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The association of a healthy lifestyle index and imaging-based body fat distribution with glycemic status and Type 2 diabetes in the Multi Ethnic Cohort: a cross-sectional analysis



As several behaviors captured by the Lifestyle Risk Factor Index (LSRI) are protective against Type 2 diabetes (T2D) and may affect body fat distribution, we examined its relation with both outcomes.


In a subset of the Multiethnic Cohort, participants from five ethnic groups (60–77 years) were assigned LSRI scores (one point each for consuming <1 (women)/<2 (men) alcoholic drinks/day, ≥1.5 physical activity hours/week, not smoking, and adhering to ≥3/7 dietary recommendations). All participants completed an extensive Quantitative Food Frequency Questionnaire to allow estimation of adherence to intake recommendations for fruits, vegetables, refined and whole grains, fish, processed and non-processed meat. Glycemic/T2D status was classified according to self-reports and fasting glucose. We estimated prevalence odds ratios (POR) of LSRI with glycemic/T2D status and DXA- and MRI-based body fat distribution using logistic regression.


Of 1713 participants, 43% had normoglycemia, 30% Pre-T2D, 9% Undiagnosed T2D, and 18% T2D. Overall, 39% scored 0–2, 49% 3, and 12% 4 LSRI points. T2D prevalence was 55% (POR 0.45; 95% confidence intervals 0.27, 0.76) lower for 4 vs. 0–2 LSRI points with weaker associations for abnormal glycemic status. Despite the low adherence to dietary recommendations (22%), this was the only component related to lower T2D prevalence. The inverse LSRI-T2D association was only observed among Latinos and Japanese Americans in ethnic-specific models. Visceral fat measures were higher in T2D patients and attenuated the LSRI-T2D association.


These findings support the role of a healthy lifestyle, especially diet, in T2D prevention with differences across ethnicity.

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Fig. 1: Association of the Lifestyle Risk Factor Index (LSRI) with Prevalence of Type 2 Diabetes (T2D) for the five ethnic groups, when adjusted for basic covariates or additionally adjusted for abdominal MRI- and DXA-based Body Fat Distribution, Adiposity Phenotype Study in Hawai’i and Los Angeles, 2013-2016.

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Data availability

The data underlying this study cannot be made publicly available because they contain patient identifying information. Data are available from the Multiethnic Cohort study ( for researchers who meet the criteria for access to data.


  1. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119.

    Article  PubMed  Google Scholar 

  2. Pan Y, Chen W, Wang Y. Prediabetes and outcome of ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis. 2019;28:683–92.

    Article  PubMed  Google Scholar 

  3. Heald AH, Stedman M, Davies M, Livingston M, Alshames R, Lunt M, et al. Estimating life years lost to diabetes: outcomes from analysis of National Diabetes Audit and Office of National Statistics data. Cardiovasc Endocrinol Metab. 2020;9:183–5.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Aune D, Ursin G, Veierod MB. Meat consumption and the risk of type 2 diabetes: a systematic review and meta-analysis of cohort studies. Diabetologia. 2009;52:2277–87.

    Article  CAS  PubMed  Google Scholar 

  5. Jannasch F, Kroger J, Schulze MB. Dietary patterns and Type 2 diabetes: a systematic literature review and meta-analysis of prospective studies. J Nutr. 2017;147:1174–82.

    Article  CAS  PubMed  Google Scholar 

  6. Steinbrecher A, Erber E, Grandinetti A, Nigg C, Kolonel LN, Maskarinec G. Physical activity and risk of type 2 diabetes among Native Hawaiians, Japanese Americans, and Caucasians: the Multiethnic Cohort. J Phys Act Health. 2012;9:634–41.

    Article  PubMed  Google Scholar 

  7. Rimm EB, Chan J, Stampfer MJ, Colditz GA, Willett WC. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ. 1995;310:555–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Lourida I, Hannon E, Littlejohns TJ, Langa KM, Hypponen E, Kuzma E, et al. Association of lifestyle and genetic risk with incidence of dementia. JAMA. 2019;322:430–7.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Liu G, Li Y, Hu Y, Zong G, Li S, Rimm EB, et al. Influence of lifestyle on incident cardiovascular disease and mortality in patients with diabetes Mellitus. J Am Coll Cardiol. 2018;71:2867–76.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Said MA, Verweij N, van der Harst P. Associations of combined genetic and lifestyle risks with incident cardiovascular disease and diabetes in the UK Biobank Study. JAMA Cardiol. 2018;3:693–702.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Baechle C, Lang A, Strassburger K, Kuss O, Burkart V, Szendroedi J, et al. Association of a lifestyle score with cardiometabolic markers among individuals with diabetes: a cross-sectional study. BMJ Open Diabetes Res Care. 2023;11:e003469.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Lee DH, Keum N, Hu FB, Orav EJ, Rimm EB, Willett WC, et al. Comparison of the association of predicted fat mass, body mass index, and other obesity indicators with type 2 diabetes risk: two large prospective studies in US men and women. Eur J Epidemiol. 2018;33:1113–23.

