 2 diabetes risk. Future studies are needed to explore this association further.

Health care professionals' experiences and perceptions of health promotion through the health dialogue intervention in the scania region, Sweden: a qualitative interview study.

BACKGROUND: Cardiovascular disease and type 2 diabetes are among the largest public health challenges in Sweden. Research indicates that a healthy lifestyle can prevent most cases. The health dialogue is an evidence-based public health programme for primary care with positive results in several regions of Sweden. This study aimed to describe health care professionals' experiences and perceptions of health promotion through the health dialogue intervention during the pilot phase in the Scania region of Sweden. METHODS: The study consists of 12 individual interviews with health care professionals educated in the health dialogue method, implementing the intervention in Scania. Qualitative content analysis with an inductive approach was used. RESULTS: The analysis resulted in 10 sub-categories and the four main categories: A more health-promoting mindset would benefit primary care; Empower individuals; Facilitate sustainable lifestyle changes; Challenges, tools and support for the implementation of the health dialogue. One overarching theme emerged: "Health dialogue, a potential start of a paradigm shift in Swedish primary care". CONCLUSIONS: Conclusions imply that the health dialogue is a well-structured method with tools to make health promotion and primary prevention an integrated part of primary care. A respectful and motivating approach during the health dialogue is recommended. It is important to have an ongoing discussion about the approach among the health care professionals. Incorporating the Health Belief Model in the health care professionals' education in the method could increase the focus on self-efficacy during counselling, which could favour the participants' change process.

Comparisons of Different Carbohydrate Quality Indices for Risk of Type 2 Diabetes in the Malmö Diet and Cancer Study.

Carbohydrate quality might be more important than quantity to reduce type 2 diabetes (T2D) risk. Various metrics of carbohydrate quality exist; however, their associations with T2D have only been studied to a limited extent. Consequently, the aim was to investigate the association between four different pre-defined carbohydrate quality indices, with various amounts of fiber (≥1 g) and free sugar (<1 or <2 g) per 10 g of carbohydrates, and T2D risk among 26,622 individuals without diabetes from the Malmö Diet and Cancer cohort. Dietary data were collected through a food diary, diet frequency questionnaire, and interview. After a mean follow-up of 18 years, 4046 cases were identified through registers. After adjusting for potential confounders, no statistically significant associations were found for any of the indices. When excluding individuals with past dietary changes and potential misreporting of energy (36% of the population), lower risk was found for the following intake ratios: 10:1:2 carbohydrate:fiber:free sugar (HR = 0.82; 95% CI = 0.70-0.97), and 10:1&1:2 carbohydrate:fiber and fiber:free sugar, respectively (HR = 0.84; 95% CI = 0.72-0.97). Our findings indicate that adherence to a diet with high amounts of fiber and moderate amounts of free sugar in relation to total carbohydrate intake may be associated with a lower risk of T2D.

Adherence to the EAT-Lancet diet, genetic susceptibility, and risk of type 2 diabetes in Swedish adults.

BACKGROUND AND AIMS: In 2019, the EAT-Lancet Commission proposed a mainly plant-based diet that nurtures human health and supports environmental sustainability. However, its association with type 2 diabetes (T2D) has not been widely studied, and it remains unclear whether genetic susceptibility for T2D can modify this association. The aim was therefore to investigate the association between the EAT-Lancet diet and risk of T2D and assess whether the association differs by the genetic predisposition to T2D. METHODS: A total of 24,494 participants from the Malmö Diet and Cancer study were analyzed. Dietary intake was assessed using a modified diet history methodology, and an EAT-Lancet diet index (range from 0 to 42 points) was constructed based on the EAT-Lancet reference diet. National and local registers were used to identify T2D cases during follow-up. Cox proportional hazards regression model was applied to estimate the association between the EAT-Lancet diet index and risk of T2D. Genetic predisposition to T2D was captured based on 116 single nucleotide polymorphisms. RESULTS: During a median of 24.3 years of follow-up, 4197 (17.1 %) T2D cases were documented. Compared with those with the lowest adherence to the EAT-Lancet diet (≤13 points), participants who had the highest adherence (≥23 points) showed an 18 % (95 % CI: 4 %-30 %) lower risk of T2D (P for trend <0.01). There was no significant multiplicative interaction between genetic predisposition to T2D and the EAT-Lancet diet index (P = 0.59). Also, no significant additive interaction between the genetic risk and the EAT-Lancet diet was seen (P = 0.44). The highest risk was observed among the 22.9 % of the individuals with high genetic risk and low EAT-Lancet diet score (HR = 1.79; 95 % CI: 1.63, 1.96). CONCLUSIONS: Our findings indicate that high adherence to the EAT-Lancet diet was associated with decreased risk of incident T2D among people with different genetic risks.

