Prevention of Non Communicable Diseases

Adherence to the Danish food-based dietary guidelines and risk of type 2 diabetes: the Danish diet, cancer, and health cohort



We evaluated the association between adherence to the 2013 Danish dietary guidelines and the risk of type 2 diabetes (T2D) in a Danish cohort.


We used data from the Danish Diet, Cancer, and Health cohort. Participants aged 50–64 years were included from 1993–1997. Information on diet and covariates was collected at baseline using questionnaires and physical assessments. A diet index was developed to assess adherence to the Danish dietary guidelines. T2D cases were identified using the Danish National Diabetes Register. Cox proportional hazards regression was used to estimate hazard ratios (HR), and the pseudo-observation method was used to estimate risk differences, and 95% confidence intervals (CI).


A total of 54,305 subject were included. During a median follow-up of 15 years, 7136 participants were diagnosed with T2D. After multivariable adjustment, the HR for high versus low adherence to the index was 0.57 (95 % CI: 0.48, 0.69) in men, and 0.71 (95% CI: 0.60, 0.83) in women. Compared with the lowest adherence to the index, high adherence was associated with a 6.58% (95% CI: −8.69; −4.47%) or 3.17% (95% CI: −4.90, −1.44%) lower risk of T2D in men and women, respectively.


High adherence to the Danish food-based dietary guidelines was associated with lower risk of T2D in a Danish cohort, both on a relative and an absolute scale. Shifting from low to high adherence to the dietary guidelines may provide public health benefit.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: Hazard ratio of type 2 diabetes across the Danish Dietary guidelines Index, among men (n = 25,748) and women (n = 28,557) in the Danish Diet, Cancer and Health cohort.
Fig. 2: Association between adherence to the Danish Dietary guidelines Index and absolute risk of type 2 diabetes in the Danish Diet, Cancer and Health cohort (Cohort: n = 54,305, n cases=7136; Men: n = 25,748, n cases=3962; Women: n = 28,557, n cases = 3174).


  1. 1.

    International Diabetes Federation. IDF Diabetes Atlas. 9th edn. (International Diabetes Federation, Brussels, 2019).

  2. 2.

    Nordisk M. Nordic Nutrition Recommendations 2012: Integrating Nutrition and Physical Activity. 5th edn. (Nordic Council of Ministers, Copenhagen, 2014).

  3. 3.

    Tetens I, Andersen LB, Astrup A, Gondolf UH, Hermansen K Evidensgrundlaget for danske råd om kost og fysisk aktivitet. 1th edn. (DTU Fødevareinstituttet, Søborg, 2013).

  4. 4.

    Hansen SH, Overvad K, Hansen CP, Dahm CC. Adherence to national food-based dietary guidelines and incidence of stroke: a cohort study of Danish men and women. PLoS One. 2018;13:e0206242.

    Article  Google Scholar 

  5. 5.

    Hansen CP, Overvad K, Tetens I, Tjonneland A, Parner ET, Jakobsen MU, et al. Adherence to the Danish food-based dietary guidelines and risk of myocardial infarction: a cohort study. Public Health Nutr. 2018;21:1286–96.

    Article  Google Scholar 

  6. 6.

    Mandalazi E, Drake I, Wirfalt E, Orho-Melander M, Sonestedt E. A high diet quality based on dietary recommendations is not associated with lower incidence of type 2 diabetes in the Malmo diet and cancer cohort. Int J Mol Sci. 2016;17:901.

    Article  Google Scholar 

  7. 7.

    Tjonneland A, Olsen A, Boll K, Stripp C, Christensen J, Engholm G, et al. Study design, exposure variables, and socioeconomic determinants of participation in Diet, Cancer and Health: a population-based prospective cohort study of 57,053 men and women in Denmark. Scand J Public Health. 2007;35:432–41.

    Article  Google Scholar 

  8. 8.

    Tjonneland A, Overvad K, Haraldsdottir J, Bang S, Ewertz M, Jensen OM. Validation of a semiquantitative food frequency questionnaire developed in Denmark. Int J Epidemiol. 1991;20:906–12.

    CAS  Article  Google Scholar 

  9. 9.

    Martinussen N FoodCalc. 2019.

  10. 10.

    Carstensen B, Kristensen JK, Marcussen MM, Borch-Johnsen K. The National Diabetes Register. Scand J Public Health. 2011;39:58–61.

    Article  Google Scholar 

  11. 11.

    Lacoppidan SA, Kyro C, Loft S, Helnaes A, Christensen J, Hansen CP, et al. Adherence to a healthy nordic food index is associated with a lower risk of type-2 diabetes-The Danish diet, cancer and health cohort study. Nutrients. 2015;7:8633–44.

    Article  Google Scholar 

  12. 12.

    Harrell FE Regression Modeling Strategies: with applications to linear models, logistic regression, and survival analysis. 2nd edn. (Springer, New York, 2001).

  13. 13.

    Andersen PK, Perme MP. Pseudo-observations in survival analysis. Stat Methods Med Res. 2010;19:71–99.

    Article  Google Scholar 

  14. 14.

    Overgaard M, Andersen PK, Parner ET. Regression analysis of censored data using pseudo-observations: an update. Stata J. 2015;15:809–21.

    Article  Google Scholar 

  15. 15.

    Cook RJ, Sackett DL. The number needed to treat: a clinically useful measure of treatment effect. BMJ. 1995;310:452–452.

    CAS  Article  Google Scholar 

  16. 16.

    Freedman LS, Schatzkin A, Midthune D, Kipnis V. Dealing with dietary measurement error in nutritional cohort studies. J Natl Cancer Inst. 2011;103:1086–92.

    Article  Google Scholar 

  17. 17.

    Schwingshackl L, Bogensberger B, Hoffmann G. Diet quality as assessed by the healthy eating index, alternate healthy eating index, dietary approaches to stop hypertension score, and health outcomes: an updated systematic review and meta-analysis of cohort studies. J Acad Nutr Diet. 2018;118:74–100.

    Article  Google Scholar 

  18. 18.

    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.

    CAS  Article  Google Scholar 

  19. 19.

    Ibsen DB, Laursen ASD, Lauritzen L, Tjønneland A, Overvad K, Jakobsen MU. Substitutions between dairy product subgroups and risk of type 2 diabetes: the Danish Diet, Cancer and Health cohort. Br J Nutr. 2017;118:989–97.

    CAS  Article  Google Scholar 

  20. 20.

    Chiuve SE, Fung TT, Rimm EB, Hu FB, McCullough ML, Wang M, et al. Alternative dietary indices both strongly predict risk of chronic disease. J Nutr. 2012;142:1009–18.

    CAS  Article  Google Scholar 

Download references


We thank the participants and the staff at the Danish Cancer Society for their invaluable contribution to this study.

Author information




The authors’ responsibilities were as follows: LM, DBI, AT, KO, CCD: Designed the study; LM, CCD, DBI performed the statistical analyses; LM, CCD, DBI wrote the manuscript and had final responsibility for the final content of the manuscript; AT, KO collected data; AT, KO supplied valuable knowledge and scientific input throughout the study; all authors read and approved the final manuscript. The study was supported by Aarhus University and the study protocol was registered internally at the Danish Cancer Society.

Corresponding author

Correspondence to Christina C. Dahm.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Markanti, L., Ibsen, D.B., Tjønneland, A. et al. Adherence to the Danish food-based dietary guidelines and risk of type 2 diabetes: the Danish diet, cancer, and health cohort. Eur J Clin Nutr (2020).

Download citation