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Synergistic Effect of Family History of Diabetes and Dietary Habits on the Risk of Type 2 Diabetes in Central China.

1. Introduction

Diabetes is now seen as a global epidemic [1]. According to the statistics published by the World Health Organization (WHO) in 2011, the prevalence of diabetes around the world has reached 366 million and most of these patients have type 2 diabetes mellitus (T2DM) [2]. The prevalence of diabetes has increased significantly in recent decades and is now reaching epidemic proportions in China [3]. Compared with 1980, the prevalence of T2DM has increased by a factor of 3 in 1994 and has approximately doubled from 1994 to 2001 [3].

Dietary habits are well known to influence the risk of T2DM. A Western pattern diet (high consumption of red meat, processed meat, refined grains, French fries, high-fat dairy products, sweets and desserts, high-sugar drinks, and eggs) has been associated with an increased risk of T2DM in both men and women [4, 5]. The Chinese have a unique dietary pattern that might have protected them from T2DM in the past, but westernization of the dietary habits in China during the recent decades may participate in the obesity and T2DM epidemics observed in China [6-8]. Nevertheless, the exact relationship between T2DM and dietary habits in China is currently poorly understood.

Recent studies reported that family history of diabetes (FHD) is associated with an increased prevalence of T2DM [9-11]. Those with a parental history of diabetes are more susceptible to suffer from T2DM compared with those without parental history [9-11]. It is likely that this elevated risk of T2DM is mediated, in part, by both genetic and shared environmental components among family members [12], but whether the FHD has the same impact on the risk of T2DM is unclear. Similarly, although some previous studies revealed that anthropometric and lifestyle-related risk factors such as body mass index (BMI), waist circumference, and physical inactivity are major risk factors for T2DM [13-15] and that the aggregation of such traits among families may account for a portion of the excess risk attributable to FHD [16], the precise factors accounting for this increase in risk are poorly understood. Moreover, the current reports about the interaction of FHD with lifestyle risk factors are few. After a first-degree relative experiences T2DM, it might be expected that other family members would take this as a warning which might lead to changes in risk factor exposure. This might be reflected in differences in risk factor exposure and odds ratios (ORs) between individuals with and without FHD.

To answer these questions, the present study was carried out using data from Henan province's study sites of the Chinese Center for Disease Control and Prevention's (CDC's) National Disease Surveillance Point System. Differences in lifestyle were compared to FHD status in patients with T2DM and non-T2DM subjects for possible relationships. The interactions between them were also analyzed.

2. Methods

2.1. Study Design and Subjects. The present work was one part of the baseline survey from REACTION study investigating the association of diabetes and cancer, which was conducted among 259,657 adults, aged 40 years and older in 25 communities across mainland China, from 2011 to 2012 [17, 18]. All subjects' data were drawn from the REACTION study. This survey was conducted in four communities in Zhengzhou city, Henan province, from July 2010 to August 2010. In this previous cross-sectional study, a complex, multistage, probability sampling design was used to select participants. This process aimed to select a study sample that was representative of civilian, noninstitutionalized Chinese adults at each site. One individual of [greater than or equal to] 18 years of age was randomly selected from each household. If the selected individuals refused or were unavailable, a similar and previously unselected replacement household was selected in the same neighborhood.

The original study was approved by Ruijin Hospital Ethics Committee. Written informed consent was obtained from all study participants. The present study was approved by the same ethics committee, but the need for individual consent was waived because of the retrospective nature of the study.

2.2. Data Collection. A standard questionnaire was administered by trained staff to obtain information on demographic characteristics, personal and family medical history, and lifestyle risk factors [19]. A pilot study was first conducted on a small group of district residents to test the validity of the questionnaire. "Current smoking" was defined as having smoked 100 cigarettes in one's lifetime. Previous smoking was defined as having stopped smoking for at least 1 year. Similarly, "Current drinking" was defined as the consumption of at least 30 g of alcohol per week for 1 year or more. Consumption of milk, eggs, meat (chicken, beef, and pork), raw vegetables, fruits, and other dietary items was divided into two or three categories according to intake frequency. Information was obtained on the amount and type of alcohol that was consumed during the previous year.

Bodyweight and height were measured according to a standard protocol, and BMI was calculated as weight in kilograms divided by height in meters squared. Waist circumference was measured on standing participants midway between the lower edge of the costal arch and the upper edge of the iliac crest.

In this study, FHD was defined as positive if the subject had at least one parent or sibling or children who had been diagnosed with T2DM.

