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Carbohydrates, glycemic index, and diabetes mellitus

The Mediterranean diet and risk of type 2 diabetes in Iranian population

European Journal of Clinical Nutritionvolume 73pages7278 (2019) | Download Citation



Type 2 diabetes (T2D) is fast increasing in recent decades. Limited prospective studies are available on Mediterranean diet protective effect against T2D development. We assessed longitudinal association of the Mediterranean diet with T2D risk in Iranian men and women.


Diet was measured using a 168-item food frequency questionnaire in 2139 adults (free of T2D), aged 20−70 years. All individuals, based on the traditional Mediterranean diet score (MDS), received scores between 0 and 8 points. Multivariate hazard ratio (HR) and 95% confidence interval (CI) were reported for the association of T2D and the MDS, with adjustment of diabetes risk score (DRS) and dietary energy intakes.


During follow-up, a total of 143 events occurred. Individuals who had higher intakes of fish/sea foods, legumes, nuts, and monounsaturated fatty acids (MUFAs) to saturated fatty acids (SFAs) ratio had a decreased risk of T2D. After adjustment for confounders, an inverse association was found between adherence to the MDS and T2D (HR = 0.48; 95% CI 0.27−0.83).


Our findings demonstrated an inverse association between the Mediterranean diet score and incidence of T2D.

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  1. 1.

    Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014;103:137–49.

  2. 2.

    Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047–53.

  3. 3.

    Zhou B, Lu Y, Hajifathalian K, Bentham J, Di Cesare M, Danaei G. et al. Worldwide trends in diabetes since1980: a pooled analysis of 751 population-based studies with 4.4 million participants. Lancet.2016;387:1513–30.

  4. 4.

    Georgoulis M, Kontogianni MD, Yiannakouris N. Mediterranean diet and diabetes: prevention and treatment. Nutrients. 2014;6:1406–23.

  5. 5.

    Lindstrom J, Eriksson JG, Valle TT, Aunola S, Cepaitis Z, Hakumaki M, et al. Prevention of diabetes mellitus in subjects with impaired glucose tolerance in the Finnish Diabetes Prevention Study: results from a randomized clinical trial. J Am Soc Nephrol. 2003;14:S108–113.

  6. 6.

    Sami W, Ansari T, Butt NS, Hamid MRA. Effect of diet on type 2 diabetes mellitus: a review. Int J Health Sci (Qassim). 2017;11:65–71.

  7. 7.

    Bahadoran Z, Golzarand M, Mirmiran P, Saadati N, Azizi F. The association of dietary phytochemical index and cardiometabolic risk factors in adults: Tehran Lipid and Glucose Study. J Hum Nutr Diet. 2013;26(Suppl 1):145–53.

  8. 8.

    Willett WC, Sacks F, Trichopoulou A, Drescher G, Ferro-Luzzi A, Helsing E, et al. Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr. 1995;61:1402S–1406S.

  9. 9.

    Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348:2599–608.

  10. 10.

    Boghossian NS, Yeung EH, Mumford SL, Zhang C, Gaskins AJ, Wactawski-Wende J, et al. Adherence to the Mediterranean diet and body fat distribution in reproductive aged women. Eur J Clin Nutr. 2013;67:289–94.

  11. 11.

    Salas-Salvado J, Bullo M, Babio N, Martinez-Gonzalez MA, Ibarrola-Jurado N, Basora J, et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care. 2011;34:14–19.

  12. 12.

    Martinez-Gonzalez MA, de la Fuente-Arrillaga C, Nunez-Cordoba JM, Basterra-Gortari FJ, Beunza JJ, Vazquez Z, et al. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ. 2008;336:1348–51.

  13. 13.

    Rossi M, Turati F, Lagiou P, Trichopoulos D, Augustin LS, La Vecchia C, et al. Mediterranean diet and glycaemic load in relation to incidence of type 2 diabetes: results from the Greek cohort of the population-based European Prospective Investigation into Cancer and Nutrition (EPIC). Diabetologia. 2013;56:2405–13.

  14. 14.

