Associations of Number of Daily Eating Occasions with Type 2 Diabetes Risk in the Women’s Health Initiative Dietary Modification Trial

Abstract

Background Over 23 million Americans have type 2 diabetes (T2D). Eating habits such as breakfast consumption, time-restricted eating and limiting daily eating occasions have been explored as behaviors for reducing T2D risk, but prior evidence is inconclusive. Objective To examine associations between number of daily eating occasions and T2D risk in the Women's Health Initiative Dietary Modification Trial (WHI-DM) and whether associations vary by body mass index (BMI), age, or race/ethnicity. Methods Participants were postmenopausal women in the WHI-DM who comprised a 4.6% subsample completing 24-hour dietary recalls (24HR) at years 3 and 6 as part of trial adherence activities (n = 2,159). Numbers of eating occasions/day were obtained from the year 3 24HR and participants were grouped into approximate tertiles as 1–3 (n = 795), 4 (n = 713) and ≥ 5 (n = 651) daily eating occasions as the exposure. Incident diabetes was self-reported on semi-annual questionnaires as the outcome. WHI-DM is registered at clinicaltrials.gov (NCT00000611). Results Fifteen % (15.4%, n = 332) of the WHI-DM 24HR cohort reported incident diabetes at follow-up Cox proportional hazards regression tested associations of eating occasions with T2D adjusted for neighborhood socioeconomic status (NSES), BMI, waist circumference, race/ethnicity, family history of T2D, recreational physical activity, Healthy Eating Index (HEI)-2005, 24HR energy intake and WHI-DM arm. Compared to women reporting 1–3 meals/day, those consuming 4 meals/day had a T2D HR = 1.38 (95%CI 1.03–1.84) without further increases in risk for ≥ 5 meals/day. In stratified analyses, associations for 4 meals/day compared to 1–3 meals/day were stronger in women with BMI < 30.0 kg/m2 (HR = 1.55, 95% CI 1.00–2.39) and women ≥ age 60 (HR = 1.61, 95% CI 1.11–2.33). Conclusions 4 daily meals/day compared to 1–3 meals/day was associated with increased risk of T2D in postmenopausal women, but no dose-response effect was observed for additional eating occasions. Further studies are needed to understand eating occasions in relation to T2D risk.

Meal frequency and incidence of type 2 diabetes: a prospective study

“…However, after further adjusting for baseline BMI, no significant association remained (RR: 1.13 [0.87, 1.46] and 1.04 [0.92, 1.17], respectively) (13) (14) . Another cohort study from the Women's Health Initiative Dietary Modification Trial (WHI-DM) showed similar results that 4 meals/d compared with 1-3 meals/d was associated with an increased risk of type 2 diabetes in postmenopausal women (HR: 1.38 [1.03, 1.84]) (15) . Overall, these 3 cohort studies of U.S. populations showed an increase in risk of type 2 diabetes among people eating 4 or 5 times/day, which may be partly explained by baseline BMI.…”

“…To our knowledge, only three prospective cohort studies (13)(14)(15) have reported the association between meal frequency and risk of type 2 diabetes. The Nurses' Health Study (NHS) of US women showed that in comparison with women who ate three times per day, the RR for type 2 diabetes were 1•09 (0•84, 1•41) for women (13) .…”

“…Also, cohort studies examining the association between meal frequency and type 2 diabetes posed controversial results. Two prospective cohort studies reported the non-significant association between eating frequency and risk of type 2 diabetes (13,14) , while one study found an increased risk of type 2 diabetes in people eating four meals per day compared with those eating 1-3 meals per day (15) .…”

“…Of note, all the three cohort studies (13)(14)(15) were performed in the USA, where the prevalence of overweight and obesity is high, and no evidence existed from Asian population on this topic. Therefore, the objective of this study was to examine the association between meal frequency and risk of type 2 diabetes in a Chinese population.…”

News and Views

“…And it's worth noting that the Women's Health Initiative no less, in its dietary modification trial reporting in July this year, amazingly found that postmenopausal women eating four meals a day had a higher risk of type 2 diabetes than those getting by on just one to three. 6…”