2.3. Statistical Analyses. The Pearson chi-square test was used to assess the differences in the frequency distribution of the categorical variables between T2DM and non-T2DM. The Mann-Whitney U test was used to assess the differences in non-normally distributed continuous variables between T2DM and non-T2DM. Multivariate logistic regression was performed to obtain OR estimates and their 95% confidence intervals (95% CI) for lifestyle factors on T2DM onset. The estimates were adjusted for age, sex, BMI, waist-to-hip ratio (WHR), and FHD. The biological interactions, defined by Rothman interactions [20], between FHD and each dietary factor were analyzed by using the synergy index (S) scores [19]. An S score of >1.0 indicates positive interaction and an S score of below <1.0 indicates an antagonistic effect [21]. All of the statistical tests were performed using SPSS 16.0 (IBM, Armonk, NY, USA). Two-sided P values <0.05 were considered statistically significant.

3. Results

3.1. Characteristics of the Patients. The present study included 9849 representative urban residents, including 1234 hospital-diagnosed patients with T2DM and 8615 non-T2DM individual. Compared with non-T2DM individuals, patients with T2DM showed a higher proportion of males (38.7% versus 31.4%, P <0.001), older age (median, 63 versus 58 years, P <0.001), higher BMI (median, 26.2 versus 25.7 kg/[m.sup.2], P < 0.001), and higher WHR (0.918 versus 0.896, P <0.001) (Table 1).

Among the patients with T2DM, 332 (26.9%) were FHD+ compared with 1025 (11.9%) among non-T2DM individuals (P <0.001). Compared with non-T2DM individuals, patients with T2DM showed a higher proportion of patients with a history of smoking [greater than or equal to] 7 cigarettes/week (10.9% versus 7.3%, P < 0.001), a lower consumption of potatoes (P <0.001), pork (P <0.001), fresh fruits (P <0.001), and freshly squeezed fruits (P < 0.001), a higher consumption of poultry (P = 0.002), and a higher level of physical activity (P < 0.001) (Table 2).

3.2. Association between FHD and T2DM. After adjustment for age, gender, BMI, and WHR, a uniparental FHD (OR = 2.84, 95% CI: 2.36-3.42, P < 0.001), a paternal history of FHD (OR = 2.53, 95% CI: 1.91-3.35, P <0.001), a maternal history of FHD (OR = 3.27, 95% CI: 2.67-4.02, P < 0.001), a biparental history of FHD (OR = 5.26, 95% CI: 2.98-9.31, P < 0.001), and a FHD, irrespective of the parent (OR = 3.59, 95% CI: 3.08-4.17, P <0.001), were associated with T2DM onset (Table 3).

3.3. Effect of Lifestyle Factors on T2DM Onset. After adjustment for age, gender, BMI, and WHR, the consumption of potatoes (<15 g/d, OR= 1.49, 95% CI: 1.30-1.71, P <0.001), beef and mutton (<4 g/d, OR = 0.78, 95% CI: 0.68-0.91, P <0.001), fresh fruits (<85 g/d, OR = 2.34, 95% CI: 2.04-2.68, P <0.001), freshly squeezed juice (no, OR = 2.23, 95% CI: 1.86-2.68, P <0.001), and soy products ([greater than or equal to] 30 g/d, OR = 1.19, 95% CI: 1.04-1.37, P = 0.01), and days of walking/week (>3, OR = 1.29, 95% CI: 1.11-1.49, P = 0.001) were associated with T2DM onset (Table 4).

3.4. Interactions between Lifestyle Habits and FHD. As shown in Table 5, there were significant interactions between FHD and consuming < 15 g/d of potatoes (S =154, 95% CI: 1.12-2.12), <8 g/d of poultry (S = 1.51, 95% CI: 1.04-2.17), <85 g/d of fresh fruits (S = 2.17, 95% CI: 1.63-2.88), and no freshly squeezed juice (S = 2.25, 95% CI: 1.46-3.49).

4. Discussion

T2DM is a major public health problem in China [22, 23]. Fortunately, there are preventive measures, and persons at risk can be readily identified using a few common risk factors [24]. In this study, we conducted a study to identify lifestyle risk factors of T2DM and their interactions with FHD in a Chinese urban population.

After adjustment for age, gender, BMI, and WHR, a uniparental FHD, a paternal history of FHD, a maternal history of FHD, a biparental history of FHD, and a FHD, irrespective of the parent, were associated with T2DM onset. After adjustment for age, gender, BMI, and WHR, the consumption of potatoes, beef and mutton, fresh fruits, freshly squeezed juice, and soy products, and days of walking/week were associated with T2DM onset. There were significant interactions between FHD and consuming < 15 g/d of potatoes, <8 g/d of poultry, <85 g/d of fresh fruits, and no freshly squeezed juice.

