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DiabetologiaDOI 10.1007/s00125-009-1516-3 Coffee and tea consumption and risk of type 2 diabetes S. van Dieren & C. S. P. M. Uiterwaal &Y. T. van der Schouw & D. L. van der A & J. M. A. Boer &A. Spijkerman & D. E. Grobbee & J. W. J. Beulens Received: 6 May 2009 / Accepted: 7 August 2009 of tea per day (p for trend=0.002). Total daily consumption Aims/hypothesis The aim of this study was to examine the of at least three cups of coffee and/or tea reduced the risk of association of consumption of coffee and tea, separately type 2 diabetes by approximately 42%. Adjusting for blood and in total, with risk of type 2 diabetes and which factors pressure, magnesium, potassium and caffeine did not Methods This research was conducted as part of the Dutch Conclusions/interpretation Drinking coffee or tea is asso- Contribution to the European Prospective Investigation into ciated with a lowered risk of type 2 diabetes, which cannot Cancer and Nutrition, which involves a prospective cohort of be explained by magnesium, potassium, caffeine or blood 40,011 participants with a mean follow-up of 10 years. A pressure effects. Total consumption of at least three cups of validated food-frequency questionnaire was used to assess coffee or tea per day may lower the risk of type 2 diabetes.
coffee and tea consumption and other lifestyle and dietaryfactors. The main outcome was verified incidence of type 2 Keywords Blood pressure . Caffeine . Coffee . Magnesium .
diabetes. Blood pressure, caffeine, magnesium and potassium Potassium . Prospective study . Tea . Type 2 diabetes were examined as possible mediating factors.
Results During follow-up, 918 incident cases of type 2 diabetes were documented. After adjustment for potential confounders, coffee and tea consumption were both inverse- Dutch Contribution to European Prospective ly associated with type 2 diabetes, with hazard ratios of 0.77 (95% CI 0.63–0.95) for 4.1–6.0 cups of coffee per day (p for trend=0.033) and 0.63 (95% CI: 0.47–0.86) for >5.0 cups Monitoring Project on Risk Factors forChronic Diseases S. van Dieren : C. S. P. M. Uiterwaal : Y. T. van der Schouw : D. E. Grobbee J. W. J. Beulens (*)Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht,P.O. Box 85500, 3508 GA Utrecht, the Netherlandse-mail: [email protected] The prevalence of type 2 diabetes mellitus has increaseddramatically in the past decades and is estimated to double from 171 million people in 2000 to 366 million in 2030 The majority of diabetes cases could be prevented by National Institute of Public Health and the Environment (RIVM),Bilthoven, the Netherlands changes in lifestyle and diet [, An inverse relationbetween coffee intake and type 2 diabetes has been reported by a number of large cohort studies []. The association of Centre for Prevention and Health Services Research, tea consumption with the risk of type 2 diabetes and the National Institute of Public Health and the Environment (RIVM),Bilthoven, the Netherlands effects of total coffee and tea consumption are not entirely clear. One study did not find an association between tea MORGEN cohort consists of men and women aged 20– intake and type 2 diabetes while another study observed 59 years recruited from three Dutch towns (Amsterdam, Doetinchem and Maastricht). From 1993 to 1997 each year The underlying mechanism for the relation between a new random sample of about 5,000 participants was coffee and tea consumption and type 2 diabetes is unclear.
examined. These rounds of enrolment add up to 22,654 Several components in coffee and tea have been suggested individuals. The participation rates were 34.5% for Prospect as possible causal factors. Magnesium plays a role in regulating insulin action and is inversely associated with At baseline, a general questionnaire and a food-frequency insulin sensitivity and type 2 diabetes []. Potassium intake questionnaire (FFQ) were mailed to all participants and these has also been associated with a reduced risk of diabetes [].
were returned at the medical examination. We excluded 246 Caffeine may affect glucose tolerance, although conflicting participants with missing data on coffee and tea consumption, results have been reported. It increases energy expenditure 615 participants with diabetes at baseline and 974 individuals and thermogenesis, which can stimulate insulin sensitivity without consent for linkage to disease registries, leaving but short-term intervention studies reported a decreased 38,176 participants for this analysis.