Associations of carbohydrates and carbohydrate-rich foods with incidence of type 2 diabetes.

Dietary carbohydrates have long been expected to be associated with risk of type 2 diabetes; however, the associations for many carbohydrates and carbohydrate-rich foods remain inconclusive. This study analysed associations between intakes of six types of carbohydrates and thirteen carbohydrate-rich foods with incident type 2 diabetes in 26 622 participants (61 % women) in the Malmö Diet and Cancer Study in southern Sweden. Dietary intake was assessed at baseline (1991-1996) by using a modified diet history method. During mean follow-up of 18 years, 4046 cases were identified. Adjusting for potential confounders (including lifestyle, BMI and dietary factors), comparing highest v. lowest quintile of intake, monosaccharides (hazard ratio (HR) 0·88; 95 % CI 0·79, 0·98; Ptrend = 0·02) and fruits (HR 0·91; 95 % CI 0·82, 1·01; Ptrend = 0·03) were inversely associated with incident type 2 diabetes, while disaccharides (HR 1·17; 95 % CI 1·04, 1·30; Ptrend = 0·002) and sweets (HR 1·09; 95 % CI 1·00, 1·19; Ptrend = 0·02) were positively associated. After stratification by sex, marmalade/honey/jam (HR 0·82; 95 % CI 0·72, 0·94; Ptrend < 0·001) and vegetables (HR 0·85; 95 % CI 0·73, 0·98; Ptrend = 0·06) were inversely associated with incident type 2 diabetes in men and chocolate (HR 1·26; 95 % CI 1·09, 1·46; Ptrend < 0·001) was positively associated in women. In conclusion, we identified inverse associations for intake of monosaccharides and fruits with type 2 diabetes risk, and positive associations for disaccharides and sweets. Additional sex-specific associations were also identified. Future studies are needed to explore these associations further.

Association between added sugar intake and micronutrient dilution: a cross-sectional study in two adult Swedish populations.

BACKGROUND: The evidence on the impact of high sugar consumption on micronutrient dilution does not yet allow for the establishment of clear thresholds of consumption. To establish upper and lower limit intake thresholds for added sugar, more studies from different countries and multiple populations are needed. The aim of this study was to examine the association between the intakes of added sugar and various micronutrients among the adult Swedish population across almost two decades. METHODS: The data were obtained from the samples from two populations: 1) Riksmaten Adults, a national dietary survey (n = 1797, 44% male, aged 18-80 years, data collection from 2010 to 11) that assessed dietary intake using a 4-day web-based food diary; and 2) the Malmö Diet and Cancer Study, a population-based cohort study (n = 12,238, 45% male, aged 45-68 years, data collection from 1991 to 1994) that assessed dietary intake via a combination of a 7-day food diary, a food frequency questionnaire and an interview. The mean daily intake of nine micronutrients (calcium, folate, iron, magnesium, potassium, selenium, vitamin C, vitamin D, and zinc), adjusted for age, sex, BMI and energy intake, were examined across six added-sugar-intake groups (< 5%E, 5-7.5%E, 7.5-10%E, 10-15%E, 15-20%E, and >  20%E). RESULTS: We observed significant inverse associations between the intake of added sugar and the intake of all micronutrients in both populations. The associations were linear; however, we could not determine the threshold of added sugar intake beyond which the micronutrient intake was clearly compromised. CONCLUSIONS: These findings suggest that in two Swedish populations the higher the intake of added sugar in the diet, the more likely it is that the intake of micronutrients will be compromised, in two Swedish populations. However, although the trends are significant and consistent with those obtained in other studies on the subject, future studies are needed in order to build the necessary scientific knowledge to establish a threshold of added sugar intake based on micronutrient dilution.