This was a comprehensive investigation of the associations between dietary habits and T2DM in the Chinese. Potatoes have hypoglycemic activity in diabetic patients [25], and the present study showed an association between consuming < 15 g/d of potatoes and T2DM. High intake of red meat such as beef and mutton has been associated with T2DM [26], supporting the present study, that is, that consuming > 4 g/d of beef and mutton was associated with T2DM. The present study also showed that consuming < 85 g/d of fresh fruits and no freshly squeezed fruit and vegetable juices was associated with T2DM, which is supported by two European prospective studies [27, 28]. Although some clinical studies supported the antidiabetic effects of vegetables and soy products in Asians [29-31], the present study suggested that consuming > 30 g/d of soy products was associated with T2DM. This discrepancy may be explained by the facts that soy products are often cooked with red meat and drinking sweetened soybean milk in middle China.

This is the first study examining the interaction between dietary factors and FHD on T2DM onset. There were significant interactions between FHD and consuming < 15 g/d of potatoes, <8 g/d of poultry, <85 g/d of fresh fruits, and no freshly squeezed juice. Of course, the individual dietary habits are influenced by the familial dietary habits (PMID: 27050725) [32], and the present study could not tell the amplitude of this influence in relation to FHD. Nevertheless, the present study provides clues about possible changes in dietary habits in individual without T2DM but with FHD.

It was observed that patients with FHD had earlier age at onset of T2DM than those without, indicating that FHD might lead to earlier occurrence of the disease, suggesting genetic and environmental (family) influences on T2DM onset [12]. The proportion of female with FHD was higher than male in both T2DM and non-T2DM groups, which suggested positive FHD might have more influence for female who suffer from T2DM. In the present study, a biparental FHD was more strongly associated with the risk of T2DM, in agreement with earlier observations (in men and women combined) [15]. A higher risk of diabetes was observed in subjects with maternal history when compared with paternal history of diabetes. Previous study indicated that a stronger influence conferred by the mother compared to the father could be due to a larger contribution of diet, lifestyle factors, and adiposity from the mother [33].

The number of risk factors of T2DM in the FHD+ group is less than that of the FHD-group after adjustment for age and sex, which is similar to previous investigations [34-36]. Some relatively hidden factors such as passive smoking might increase the risk of suffering type 2 diabetes for the FHD+ population. In addition, some common risk factors for T2DM such as smoking, drinking, and obesity might increase the risk of T2DM for people without FHD. Previous smoking but not current smoking was associated with T2DM, which suggested patients may quit smoking after diagnosis of T2DM. This study also indicated more walking and higher BMI in T2DM group. The patients may increase physical activity deliberately but not enough to lose weight. The value of health education should be noticed.

Nevertheless, some limitations of this study should also be noted. Most of the information was obtained through an interview, resulting in possible inaccuracy in the risk factor metrics. The potential for recall bias was the second limitation. In studies with a cross-sectional design, a common limitation is the potential reverse causation bias. Associations between some risk factors and T2DM were in unexpected directions, and it might be due to an uncertainty whether exposure preceded the outcome or not. On the other hand, the subjects in the control group could have parents of diabetics, so the exposure level of control group might be raised, which would generate bias in the analysis of infected factors associated T2DM. The last issue might be information bias. A lot of measures were taken to minimize the biases. For example, our questionnaires were administered and checked by well-trained interviewers to exclude inter-interviewer variation, and we conducted the questionnaire study before the diseases were identified.

5. Conclusions

FHD was significantly associated with the risk of diabetes. There was a clear positive interaction between daily intake of potatoes and FHD, while an antagonistic interaction was observed between freshly squeezed vegetables and juices and FHD. FHD could have an appreciable influence on risk factors for T2DM and support that Chinese individuals with FHD should improve their lifestyle before T2DM onset.

https://doi.org/10.1155/2017/9707284

Conflicts of Interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

Authors' Contributions

The first authors Yanyan Zhao and Chunhua Song contributed equally to this work. All authors have conceived and designed the study, performed the experiments, analyzed the data, and written the paper.

Acknowledgments

The authors would like to thank Dr. Chunhua Song, Department of Epidemiology, School of Public Health of Zhengzhou University, Henan, China, for her advice on the study design. This study was supported by the REACTION study (NO12020340324) from the Chinese Medical Association and Chinese Society of Endocrinology. This study was supported by the grants from the Chinese Society of Endocrinology and the National Clinical Research Center for Metabolic Diseases (2013BAI09B13).

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Yanyan Zhao, (1) Chunhua Song, (2) Xiaokun Ma, (1) Xiaojun Ma, (1) Qingzhu Wang, (1) Hongfei Ji, (1) Feng Guo, (1) and Guijun Qin (1)

(1) Division of Endocrinology, Department of Internal Medicine, The First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China

(2) Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou 450052, China

Correspondence should be addressed to Guijun Qin; hyqingj@zzu.edu.cn

Received 30 November 2016; Revised 24 February 2017; Accepted 19 March 2017; Published 13 April 2017

Academic Editor: Andrea Tura
Table 1: Characteristics of the participants.

