Dietary carbohydrates have long been expected to be associated with risk of type 2 diabetes; however, the associations for many carbohydrates and carbohydrate-rich foods remain inconclusive. This study analysed associations between intakes of six types of carbohydrates and thirteen carbohydrate-rich foods with incident type 2 diabetes in 26 622 participants (61 % women) in the Malmö Diet and Cancer Study in southern Sweden. Dietary intake was assessed at baseline (1991–1996) by using a modified diet history method. During mean follow-up of 18 years, 4046 cases were identified. Adjusting for potential confounders (including lifestyle, BMI and dietary factors), comparing highest v. lowest quintile of intake, monosaccharides (hazard ratio (HR) 0·88; 95 % CI 0·79, 0·98; Ptrend = 0·02) and fruits (HR 0·91; 95 % CI 0·82, 1·01; Ptrend = 0·03) were inversely associated with incident type 2 diabetes, while disaccharides (HR 1·17; 95 % CI 1·04, 1·30; Ptrend = 0·002) and sweets (HR 1·09; 95 % CI 1·00, 1·19; Ptrend = 0·02) were positively associated. After stratification by sex, marmalade/honey/jam (HR 0·82; 95 % CI 0·72, 0·94; Ptrend < 0·001) and vegetables (HR 0·85; 95 % CI 0·73, 0·98; Ptrend = 0·06) were inversely associated with incident type 2 diabetes in men and chocolate (HR 1·26; 95 % CI 1·09, 1·46; Ptrend < 0·001) was positively associated in women. In conclusion, we identified inverse associations for intake of monosaccharides and fruits with type 2 diabetes risk, and positive associations for disaccharides and sweets. Additional sex-specific associations were also identified. Future studies are needed to explore these associations further.

The aim of this study was to derive dietary patterns associated with cardio-metabolic traits and to examine whether these predict prospective changes in these traits and incidence of the metabolic syndrome (iMetS). Subjects from the Malmö Diet and Cancer Study cardiovascular cohort without cardio-metabolic disease and related drug treatments at baseline (n 4071; aged 45–67 years, 40 % men) were included. We applied reduced rank regression on thirty-eight foods to derive patterns that explain variation in response variables measured at baseline (waist circumference, TAG, HDL- and LDL-cholesterol, systolic and diastolic blood pressure, fasting glucose and insulin). Patterns were examined in relation to change in cardio-metabolic traits and iMetS in subjects who were re-examined after 16·7 years (n 2704). Two dietary patterns (‘Western’ and ‘Drinker’) were retained and explained 3·2 % of the variation in response variables. The ‘Western’ dietary pattern was inversely associated with HDL-cholesterol and positively with all other response variables (both at baseline and follow-up), but there was no association with LDL at follow-up. After adjustment for potential confounders, the ‘Western’ dietary pattern was associated with higher risk of iMetS (hazard ratio Q4 v. Q1: 1·47; 95 % CI 1·23, 1·77; Ptrend=1·5×10−5). The ‘Drinker’ dietary pattern primarily explained variation in HDL and was not associated with iMetS. In conclusion, this study supports current food-based dietary guidelines suggesting that a ‘Western’ dietary pattern with high intakes of sugar-sweetened beverages and red and processed meats and low intakes of wine, cheese, vegetables and high-fibre foods is associated with detrimental effects on cardio-metabolic health.