    Abiemo EE, Alonso A, Nettleton JA, Steffen LM, Bertoni AG, Jain A, et al. Relationships of the Mediterranean dietary pattern with insulin resistance and diabetes incidence in the Multi-Ethnic Study of Atherosclerosis (MESA). Br J Nutr. 2013;109:1490–7.

  15. 15.

    Bos MB, de Vries JH, Feskens EJ, van Dijk SJ, Hoelen DW, Siebelink E, et al. Effect of a high monounsaturated fatty acids diet and a Mediterranean diet on serum lipids and insulin sensitivity in adults with mild abdominal obesity. Nutr Metab Cardiovasc Dis. 2010;20:591–8.

  16. 16.

    Azizi F, Ghanbarian A, Momenan AA, Hadaegh F, Mirmiran P, Hedayati M, et al. Prevention of non-communicable disease in a population in nutrition transition: Tehran Lipid and Glucose Study phase II. Trials. 2009;10:5.

  17. 17.

    Momenan AA, Delshad M, Sarbazi N, Ghaleh NR, Ghanbarian A, Azizi F. Reliability and validity of the modifiable activity questionnaire (MAQ) in an Iranian urban adult population. Arch Iran Med. 2012;15:279–82.

  18. 18.

    Hosseini-Esfahani F, Jessri M, Mirmiran P, Bastan S, Azizi F. Adherence to dietary recommendations and risk of metabolic syndrome: Tehran Lipid and Glucose Study. Metabolism. 2010;59:1833–42.

  19. 19.

    Esfahani FH, Asghari G, Mirmiran P, Azizi F. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. J Epidemiol. 2010;20:150–8.

  20. 20.

    Samieri C, Grodstein F, Rosner BA, Kang JH, Cook NR, Manson JE, et al. Mediterranean diet and cognitive function in older age. Epidemiology. 2013;24:490–9.

  21. 21.

    Smidowicz A, Regula J. Effect of nutritional status and dietary patterns on human serum C-reactive protein and interleukin-6 concentrations. Adv Nutr. 2015;6:738–47.

  22. 22.

    Bozorgmanesh M, Hadaegh F, Ghaffari S, Harati H, Azizi F. A simple risk score effectively predicted type 2 diabetes in Iranian adult population: population-based cohort study. Eur J Public Health. 2011;21:554–9.

  23. 23.

    Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition recommendations and interventions for diabetes--2006: a position statement of the American Diabetes Association. Diabetes Care. 2006;29:2140–57.

  24. 24.

    Romaguera D, Guevara M, Norat T, Langenberg C, Forouhi NG, Sharp S, et al. Mediterranean diet and type 2 diabetes risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) study: the InterAct project. Diabetes Care. 2011;34:1913–8.

  25. 25.

    Mozaffarian D, Marfisi R, Levantesi G, Silletta MG, Tavazzi L, Tognoni G, et al. Incidence of new-onset diabetes and impaired fasting glucose in patients with recent myocardial infarction and the effect of clinical and lifestyle risk factors. Lancet. 2007;370:667–75.

  26. 26.

    Esposito K, Maiorino MI, Petrizzo M, Bellastella G, Giugliano D. The effects of a Mediterranean diet on the need for diabetes drugs and remission of newly diagnosed type 2 diabetes: follow-up of a randomized trial. Diabetes Care. 2014;37:1824–30.

  27. 27.

    Kastorini CM, Panagiotakos DB. Mediterranean diet and diabetes prevention: myth or fact? World J Diabetes. 2010;1:65–67.

  28. 28.

    Paniagua JA, de la Sacristana AG, Sanchez E, Romero I, Vidal-Puig A, Berral FJ, et al. A MUFA-rich diet improves posprandial glucose, lipid and GLP-1 responses in insulin-resistant subjects. J Am Coll Nutr. 2007;26:434–44.

  29. 29.

    Keapai W, Apichai S, Amornlerdpison D, Lailerd N. Evaluation of fish oil-rich in MUFAs for anti-diabetic and anti-inflammation potential in experimental type 2 diabetic rats. Korean J Physiol Pharmacol. 2016;20:581–93.