                                           T2DM
                                          N (%)

Sex (male/female)                        477/757
Age (median, range)                    63 (36, 90)
  [less than or equal to] 49            117 (9.5%)
  50-59                                336 (27.3%)
  60-69                                481 (39.0%)
  70-79                                268 (21.8%)
  [greater than or equal to] 80         30 (2.4%)
BMI (median, range)                 26.2 (15.8, 39.7)
  <18.5                                  7 (0.6%)
  18.5-23.9                            283 (23.1%)
  24-27.9                              546 (44.6%)
  [greater than or equal to] 28        388 (31.7%)
WHR (median, range)                0.918 (0.596, 1.600)

                                         Non-T2DM         P value
                                          N (%)

Sex (male/female)                       2705/5910         <0.001
Age (median, range)                    58 (23, 101)       <0.001
  [less than or equal to] 49           1929 (22.4%)       <0.001
  50-59                                2973 (34.5%)         --
  60-69                                2508 (29.1%)         --
  70-79                                1066 (12.4%)         --
  [greater than or equal to] 80         138 (1.6%)          --
BMI (median, range)                 25.7 (14.2, 39.6)     <0.001
  <18.5                                 77 (0.9%)         <0.001
  18.5-23.9                            2534 (29.6%)         --
  24-27.9                              3683 (43.0%)         --
  [greater than or equal to] 28        2282 (26.6%)         --
WHR (median, range)                0.896 (0.420, 1.598)   <0.001

BMI: body mass index; WHR: waist-to-hip ratio.

Table 2: FHD and lifestyle of the participants.

                     Variables           T2DM            Non-T2DM
                                         N (%)             N (%)

FHD                     Yes           332 (26.9%)      1025 (11.9%)

                        No            902 (73.1%)      7590 (88.1%)

Current smoking        Never         1063 (86.2%)      7278 (84.6%)

                  <7 cigarettes/       47 (3.8%)        285 (3.31%)
                       week

                   [greater than      123 (10.0%)      1037 (12.1%)
                  or equal to] 7
                    cigarettes/
                       week

Previous
smoking
                       Never          920 (81.9%)      6647 (86.3%)

                        <7             81 (7.2%)        496 (6.4%)
                  cigarettes/week

                   [greater than      123 (10.9%)       558 (7.3%)
                  or equal to] 7
                  cigarettes/week

Current                Never          988 (80.1%)      6719 (78.1%)
drinking
                    < once/week       171 (13.9%)      1264 (14.7%)

                   [greater than       74 (6.0%)        616 (7.2%)
                   or equal to]
                     once/week

Grain (g/d)            <300           249 (20.2%)      1682 (19.6%)

                   [greater than      984 (79.8%)      6915 (80.4%)
                   or equal to]
                        300

Potatoes (g/d)          <15           761 (61.7%)      4328 (50.4%)

                   [greater than      472 (38.3%)      4263 (49.6%)
                  or equal to] 15

Pork (g/d)              <15           759 (61.6%)      4856 (56.5%)

                   [greater than      473 (38.4%)      3735 (43.5%)
                  or equal to] 15

Beef and mutton         <4            626 (50.8%)      4341 (50.5%)
(g/d)
                   [greater than      607 (49.2%)      4250 (49.5%)
                  or equal to] 4

Poultry (g/d)           <8            713 (57.8%)      4568 (53.2%)

                   [greater than      520 (42.2%)      4024 (46.8%)
                  or equal to] 8

Fish and                <7            724 (58.7%)      4943 (57.5%)
seafood (g/d)
                   [greater than      509 (41.3%)      3649 (42.5%)
                  or equal to] 7

Vegetable (g/d)        <300           452 (36.7%)      3081 (35.9%)

                   [greater than      781 (63.3%)      5514 (64.2%)
                   or equal to]
                        300

Fresh fruits            <85           834 (67.6%)      4126 (48.0%)
(g/d)
                   [greater than      399 (32.4%)      4466 (52.0%)
                  or equal to] 85

Freshly                 Yes           181 (14.7%)      2301 (26.8%)
squeezed
vegetable and           No           1052 (85.3%)      6288 (73.2%)
fruit juices

Eggs (g/d)              <50           491 (39.8%)      3611 (42.0%)

                   [greater than      743 (60.2%)      4982 (58.0%)
                  or equal to] 50

Soy products            <30           779 (63.2%)      5569 (64.8%)
(g/d)
                   [greater than      454 (36.8%)      3025 (35.2%)
                  or equal to] 30

Days of                 <3            310 (25.1%)      2748 (31.9%)
walking/week
                   [greater than      924 (74.9%)      5867 (68.1%)
                  or equal to] 3

