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Nutrition Epidemiology Highlights Original Article

The association between a biomarker score for fruit and vegetable intake and incident type 2 diabetes: the EPIC-Norfolk study



Biomarkers for a mixed fruit and vegetable (FV) diet are needed to provide a better understanding of the association between FV intake and type 2 diabetes. We aimed to examine the prospective association between a composite score comprised of three biomarkers of FV intake in free-living populations and incident diabetes.


A total of 318 incident diabetes cases and 926 controls from the EPIC (European Prospective Investigation of Cancer)-Norfolk study aged 40–79 years at baseline (1993–1997), completed 7-day prospective food diary and had plasma vitamin C and carotenoid measures. A composite biomarker score (CB-score) comprising the sum of plasma vitamin C, beta-carotene and lutein was derived. Odds ratios (ORs) and 95% confidence intervals (CIs) for incident diabetes were estimated using multivariable logistic regression.


A strong inverse association was found between the CB-score and incident diabetes. The ORs (95% CI) of diabetes comparing quartiles Q2, Q3 and Q4 of the CB-score with Q1 (reference category) were 0.70 (0.49, 1.00), 0.34 (0.23, 0.52) and 0.19 (0.12, 0.32), respectively, and 0.49 (0.40, 0.58) per s.d. change in CB-score in a model adjusted for demographic and lifestyle factors. The association was marginally attenuated after additionally adjusting for body mass index and waist circumference (0.60 (0.49 and 0.74) per s.d. change in CB-score).


A combination of biomarkers representing the intake of a mixed FV diet was strongly inversely associated with incident diabetes. These findings provide further support for measuring dietary biomarkers in studies of diet-disease associations and highlight the importance of consuming FV for the prevention of diabetes.

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We thank the EPIC-Norfolk participants and the EPIC-Norfolk team for their contributions. We also thank Amit Bhaniani, Department of Public Health and Primary Care, University of Cambridge, for help with data. The EPIC-Norfolk study is supported by programme grants from the Medical Research Council UK and Cancer Research UK. The sponsors did not participate in the design or conduct of this study; in the collection, management, analysis, or interpretation of data; in the writing of the manuscript; or in the preparation, review, approval, or decision to submit this manuscript for publication. We acknowledge support from the MRC Epidemiology Unit (MC_UU_12015/5).

Author Contributions

AJMC had full access to all the data in the study and takes responsibility for the accuracy of the data analysis. NGF, NJW and K-TK are the guarantors of this work and, as such, had full access to all data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. NJW, K-TK and RNL acquired the data. AJMC and NGF conceived and designed the study. AJMC, NGF and SJS analysed and interpreted the data. AJMC drafted the manuscript, and all authors critically revised the manuscript for important intellectual content and have approved the final version.

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Correspondence to N G Forouhi.

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Cooper, A., Sharp, S., Luben, R. et al. The association between a biomarker score for fruit and vegetable intake and incident type 2 diabetes: the EPIC-Norfolk study. Eur J Clin Nutr 69, 449–454 (2015).

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