Two web-based dietary assessment tools have been developed for use in large-scale studies: the Riksmaten method (4-d food record) and MiniMeal-Q (food-frequency method). The aim of the present study was to examine the ability of these methods to capture energy intake against objectively measured total energy expenditure (TEE) with the doubly labelled water technique (TEEDLW), and to compare reported energy and macronutrient intake. This study was conducted within the pilot study of the Swedish CArdioPulmonary bioImage Study (SCAPIS), which included 1111 randomly selected men and women aged 50–64 years from the Gothenburg general population. Of these, 200 were enrolled in the SCAPIS diet substudy. TEEDLW was measured in a subsample (n 40). Compared with TEEDLW, both methods underestimated energy intake: −2·5 (sd  2·9) MJ with the Riksmaten method; −2·3 (sd 3·6) MJ with MiniMeal-Q. Mean reporting accuracy was 80 and 82 %, respectively. The correlation between reported energy intake and TEEDLW was r 0·4 for the Riksmaten method (P < 0·05) and r 0·28 (non-significant) for MiniMeal-Q. Women reported similar average intake of energy and macronutrients in both methods whereas men reported higher intakes with the Riksmaten method. Energy-adjusted correlations ranged from 0·14 (polyunsaturated fat) to 0·77 (alcohol). Bland–Altman plots showed acceptable agreement for energy and energy-adjusted protein and carbohydrate intake, whereas the agreement for fat intake was poorer. According to energy intake data, both methods displayed similar precision on energy intake reporting. However, MiniMeal-Q was less successful in ranking individuals than the Riksmaten method. The development of methods to achieve limited under-reporting is a major challenge for future research.

Improvements in colorectal cancer (CRC) detection and treatment have led to greater numbers of CRC survivors, for whom there is limited evidence on which to provide dietary guidelines to improve survival outcomes. Higher intake of red and processed meat and lower intake of fibre are associated with greater risk of developing CRC, but there is limited evidence regarding associations with survival after CRC diagnosis. Among 3789 CRC cases in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort, pre-diagnostic consumption of red meat, processed meat, poultry and dietary fibre was examined in relation to CRC-specific mortality (n 1008) and all-cause mortality (n 1262) using multivariable Cox regression models, adjusted for CRC risk factors. Pre-diagnostic red meat, processed meat or fibre intakes (defined as quartiles and continuous grams per day) were not associated with CRC-specific or all-cause mortality among CRC survivors; however, a marginal trend across quartiles of processed meat in relation to CRC mortality was detected (P 0·053). Pre-diagnostic poultry intake was inversely associated with all-cause mortality among women (hazard ratio (HR)/20 g/d 0·92; 95 % CI 0·84, 1·00), but not among men (HR 1·00; 95 % CI 0·91, 1·09) (Pfor heterogeneity=0·10). Pre-diagnostic intake of red meat or fibre is not associated with CRC survival in the EPIC cohort. There is suggestive evidence of an association between poultry intake and all-cause mortality among female CRC survivors and between processed meat intake and CRC-specific mortality; however, further research using post-diagnostic dietary data is required to confirm this relationship.

Studies on fibre intake and incident colorectal cancer (CRC) indicate inverse associations. Differences by tumour stage have not been examined. We examined associations between fibre intake and its sources, and incidental CRC. Separate analyses were carried out on the basis of sex, tumour location and the Tumour, Node, Metastasis (TNM) classification. The Malmö Diet and Cancer Study is a population-based cohort study, including individuals aged 45–74 years. Dietary data were collected through a modified diet history method. The TNM classification was obtained from pathology/clinical records and re-evaluated. Among 27 931 individuals (60 % women), we found 728 incident CRC cases during 428 924 person-years of follow-up. Fibre intake was inversely associated with CRC risk (Ptrend=0·026). Concerning colon cancer, we observed borderline interaction between fibre intake and sex (P=0·052) and significant protective association restricted to women (Ptrend=0·013). Intake of fruits and berries was inversely associated with colon cancer in women (Ptrend=0·022). We also observed significant interactions between intakes of fibre (P=0·048) and vegetables (P=0·039) and sex on rectal cancer, but no significant associations were seen between intake of fibre, or its sources, in either of the sexes. Except for inverse associations between intake of fibre-rich cereal products and N0- and M0-tumours, we did not observe significant associations with different TNM stages. Our findings suggest different associations between fibre intake and CRC depending on sex, tumour site and fibre source. High fibre intake, especially from fruits and berries, may, above all, prevent tumour development in the colon in women. No clear differences by TNM classification were detected.