Sitting time on         <3            290 (23.5%)      2116 (24.6%)
weekdays (h/d)
                        3-5           503 (40.8%)      3603 (41.8%)

                        >5            441 (35.7%)      2896 (33.6%)

Sitting time on         <3            323 (26.2%)      2357 (27.4%)
weekend (h/d)
                        3-5           501 (40.6%)      3424 (39.7%)

                        >5            410 (33.2%)      2834 (32.9%)

                     Variables          P value

FHD                     Yes             <0.001

                        No

Current smoking        Never             0.079

                  <7 cigarettes/
                       week

                   [greater than
                  or equal to] 7
                    cigarettes/
                       week

Previous                                <0.001
smoking
                       Never            <0.001

                        <7               0.332
                  cigarettes/week

                   [greater than        <0.001
                  or equal to] 7
                  cigarettes/week

Current                Never             0.209
drinking
                    < once/week

                   [greater than
                   or equal to]
                     once/week

Grain (g/d)            <300              0.603

                   [greater than
                   or equal to]
                        300

Potatoes (g/d)          <15             <0.001

                   [greater than
                  or equal to] 15

Pork (g/d)              <15             <0.001

                   [greater than
                  or equal to] 15

Beef and mutton         <4               0.874
(g/d)
                   [greater than
                  or equal to] 4

Poultry (g/d)           <8               0.002

                   [greater than
                  or equal to] 8

Fish and                <7               0.430
seafood (g/d)
                   [greater than
                  or equal to] 7

Vegetable (g/d)        <300              0.578

                   [greater than
                   or equal to]
                        300

Fresh fruits            <85             <0.001
(g/d)
                   [greater than
                  or equal to] 85

Freshly                 Yes             <0.001
squeezed
vegetable and           No
fruit juices

Eggs (g/d)              <50              0.137

                   [greater than
                  or equal to] 50

Soy products            <30              0.265
(g/d)
                   [greater than
                  or equal to] 30

Days of                 <3              <0.001
walking/week
                   [greater than
                  or equal to] 3

Sitting time on         <3               0.329
weekdays (h/d)
                        3-5

                        >5

Sitting time on         <3               0.674
weekend (h/d)
                        3-5

                        >5

FHD: family history of diabetes.

Table 3: Associations of T2DM with a parental history of T2DM.

                   Crude OR       95% CI       P value

Uniparental FHD     2.022     (1.698, 2.408)   <0.001
Paternal FHD        1.851     (1.416, 2.421)   <0.001
Maternal FHD        2.319     (1.913, 2.812)   <0.001
Biparental FHD       3.53     (2.029, 6.143)   <0.001
FHD                 2.726     (2.366, 3.141)   <0.001

                   Adjusted OR *       95% CI       P value

Uniparental FHD        2.841       (2.358, 3.423)   <0.001
Paternal FHD           2.530       (1.911, 3.349)   <0.001
Maternal FHD           3.274       (2.669, 4.016)   <0.001
Biparental FHD         5.264       (2.975, 9.314)   <0.001
FHD                    3.586       (3.082, 4.173)   <0.001

* Adjusted OR for age, gender, body mass index, and waist-to-hip
ratio. FHD: family history of diabetes.

Table 4: Multivariate analysis of associations between T2DM and
lifestyle.

Variables                              N       Crude OR

Age

BMI

WHR                 Unit = 0.1

FHD                Yes versus no

Sex                 Male versus
                      female

Current smoking        Never          8305        --

                        <7            330        1.28
                  cigarettes/week

                   [greater than      1156      0.831
                  or equal to] 7
                  cigarettes/week

                       Never          7679        --
Current             <once/week        1426      0.889
drinking
                   [greater than      686       0.798
                   or equal to]
                     once/week

Grain (g/d)        [greater than      7877        --
                   or equal to]
                        300

                       <300           1914      1.001

Potatoes (g/d)     [greater than      4720        --
                  or equal to] 15

                        <15           5071      1.411

Pork (g/d)         [greater than      4199        --
                  or equal to] 15

                        <15           5592      1.121

Beef and mutton    [greater than      4836        --
(g/d)             or equal to] 4

                        <4            4955      0.768

Poultry (g/d)      [greater than      4529        --
                  or equal to] 8

                        <8            5262      1.116

Fish and           [greater than      4144        --
seafood (g/d)     or equal to] 7

                        <7            5647      0.876

Vegetable (g/d)    [greater than      6274        --
                   or equal to]
                        300

                       <300           3517      0.973

Fresh fruits       [greater than      4846        --
(g/d)             or equal to] 85

                        <85           4945      2.483

Freshly                 Yes           2478        --
squeezed
vegetable and           No            7313      2.429
fruit juices

Egg (g/d)               <50           3380        --

                   [greater than      706       1.185
                  or equal to] 50

Soy products            <30           5705        --
(g/d)
                   [greater than      6325      1.244
                  or equal to] 30