    Article  CAS  PubMed  Google Scholar 

  13. Hardoon SL, Morris RW, Thomas MC, Wannamethee SG, Lennon LT, Whincup PH. Is the recent rise in type 2 diabetes incidence from 1984 to 2007 explained by the trend in increasing BMI?: evidence from a prospective study of British men. Diabetes Care. 2010;33:1494–6.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Maskarinec G, Grandinetti A, Matsuura G, Sharma S, Mau M, Henderson BE, et al. Diabetes prevalence and body mass index differ by ethnicity: the Multiethnic Cohort. Ethn Dis. 2009;19:49–55.

    PubMed  Google Scholar 

  15. Maskarinec G, Raquinio P, Kristal BS, Franke AA, Buchthal SD, Ernst TM, et al. Body fat distribution, glucose metabolism, and diabetes status among older adults: the multiethnic cohort adiposity phenotype study. J Epidemiol. 2022;32:314–22.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Wander PL, Boyko EJ, Leonetti DL, McNeely MJ, Kahn SE, Fujimoto WY. Change in visceral adiposity independently predicts a greater risk of developing type 2 diabetes over 10 years in Japanese Americans. Diabetes Care. 2013;36:289–93.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Feng X, Wang J, Wu S, Wang Z, Wei Y, Li L, et al. Correlation analysis of anthropometric indices and type 2 diabetes mellitus in residents aged 60 years and older. Front Public Health. 2023;11:1122509.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Fujimoto WY, Boyko EJ, Hayashi T, Kahn SE, Leonetti DL, McNeely MJ, et al. Risk factors for Type 2 diabetes: lessons learned from Japanese Americans in Seattle. J Diabetes Investig. 2012;3:212–24.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Pischon T, Boeing H, Hoffmann K, Bergmann M, Schulze MB, Overvad K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008;359:2105–20.

    Article  CAS  PubMed  Google Scholar 

  20. Nimptsch K, Konigorski S, Pischon T. Diagnosis of obesity and use of obesity biomarkers in science and clinical medicine. Metabolism. 2019;92:61–70.

    Article  CAS  PubMed  Google Scholar 

  21. Lim U, Monroe KR, Buchthal S, Fan B, Cheng I, Kristal BS, et al. Propensity for intra-abdominal and hepatic adiposity varies among ethnic groups. Gastroenterology. 2019;156:966–75.e10.

    Article  PubMed  Google Scholar 

  22. Wang N, Sun Y, Zhang H, Chen C, Wang Y, Zhang J, et al. Total and regional fat-to-muscle mass ratio measured by bioelectrical impedance and risk of incident type 2 diabetes. J Cachexia Sarcopenia Muscle. 2021;12:2154–62.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Snijder MB, Dekker JM, Visser M, Bouter LM, Stehouwer CD, Yudkin JS, et al. Trunk fat and leg fat have independent and opposite associations with fasting and postload glucose levels: the Hoorn study. Diabetes Care. 2004;27:372–7.

    Article  PubMed  Google Scholar 

  24. Vasan SK, Osmond C, Canoy D, Christodoulides C, Neville MJ, Di Gravio C, et al. Comparison of regional fat measurements by dual-energy X-ray absorptiometry and conventional anthropometry and their association with markers of diabetes and cardiovascular disease risk. Int J Obes. 2018;42:850–7.

    Article  CAS  Google Scholar 

  25. Kouda K, Fujita Y, Ohara K, Tachiki T, Tamaki J, Yura A, et al. Associations between trunk-to-peripheral fat ratio and cardiometabolic risk factors in elderly Japanese men: baseline data from the Fujiwara-kyo Osteoporosis Risk in Men (FORMEN) study. Environ Health Prev Med. 2021;26:35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Zhong P, Tan S, Zhu Z, Zhu Z, Liang Y, Huang W, et al. Normal-weight central obesity and risk of cardiovascular and microvascular events in adults with prediabetes or diabetes: Chinese and British cohorts. Diabetes Metab Res Rev. 2023;39:e3707.

    Article  PubMed  Google Scholar 

  27. Kolonel LN, Henderson BE, Hankin JH, Nomura AMY, Wilkens LR, Pike MC, et al. A multiethnic cohort in Hawaii and Los Angeles: baseline characteristics. Am J Epidemiol. 2000;151:346–57.