Phenolic acids are secondary plant metabolites that may have protective effects against oxidative stress, inflammation and cancer in experimental studies. To date, limited data exist on the quantitative intake of phenolic acids. We estimated the intake of phenolic acids and their food sources and associated lifestyle factors in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Phenolic acid intakes were estimated for 36 037 subjects aged 35–74 years and recruited between 1992 and 2000 in ten European countries using a standardised 24 h recall software (EPIC-Soft), and their food sources were identified. Dietary data were linked to the Phenol-Explorer database, which contains data on forty-five aglycones of phenolic acids in 452 foods. The total phenolic acid intake was highest in Aarhus, Denmark (1265·5 and 980·7 mg/d in men and women, respectively), while the intake was lowest in Greece (213·2 and 158·6 mg/d in men and women, respectively). The hydroxycinnamic acid subclass was the main contributor to the total phenolic acid intake, accounting for 84·6–95·3 % of intake depending on the region. Hydroxybenzoic acids accounted for 4·6–14·4 %, hydroxyphenylacetic acids 0·1–0·8 % and hydroxyphenylpropanoic acids ≤ 0·1 % for all regions. An increasing south–north gradient of consumption was also found. Coffee was the main food source of phenolic acids and accounted for 55·3–80·7 % of the total phenolic acid intake, followed by fruits, vegetables and nuts. A high heterogeneity in phenolic acid intake was observed across the European countries in the EPIC cohort, which will allow further exploration of the associations with the risk of diseases.

Different lifestyle patterns across Europe may influence plasma concentrations of B-vitamins and one-carbon metabolites and their relation to chronic disease. Comparison of published data on one-carbon metabolites in Western European regions is difficult due to differences in sampling procedures and analytical methods between studies. The present study aimed, to compare plasma concentrations of one-carbon metabolites in Western European regions with one laboratory performing all biochemical analyses. We performed the present study in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort among 5446 presumptively healthy individuals. Quantile regression was used to compare sex-specific median concentrations between Northern (Denmark and Sweden), Central (France, Germany, The Netherlands and United Kingdom) and Southern (Greece, Spain and Italy) European regions. The lowest folate concentrations were observed in Northern Europe (men, 10·4 nmol/l; women, 10·7 nmol/l) and highest concentrations in Central Europe. Cobalamin concentrations were slightly higher in Northern Europe (men, 330 pmol/l; women, 352 pmol/l) compared with Central and Southern Europe, but did not show a clear north–south gradient. Vitamin B2 concentrations were highest in Northern Europe (men, 22·2 nmol/l; women, 26·0 nmol/l) and decreased towards Southern Europe (Ptrend< 0·001). Vitamin B6 concentrations were highest in Central Europe in men (77·3 nmol/l) and highest in the North among women (70·4 nmol/l), with decreasing concentrations towards Southern Europe in women (Ptrend< 0·001). In men, concentrations of serine, glycine and sarcosine increased from the north to south. In women, sarcosine increased from Northern to Southern Europe. These findings may provide relevant information for the study of regional differences of chronic disease incidence in association with lifestyle.

A greater adherence to the traditional Mediterranean (MED) diet is associated with a reduced risk of developing chronic diseases. This dietary pattern is based on higher consumption of plant products that are rich in flavonoids. We compared the total flavonoid dietary intakes, their food sources and various lifestyle factors between MED and non-MED countries participating in the EPIC study. Flavonoid intakes and their food sources for 35 628 subjects, aged 35–74 years and recruited between 1992 and 2000, in twenty-six study centres were estimated using standardised 24 h dietary recall software (EPIC-Soft®). An ad hoc food composition database on flavonoids was compiled using analytical data from the United States Department of Agriculture and Phenol-Explorer databases. Moreover, it was expanded to include using recipes, estimations of missing values and flavonoid retention factors. No significant differences in total flavonoid mean intake between non-MED countries (373·7 mg/d) and MED countries (370·2 mg/d) were observed. In the non-MED region, the main contributors were proanthocyanidins (48·2 %) and flavan-3-ol monomers (24·9 %) and the principal food sources were tea (25·7 %) and fruits (32·8 %). In the MED region, proanthocyanidins (59·0 %) were by far the most abundant contributor and fruits (55·1 %), wines (16·7 %) and tea (6·8 %) were the main food sources. The present study shows similar results for total dietary flavonoid intakes, but significant differences in flavonoid class intakes, food sources and some characteristics between MED and non-MED countries. These differences should be considered in studies about the relationships between flavonoid intake and chronic diseases.