Days of            [less than or      1510        --
walking/week        equal to] 3

                        >3            1956      1.418

Sitting time on         <3            3040        --
weekdays (h/d)
                        3-5           6751      0.981

                        >5            2380      1.367

Sitting time on         <3            4086        --
weekend (h/d)
                        3-5           3325      1.046

                        >5            2650      0.826

Variables                               95% CI          P

Age

BMI

WHR                 Unit = 0.1

FHD                Yes versus no

Sex                 Male versus
                      female

Current smoking        Never              --            --

                        <7          (0.912, 1.794)    0.153
                  cigarettes/week

                   [greater than    (0.661, 1.045)    0.114
                  or equal to] 7
                  cigarettes/week

                       Never              --            --
Current             <once/week      (0.734, 1.078)    0.232
drinking
                   [greater than    (0.601, 1.061)     0.12
                   or equal to]
                     once/week

Grain (g/d)        [greater than          --            --
                   or equal to]
                        300

                       <300         (0.852, 1.175)    0.993

Potatoes (g/d)     [greater than          --            --
                  or equal to] 15

                        <15         (1.236, 1.61)     <0.001

Pork (g/d)         [greater than          --            --
                  or equal to] 15

                        <15         (0.978, 1.284)     0.1

Beef and mutton    [greater than          --            --
(g/d)             or equal to] 4

                        <4          (0.667, 0.884)    <0.001

Poultry (g/d)      [greater than          --            --
                  or equal to] 8

                        <8          (0.968, 1.287)     0.13

Fish and           [greater than          --            --
seafood (g/d)     or equal to] 7

                        <7          (0.762, 1.008)    0.065

Vegetable (g/d)    [greater than          --            --
                   or equal to]
                        300

                       <300         (0.849, 1.114)    0.687

Fresh fruits       [greater than          --            --
(g/d)             or equal to] 85

                        <85         (2.175,2.835)     <0.001

Freshly                 Yes               --            --
squeezed
vegetable and           No          (2.035, 2.899)    <0.001
fruit juices

Egg (g/d)               <50               --            --

                   [greater than    (1.043, 1.346)    0.009
                  or equal to] 50

Soy products            <30               --            --
(g/d)
                   [greater than    (1.089, 1.42)     0.001
                  or equal to] 30

Days of            [less than or          --            --
walking/week        equal to] 3

                        >3          (1.231, 1.634)    <0.001

Sitting time on         <3                --            --
weekdays (h/d)
                        3-5         (0.781, 1.232)    0.869

                        >5          (1.018, 1.836)    0.038

Sitting time on         <3                --            --
weekend (h/d)
                        3-5         (0.838, 1.305)    0.692

                        >5          (0.618, 1.104)    0.197

Variables                              N       Adjusted OR *

Age                                                1.045

BMI                                                1.022

WHR                 Unit = 0.1                     1.554

FHD                Yes versus no                   3.509

Sex                 Male versus                    1.381
                      female

Current smoking        Never          8254          --

                        <7            327          1.026
                  cigarettes/week

                   [greater than      1150         0.734
                  or equal to] 7
                  cigarettes/week

                       Never          7630          --
Current             <once/week        1418         0.785
drinking
                   [greater than      683          0.672
                   or equal to]
                     once/week

Grain (g/d)        [greater than      7832          --
                   or equal to]
                        300

                       <300           1899         1.04

Potatoes (g/d)     [greater than      4692          --
                  or equal to] 15

                        <15           5039         1.489

Pork (g/d)         [greater than      4175          --
                  or equal to] 15

                        <15           5556         1.051

Beef and mutton    [greater than      4801          --
(g/d)             or equal to] 4

                        <4            4930         0.782

Poultry (g/d)      [greater than      4503          --
                  or equal to] 8

                        <8            5228          1.1

Fish and           [greater than      4120          --
seafood (g/d)     or equal to] 7

                        <7            5611         0.847

Vegetable (g/d)    [greater than      6236          --
                   or equal to]
                        300

                       <300           3495         0.921

Fresh fruits       [greater than      4818          --
(g/d)             or equal to] 85

                        <85           4913         2.339

Freshly                 Yes           2464          --
squeezed
vegetable and           No            7267         2.232
fruit juices

Egg (g/d)               <50           3358          --

                   [greater than      700          1.122
                  or equal to] 50

Soy products            <30           5673          --
(g/d)
                   [greater than      6282         1.191
                  or equal to] 30

Days of            [less than or      1506          --
walking/week        equal to] 3

                        >3            1943         1.29

Sitting time on         <3            3022          --
weekdays (h/d)
                        3-5           6709         0.99

                        >5            2363         1.385

Sitting time on         <3            4069          --
weekend (h/d)
                        3-5           3299         0.986