    Article  CAS  PubMed  Google Scholar 

  28. Stram DO, Hankin JH, Wilkens LR, Pike MC, Monroe KR, Park S, et al. Calibration of the dietary questionnaire for a multiethnic cohort in Hawaii and Los Angeles. Am J Epidemiol. 2000;151:358–70.

    Article  CAS  PubMed  Google Scholar 

  29. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary guidelines for Americans 2020–2025 Washington, DC2020 updated 12/2020. 9th:Available from:

  30. Xia MF, Lin HD, Chen LY, Wu L, Ma H, Li Q, et al. Association of visceral adiposity and its longitudinal increase with the risk of diabetes in Chinese adults: A prospective cohort study. Diabetes Metab Res Rev. 2018;34:e3048.

    Article  PubMed  Google Scholar 

  31. Shi L, Shu XO, Li H, Cai H, Liu Q, Zheng W, et al. Physical activity, smoking, and alcohol consumption in association with incidence of type 2 diabetes among middle-aged and elderly Chinese men. PLoS One. 2013;8:e77919.

    Article  ADS  CAS  PubMed  PubMed Central  Google Scholar 

  32. Maddatu J, Anderson-Baucum E, Evans-Molina C. Smoking and the risk of type 2 diabetes. Transl Res. 2017;184:101–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Li XH, Yu FF, Zhou YH, He J. Association between alcohol consumption and the risk of incident type 2 diabetes: a systematic review and dose-response meta-analysis. Am J Clin Nutr. 2016;103:818–29.

    Article  CAS  PubMed  Google Scholar 

  34. Burchfiel CM, Sharp DS, Curb JD, Rodriguez BL, Hwang LJ, Marcus EB, et al. Physical activity and incidence of diabetes: the Honolulu Heart Program. Am J Epidemiol. 1995;141:360–8.

    Article  CAS  PubMed  Google Scholar 

  35. Aune D, Norat T, Leitzmann M, Tonstad S, Vatten LJ. Physical activity and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis. Eur J Epidemiol. 2015;30:529–42.

    Article  PubMed  Google Scholar 

  36. International Diabetes Federation (IDF). Diabetes risk factors: IDF; 2018 [Available from:

  37. Jacobs S, Boushey CJ, Franke AA, Shvetsov YB, Monroe KR, Haiman CA, et al. A priori-defined diet quality indices, biomarkers and risk for type 2 diabetes in five ethnic groups: the Multiethnic Cohort. Br J Nutr. 2017;118:312–20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Boonpor J, Petermann-Rocha F, Parra-Soto S, Pell JP, Gray SR, Celis-Morales C, et al. Types of diet, obesity, and incident type 2 diabetes: Findings from the UK Biobank prospective cohort study. Diabetes Obes Metab. 2022;24:1351–9.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Branski LK, Norbury WB, Herndon DN, Chinkes DL, Cochran A, Suman O, et al. Measurement of body composition in burned children: is there a gold standard? JPEN J Parenter Enteral Nutr. 2010;34:55–63.

    Article  PubMed  Google Scholar 

  40. American Diabetes A. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33:S62–9.

    Article  Google Scholar 

  41. Chung ST, Courville AB, Onuzuruike AU, Galvan-De La Cruz M, Mabundo LS, DuBose CW, et al. Gluconeogenesis and risk for fasting hyperglycemia in Black and White women. JCI Insight. 2018;3:e121495.

    Article  PubMed  PubMed Central  Google Scholar 

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This research was funded by grants from the US National Institutes of Health (P01 CA168530, U01CA164973, P30CA071789). GM was supported by Berlin Institute of Health Visiting Professorship, funded by Stiftung Charité. CG was supported by a postdoctoral fellowship, funded by the University of Hawai’i Cancer Center (T32CA229110).

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Authors and Affiliations



LLM, LRW, UL, and JS led the design and implementation of the APS study; RK, and GM analyzed the data and wrote the first draft of the paper; RK, KN, TP, LRW, UL, CG, VWS, JS, LLM, GM contributed to the interpretation of data and the critical revision of the article for important intellectual content. All authors provided final approval of the version to be published. RK and GM have overall responsibility for the final content.

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Correspondence to Gertraud Maskarinec.

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The authors declare no competing interests.

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The study protocol was approved by the Institutional Review Boards at the University of Hawai’i (CHS# 17200) and the University of Southern California (#HS-12-00623). Informed consent forms were signed by all participants.

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Klapp, R., Nimptsch, K., Pischon, T. et al. The association of a healthy lifestyle index and imaging-based body fat distribution with glycemic status and Type 2 diabetes in the Multi Ethnic Cohort: a cross-sectional analysis. Eur J Clin Nutr 78, 236–242 (2024).

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