Diets high in protein have shown positive effects on short-term weight reduction and glycaemic control. However, the understanding of how dietary macronutrient composition relates to long-term risk of type 2 diabetes is limited. The aim of the present study was to examine intakes of macronutrients, fibre and protein sources in relation to incident type 2 diabetes. In total, 27 140 individuals, aged 45–74 years, from the population-based Malmö Diet and Cancer cohort, were included. Dietary data were collected with a modified diet history method, including registration of cooked meals. During 12 years of follow-up, 1709 incident type 2 diabetes cases were identified. High protein intake was associated with increased risk of type 2 diabetes (hazard ratio (HR) 1·27 for highest compared with lowest quintile; 95 % CI 1·08, 1·49; P for trend = 0·01). When protein consumption increased by 5 % of energy at the expense of carbohydrates (HR 1·20; 95 % CI 1·09, 1·33) or fat (HR 1·21; 95 % CI 1·09, 1·33), increased diabetes risk was observed. Intakes in the highest quintiles of processed meat (HR 1·16; 95 % CI 1·00, 1·36; P for trend = 0·01) and eggs (HR 1·21; 95 % CI 1·04, 1·41; P for trend = 0·02) were associated with increased risk. Intake of fibre-rich bread and cereals was inversely associated with type 2 diabetes (HR 0·84; 95 % CI 0·73, 0·98; P for trend = 0·004). In conclusion, results from the present large population-based prospective study indicate that high protein intake is associated with increased risk of type 2 diabetes. Replacing protein with carbohydrates may be favourable, especially if fibre-rich breads and cereals are chosen as carbohydrate sources.

Epidemiological studies suggest health-protective effects of flavan-3-ols and their derived compounds on chronic diseases. The present study aimed to estimate dietary flavan-3-ol, proanthocyanidin (PA) and theaflavin intakes, their food sources and potential determinants in the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration cohort. Dietary data were collected using a standardised 24 h dietary recall software administered to 36 037 subjects aged 35–74 years. Dietary data were linked with a flavanoid food composition database compiled from the latest US Department of Agriculture and Phenol-Explorer databases and expanded to include recipes, estimations and retention factors. Total flavan-3-ol intake was the highest in UK Health-conscious men (453·6 mg/d) and women of UK General population (377·6 mg/d), while the intake was the lowest in Greece (men: 160·5 mg/d; women: 124·8 mg/d). Monomer intake was the highest in UK General population (men: 213·5 mg/d; women: 178·6 mg/d) and the lowest in Greece (men: 26·6 mg/d in men; women: 20·7 mg/d). Theaflavin intake was the highest in UK General population (men: 29·3 mg/d; women: 25·3 mg/d) and close to zero in Greece and Spain. PA intake was the highest in Asturias (men: 455·2 mg/d) and San Sebastian (women: 253 mg/d), while being the lowest in Greece (men: 134·6 mg/d; women: 101·0 mg/d). Except for the UK, non-citrus fruits (apples/pears) were the highest contributors to the total flavan-3-ol intake. Tea was the main contributor of total flavan-3-ols in the UK. Flavan-3-ol, PA and theaflavin intakes were significantly different among all assessed groups. This study showed heterogeneity in flavan-3-ol, PA and theaflavin intake throughout the EPIC countries.