                        >5            2638         0.747

Variables                               95% CI          P

Age                                 (1.038, 1.053)    <0.001

BMI                                 (1.003, 1.042)    0.021

WHR                 Unit = 0.1      (1.386, 1.742)    <0.001

FHD                Yes versus no    (2.999, 4.107)    <0.001

Sex                 Male versus     (1.165, 1.637)    <0.001
                      female

Current smoking        Never              --            --

                        <7          (0.719, 1.463)    0.888
                  cigarettes/week

                   [greater than    (0.574, 0.939)    0.014
                  or equal to] 7
                  cigarettes/week

                       Never              --            --
Current             <once/week      (0.636, 0.968)    0.024
drinking
                   [greater than    (0.498, 0.906)    0.009
                   or equal to]
                     once/week

Grain (g/d)        [greater than          --            --
                   or equal to]
                        300

                       <300         (0.879, 1.229)    0.649

Potatoes (g/d)     [greater than          --            --
                  or equal to] 15

                        <15         (1.297, 1.709)    <0.001

Pork (g/d)         [greater than          --            --
                  or equal to] 15

                        <15         (0.911,1.212)     0.495

Beef and mutton    [greater than          --            --
(g/d)             or equal to] 4

                        <4          (0.675, 0.907)    0.001

Poultry (g/d)      [greater than          --            --
                  or equal to] 8

                        <8          (0.947,1.277)     0.211

Fish and           [greater than          --            --
seafood (g/d)     or equal to] 7

                        <7           (0.731,0.98)     0.026

Vegetable (g/d)    [greater than          --            --
                   or equal to]
                        300

                       <300          (0.8, 1.061)     0.255

Fresh fruits       [greater than          --            --
(g/d)             or equal to] 85

                        <85         (2.038, 2.684)    <0.001

Freshly                 Yes               --            --
squeezed
vegetable and           No          (1.86, 2.679)     <0.001
fruit juices

Egg (g/d)               <50               --            --

                   [greater than    (0.981, 1.283)    0.092
                  or equal to] 50

Soy products            <30               --            --
(g/d)
                   [greater than    (1.037,1.368)     0.013
                  or equal to] 30

Days of            [less than or          --            --
walking/week        equal to] 3

                        >3          (1.114,1.494)     0.001

Sitting time on         <3                --            --
weekdays (h/d)
                        3-5         (0.779,1.258)     0.934

                        >5          (1.015,1.888)      0.04

Sitting time on         <3                --            --
weekend (h/d)
                        3-5         (0.781,1.245)     0.905

                        >5          (0.551,1.014)     0.061

* Adjusted OR for age, gender, body mass index, waist-to-hip ratio,
and family history of diabetes.

Table 5: Interaction effects between FHD and dietary factors.

                                     Number of      OR of diabetes
                                      exposed
Exposure                               cases

Grain [greater than or equal to]       6818
300 without FHD (reference)

Grain < 300 without FHD                1659      1.061 (0.894, 1.26)

Grain [greater than or equal to]       1081      2.791 (2.382, 3.27)
300 with FHD

Grain < 300 with FHD                    272      2.672 (2.001, 3.568)

Pork [greater than or equal to]        3560
15 without FHD (reference)

Pork < 15 without FHD                  4912      1.306 (1.131, 1.507)

Pork [greater than or equal to]         648      2.876 (2.316, 3.571)
15 with FHD

Pork < 15 with FHD                      703      3.557 (2.905, 4.356)

Potatoes [greater than or equal        4066
to] 15 without FHD (reference)

Potatoes < 15 without FHD              4405      1.599 (1.388, 1.843)

Potatoes [greater than or equal         669      2.694 (2.161, 3.358)
to] 15 with FHD

Potatoes < 15 with FHD                  684      4.529 (3.713, 5.525)

Beef and mutton [greater than or       4132
equal to] 4 without FHD
(reference)

Beef and mutton < 4 without FHD        4339      1.002 (0.873, 1.151)

Beef and mutton [greater than or        725      2.537 (2.08, 3.096)
equal to] 4 with FHD

Beef and mutton < 4 with FHD            628      2.974 (2.426, 3.645)

Poultry [greater than or equal         3841
to] 8 without FHD (reference)

Poultry < 8 without FHD                4631      1.215 (1.056, 1.398)

Poultry [greater than or equal          703      2.545 (2.063, 3.139)
to] 8 with FHD

Poultry < 8 with FHD                    650      3.649 (2.981, 4.465)

Fish and seafood [greater than or      3546
equal to] 7 without FHD
(reference)

Fish and seafood < 7 without FHD       4926      1.048 (0.91, 1.206)

Fish and seafood [greater than or       612      2.585 (2.081, 3.212)
equal to] 7 with FHD