Association between added sugar intake and mortality is nonlinear and dependent on sugar source in 2 Swedish population-based prospective cohorts.

Background: Although sugar consumption has been associated with several risk factors for cardiometabolic diseases, evidence for harmful long-term effects is lacking. In addition, most studies have focused on sugar-sweetened beverages (SSBs), not sugar per se. Objective: The aim of this study was to examine the associations between added and free sugar intake, intake of different sugar sources, and mortality risk. Methods: Two prospective population-based cohorts were examined: the Malmö Diet and Cancer Study (MDCS; n = 24,272), which collected dietary data by combining a food diary, interview, and food-frequency questionnaire (FFQ), and the Northern Swedish Health and Disease Study (NSHDS; n = 24,475), which assessed diet with an FFQ. Sugar intakes defined as both added and free sugar and different sugar sources were examined. The associations with mortality were examined using a multivariable Cox proportional hazards regression. Results: Higher sugar consumption was associated with a less favorable lifestyle in general. The lowest mortality risk was found with added sugar intakes between 7.5% and 10% of energy (E%) intake in both cohorts. Intakes >20E% were associated with a 30% increased mortality risk, but increased risks were also found at intakes <5E% [23% in the MDCS and 9% (nonsignificant) in the NSHDS]. Similar U-shaped associations were found for both cardiovascular and cancer mortality in the MDCS. By separately analyzing the different sugar sources, the intake of SSBs was positively associated with mortality, whereas the intake of treats was inversely associated. Conclusions: Our findings indicate that a high sugar intake is associated with an increased mortality risk. However, the risk is also increased among low sugar consumers, although they have a more favorable lifestyle in general. In addition, the associations are dependent on the type of sugar source.

Climate warming and land-use changes drive broad-scale floristic changes in Southern Sweden.

Land-use changes, pollution and climate warming during the 20th century have caused changes in biodiversity across the world. However, in many cases, the environmental drivers are poorly understood. To identify and rank the drivers currently causing broad-scale floristic changes in N Europe, we analysed data from two vascular plant surveys of 200 randomly selected 2.5 × 2.5 km grid-squares in Scania, southernmost Sweden, conducted 1989-2006 and 2008-2015, respectively, and related the change in frequency (performance) of the species to a wide range of species-specific plant traits. We chose traits representing all plausible drivers of recent floristic changes: climatic change (northern distribution limit, flowering time), land-use change (light requirement, response to grazing/mowing, response to soil disturbance), drainage (water requirement), acidification (pH optimum), nitrogen deposition and eutrophication (N requirement, N fixation ability, carnivory, parasitism, mycorrhizal associations), pollinator decline (mode of reproduction) and changes in CO2 levels (photosynthetic pathway). Our results suggest that climate warming and changes in land-use were the main drivers of changes in the flora during the last decades. Climate warming appeared as the most influential driver, with northern distribution limit explaining 30%-60% of the variance in the GLMM models. However, the relative importance of the drivers differed among habitat types, with grassland species being affected the most by cessation of grazing/mowing and species of ruderal habitats by on-going concentration of both agriculture and human population to the most productive soils. For wetland species, only pH optimum was significantly related to species performance, possibly an effect of the increasing humification of acidic water bodies. An observed relative decline of mycorrhizal species may possibly be explained by decreasing nitrogen deposition resulting in less competition for phosphorus. We found no effect of shortage or decline of pollinating lepidopterans and bees.