Folate plays an important role in the synthesis and methylation of DNA as a cofactor in one-carbon metabolism. Inadequate folate intake has been linked to adverse health events. However, comparable information on dietary folate intake across European countries has never been reported. The objective of the present study was to describe the dietary folate intake and its food sources in ten countries in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. A cross-sectional analysis was conducted in 36 034 participants (aged 35–74 years) who completed a single 24 h dietary recall using a computerised interview software program, EPIC-Soft® (International Agency for Research on Cancer, Lyon). Dietary folate intake was estimated using the standardised EPIC Nutrient DataBase, adjusted for age, energy intake, weight and height and weighted by season and day of recall. Adjusted mean dietary folate intake in most centres ranged from 250 to 350 μg/d in men and 200 to 300 μg/d in women. Folate intake tended to be lower among current smokers and heavier alcohol drinkers and to increase with educational level, especially in women. Supplement users (any types) were likely to report higher dietary folate intake in most centres. Vegetables, cereals and fruits, nuts and seeds were the main contributors to folate intake. Nonetheless, the type and pattern of consumption of these main food items varied across the centres. These first comparisons of standardised dietary folate intakes across different European populations show moderate regional differences (except the UK health conscious group), and variation by sex, educational level, smoking and alcohol-drinking status, and supplement use.

Anthocyanidins are bioactive flavonoids with potential health-promoting effects. These may vary among single anthocyanidins considering differences in their bioavailability and some of the mechanisms involved. The aim of the present study was to estimate the dietary intake of anthocyanidins, their food sources and the lifestyle factors (sex, age, BMI, smoking status, educational level and physisical activity) involved among twenty-seven centres in ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Anthocyanidin intake and their food sources for 36 037 subjects, aged between 35 and 74 years, in twenty-seven redefined centres were obtained using standardised 24 h dietary recall software (EPIC-SOFT). An ad hoc food composition database on anthocyanidins (cyanidin, delphinidin, malvidin, pelargonidin, peonidin, petunidin) was compiled using data from the US Department of Agriculture and Phenol-Explorer databases and was expanded by adding recipes, estimated values and cooking factors. For men, the total anthocyanidin mean intake ranged from 19·83 (se 1·53) mg/d (Bilthoven, The Netherlands) to 64·88 (se 1·86) mg/d (Turin, Italy), whereas for women the range was 18·73 (se 2·80) mg/d (Granada, Spain) to 44·08 (se 2·45) mg/d (Turin, Italy). A clear south to north gradient intake was observed. Cyanidins and malvidins were the main anthocynidin contributors depending on the region and sex. Anthocyanidin intake was higher in non-obese older females, non-smokers, and increased with educational level and physical activity. The major food sources were fruits, wine, non-alcoholic beverages and some vegetables. The present study shows differences in both total and individual anthocyanidin intakes and various lifestyle factors throughout Europe, with some geographical variability in their food sources.

The role of eating frequency in obesity development is debated. Therefore, we investigated the association between eating frequency, BMI and waist circumference (WC), as well as how eating frequency is related to diet composition and lifestyle factors. A subsample (aged 47–68 years) of men (n 1355) and women (n 1654) from the Malmö Diet and Cancer cohort was used for the present cross-sectional study. The daily eating frequency was calculated based on the number of self-reported eating occasions during an ordinary day. Regression analysis and ANOVA examined the associations between eating frequency, BMI and WC, while adjusting for potential confounders. The energy percentage (E%) from carbohydrates as well as relative fibre intake (g/MJ) increased with higher eating frequency; while E% from fat, protein and alcohol decreased. A low daily eating frequency was associated with smoking, higher alcohol consumption, and lower leisure-time physical activity. Eating three or fewer meals per d was also associated with increased likelihood of general and central obesity in men when adjusting for total energy intake, lifestyle and dietary factors. However, results did not reach statistical significance among women. The present study suggests that a high daily eating frequency is associated with a healthy lifestyle and dietary pattern in both men and women, and a reduced likelihood of general and central obesity in men. There is a need for prospective studies investigating the association between eating frequency, diet and body composition.