  30. 30.

    Dai J, Jones DP, Goldberg J, Ziegler TR, Bostick RM, Wilson PW, et al. Association between adherence to the Mediterranean diet and oxidative stress. Am J Clin Nutr. 2008;88:1364–70.

  31. 31.

    Giugliano D, Esposito K. Mediterranean diet and metabolic diseases. Curr Opin Lipidol. 2008;19:63–68.

  32. 32.

    Riserus U, Willett WC, Hu FB. Dietary fats and prevention of type 2 diabetes. Prog Lipid Res. 2009;48:44–51.

  33. 33.

    Rylander C, Sandanger TM, Engeset D, Lund E. Consumption of lean fish reduces the risk of type 2 diabetes mellitus: a prospective population based cohort study of Norwegian women. PLoS ONE. 2014;9:e89845.

  34. 34.

    Becerra-Tomas N, Diaz-Lopez A, Rosique-Esteban N, Ros E, Buil-Cosiales P, Corella D. et al. Legume consumption is inversely associated with type 2 diabetes incidence in adults: a prospective assessment from the PREDIMED study. Clin Nutr. 2017;37:906–13.

  35. 35.

    Agrawal S, Ebrahim S. Association between legume intake and self-reported diabetes among adult men and women in India. BMC Public Health. 2013;13:706.

  36. 36.

    Asghari G, Ghorbani Z, Mirmiran P, Azizi F. Nut consumption is associated with lower incidence of type 2 diabetes: the Tehran Lipid and Glucose Study. Diabetes Metab. 2017;43:18–24.

  37. 37.

    Kochar J, Gaziano JM, Djousse L. Nut consumption and risk of type II diabetes in the Physicians’ Health Study. Eur J Clin Nutr. 2010;64:75–79.

  38. 38.

    Marushka L, Batal M, David W, Schwartz H, Ing A, Fediuk K, et al. Association between fish consumption, dietary omega-3 fatty acids and persistent organic pollutants intake, and type 2 diabetes in 18 First Nations in Ontario, Canada. Environ Res. 2017;156:725–37.

  39. 39.

    Mirmiran P, Hosseinpour-Niazi S, Naderi Z, Bahadoran Z, Sadeghi M, Azizi F. Association between interaction and ratio of omega-3 and omega-6 polyunsaturated fatty acid and the metabolic syndrome in adults. Nutrition. 2012;28:856–63.

  40. 40.

    Maiorino MI, Bellastella G, Petrizzo M, Scappaticcio L, Giugliano D, Esposito K. Anti-inflammatory effect of Mediterranean diet in type 2 diabetes is durable: 8-year follow-up of a controlled trial. Diabetes Care. 2016;39:e44–45.

  41. 41.

    Agnoli C, Sieri S, Ricceri F, Giraudo MT, Masala G, Assedi M, et al. Adherence to a Mediterranean diet and long-term changes in weight and waist circumference in the EPIC-Italy cohort. Nutr Diabetes. 2018;8:22.

  42. 42.

    Mirmiran P, Bahadoran Z, Delshad H, Azizi F. Effects of energy-dense nutrient-poor snacks on the incidence of metabolic syndrome: a prospective approach in Tehran Lipid and Glucose Study. Nutrition. 2014;30:538–43.

  43. 43.

    Bahadoran Z, Mirmiran P, Delshad H, Azizi F. White rice consumption is a risk factor for metabolic syndrome in Tehrani adults: a prospective approach in Tehran Lipid and Glucose Study. Arch Iran Med. 2014;17:435–40.

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The authors appreciate all the field investigators of the TLGS and participants of the cohort study for their valuable cooperation. We would like to thank Ms. Niloofar Shiva.

Author information


  1. Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    • Sajjad Khalili-Moghadam
    •  & Zahra Bahadoran
  2. Department of Clinical Nutrition and Diet Therapy, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    • Parvin Mirmiran
  3. Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    • Fereidoun Azizi


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The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Parvin Mirmiran.

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