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Background  A Mediterranean-style eating pattern is consistently associated with a decreased diabetes risk in Mediterranean and European populations. However, results in U.S. populations are inconsistent. The objective of this study was to assess whether a Mediterranean-style eating pattern would be associated with diabetes risk in a large, nationally representative U.S. cohort of black and white men and women.    Methods  Participants from the Atherosclerosis Risk in Communities study prospective cohort without diabetes, cardiovascular disease, or cancer at baseline (visit 1, 1987–1989;  n  = 11,991) were included (mean age 54 years, 56% female, 75% white). Alternate Mediterranean Diet scores (aMed) were calculated using the mean dietary intake self-reported at visit 1 and visit 3 (1993–1995) or visit 1 only for participants censored before visit 3. Participants were followed from visit 1 through 31 December 2016 for incident diabetes. We used Cox regression models to characterize associations of aMed (quintiles as well as per 1-point higher) with incident diabetes adjusted for energy intake, age, sex, race and study center, and education (Model 1) for all participants then stratified by race and body mass index (BMI). Model 2 included potential mediating behavioral and clinical measures associated with diabetes. Results are presented as hazard ratios and 95% confidence intervals.    Results  Over a median follow-up of 22 years, there were 4024 incident cases of diabetes. Higher aMed scores were associated with lower diabetes risk [Model 1: 0.83 (0.73–0.94) for Q5 vs Q1 ( p -trend < 0.001) and 0.96 (0.95–0.98) for 1-point higher]. Associations were stronger for black vs white participants (interaction  p  < 0.001) and weaker for obese vs normal BMI (interaction  p  < 0.01). Associations were attenuated but statistically significant in Model 2.    Conclusions  An eating pattern high in fruits, vegetables, whole grains, legumes, nuts, and fish, and moderate in alcohol was associated with a lower risk of diabetes in a community-based U.S. population.

Adherence to a Mediterranean-style eating pattern and risk of diabetes in a U.S. prospective cohort study