Fish and seafood < 7 with FHD           741      2.999 (2.463, 3.652)

Vegetable [greater than or equal       5400
to] 300 without FHD (reference)

Vegetable < 300 without FHD            3075      1.055 (0.915, 1.217)

Vegetable [greater than or equal        895      2.744 (2.302, 3.273)
to] 300 with FHD

Vegetable < 300 with FHD                458      2.875 (2.288, 3.613)

Fresh fruits [greater than or          4166
equal to] 85 without FHD
(reference)

Fresh fruits < 85 without FHD          4307      2.222 (1.918, 2.574)

Fresh fruits [greater than or           699      2.505 (1.979, 3.172)
equal to] 85 with FHD

Fresh fruits < 85 with FHD              653      6.91 (5.651, 8.451)

Freshly squeezed juice (yes)           2210
without FHD (reference)

Freshly squeezed juice (no)            6259      1.922 (1.599, 2.31)
without FHD

Freshly squeezed juice (yes) with       272      2.005 (1.349, 2.98)
FHD

Freshly squeezed juice (no) with       1081      5.342 (4.313, 6.616)
FHD

Egg < 50 without FHD (reference)       3560

Egg [greater than or equal to] 50      4915      1.102 (0.957, 1.268)
without FHD

Egg < 50 with FHD                      1081      2.833 (2.263, 3.548)

Egg [greater than or equal to] 50       810      2.934 (2.419, 3.559)
with FHD

Soy products < 30 without FHD          5506
(reference)

Soy products [greater than or          1659       1.03 (0.892, 1.19)
equal to] 30 without FHD

Soy products < 30 with FHD              842      2.629 (2.194, 3.149)

Soy products [greater than or           511      2.989 (2.409, 3.707)
equal to] 30 with FHD

                                          S (95% CI)

Exposure

Grain [greater than or equal to]
300 without FHD (reference)

Grain < 300 without FHD

Grain [greater than or equal to]
300 with FHD

Grain < 300 with FHD                 0.902 (0.547, 1.489)

Pork [greater than or equal to]
15 without FHD (reference)

Pork < 15 without FHD

Pork [greater than or equal to]
15 with FHD

Pork < 15 with FHD                   1.172 (0.83, 1.657)

Potatoes [greater than or equal
to] 15 without FHD (reference)

Potatoes < 15 without FHD

Potatoes [greater than or equal
to] 15 with FHD

Potatoes < 15 with FHD               1.539 (1.117, 2.121)

Beef and mutton [greater than or
equal to] 4 without FHD
(reference)

Beef and mutton < 4 without FHD

Beef and mutton [greater than or
equal to] 4 with FHD

Beef and mutton < 4 with FHD         1.282 (0.856, 1.919)

Poultry [greater than or equal
to] 8 without FHD (reference)

Poultry < 8 without FHD

Poultry [greater than or equal
to] 8 with FHD

Poultry < 8 with FHD                 1.505 (1.044, 2.171)

Fish and seafood [greater than or
equal to] 7 without FHD
(reference)

Fish and seafood < 7 without FHD

Fish and seafood [greater than or
equal to] 7 with FHD

Fish and seafood < 7 with FHD        1.224 (0.821, 1.824)

Vegetable [greater than or equal
to] 300 without FHD (reference)

Vegetable < 300 without FHD

Vegetable [greater than or equal
to] 300 with FHD

Vegetable < 300 with FHD             1.042 (0.693, 1.566)

Fresh fruits [greater than or
equal to] 85 without FHD
(reference)

Fresh fruits < 85 without FHD

Fresh fruits [greater than or
equal to] 85 with FHD

Fresh fruits < 85 with FHD           2.167 (1.633, 2.877)

Freshly squeezed juice (yes)
without FHD (reference)

Freshly squeezed juice (no)
without FHD

Freshly squeezed juice (yes) with
FHD

Freshly squeezed juice (no) with     2.253 (1.456, 3.487)
FHD

Egg < 50 without FHD (reference)

Egg [greater than or equal to] 50
without FHD

Egg < 50 with FHD

Egg [greater than or equal to] 50    0.999 (0.681, 1.467)
with FHD

Soy products < 30 without FHD
(reference)

Soy products [greater than or
equal to] 30 without FHD

Soy products < 30 with FHD

Soy products [greater than or        1.199 (0.803, 1.79)
equal to] 30 with FHD

FHD: family history of diabetes.
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Title Annotation:Research Article
Author:Zhao, Yanyan; Song, Chunhua; Ma, Xiaokun; Ma, Xiaojun; Wang, Qingzhu; Ji, Hongfei; Guo, Feng; Qin, G
Publication:International Journal of Endocrinology
Article Type:Report
Geographic Code:9CHIN
Date:Jan 1, 2017
Words:7132
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