insulin sensitivity after caffeine intake , Finally, at All participants gave written informed consent prior to least two studies found an inverse relation between coffee study inclusion. Both cohorts comply with the Declaration consumption and occurrence of hypertension , and of Helsinki. Prospect was approved by the Institutional previous studies showed that elevated blood pressure Review Board of the University Medical Centre Utrecht predates type 2 diabetes and is independently associated and MORGEN was approved by the Medical Ethics with risk of type 2 diabetes , ]. This could be Committee of the Netherlands Organization for Applied explained by the inverse relation between high blood pressure and the ability of insulin to stimulate skeletalblood flow, which causes insulin resistance ]. So far General assessments The general questionnaires contained there is no conclusive evidence about whether these factors questions on demographic characteristics and risk factors explain the inverse relation between coffee and tea intake for the presence of chronic diseases. Although the general questionnaires for the cohorts were not identical, similar Therefore, we investigated the associations of coffee and questions were asked with slightly different answer cate- tea consumption with risk of type 2 diabetes, and whether gories. Coding of this information was standardised and these relations are mediated by blood pressure and intake of merged into one uniform database. Body weight, height and potassium, magnesium and caffeine, in the Dutch Contri- waist and hip circumferences were measured. Blood bution to European Prospective Investigation into Cancer pressure was measured twice on the left arm while the and Nutrition (EPIC-NL), involving a prospective cohort of participants were in a supine position. The mean of the two 40,011 Dutch men and women. This research is an blood pressure measurements was used in the analysis. In extension of an earlier investigation in which the associa- the Prospect study, the systolic and diastolic blood tion of coffee consumption and risk of type 2 diabetes was pressures were measured using a Boso Oscillomat (Bosch investigated. The current study was not only focused on & Sohn, Jungingen, Germany), while a random zero coffee consumption, but the association of tea consumption sphygmomanometer (Hawksley & Sons, Lancing, UK) and total consumption of coffee and tea with risk of type 2 was used in the MORGEN cohort. The comparability of diabetes was assessed. In addition, this study has six these different measurement procedures has been described additional years of follow-up from 40,011 participants, in more detail by Schulze et al. ]. The assessment of the compared with 17,000 participants, and it was based on Prospect cohort slightly overestimated the blood pressure In both cohorts daily food intake was assessed using the same validated FFQ, which included questions on the usual frequency of consumption of 77 main food groups duringthe year preceding enrolment. Overall, the questionnaire Study population and design The EPIC-NL cohort com- allows estimation of the average daily consumption of 178 prises the Monitoring Project on Risk Factors for Chronic foods. The FFQ was validated against 12 months of 24 h Diseases (MORGEN) and Prospect cohorts [The recalls in 121 participants before the start of the study [ methods used are described in more detail elsewhere ].
]. Hypertension was defined as present based on several In brief, Prospect is a prospective population-based cohort aspects: a physician-diagnosed self-report or measured study of 17,357 women aged 49–70 years who participated hypertension >140 mmHg systolic or >90 mmHg diastolic in breast cancer screening between 1993 and 1997. The or the use of blood-pressure-lowering medication. Postal follow-up questionnaires were sent every 3–5 years to all if so, additional questions were asked about the year of participants in order to detect changes in health status.
diagnosis and treatment. The incidence of type 2 diabetes To investigate if coffee and tea consumption are also was assessed by self-report in follow-up questionnaires.
associated with biomarkers of type 2 diabetes, several With the first follow-up questionnaire, participants received biomarkers were measured in a 6.5% random sample (n= a urinary glucose strip test and were asked whether the 2,604) and in incident cases of type 2 diabetes. HbA1c was urine strip had turned purple after 10 s, indicating measured in erythrocytes using an immunoturbidimetric glucosuria. Also, data on the diagnosis of type 2 diabetes latex test. Alanine aminotransferase, aspartate aminotrans- were obtained from the Dutch Centre for Health Care ferase, gamma-glutamyltransferase, total cholesterol and Information, which holds a standardised computerised triacylglycerol were measured using enzymatic methods, register of hospital discharge diagnoses (all diagnoses were while high-sensitive C-reactive protein was measured with coded according to the International Classification of a turbidimetric method. HDL-cholesterol and LDL- Diseases, ninth revision [ICD-9, ICD codes 250]) [ cholesterol were measured using homogeneous assays with The records from this database were linked to the EPIC-NL cohort with a validated probabilistic method ]. Type 2diabetes was defined as potentially present when self-report, Assessment of beverages The FFQ was used to assess the urinary glucose strip test or hospital discharge diagnoses amount of coffee and tea consumed daily. Participants were reported a positive response. All potential cases of type 2 asked how many cups of coffee and tea on average they diabetes were verified against medical records of the general consumed per day/per week/per month/per year. Further- practitioners and pharmacists. They were asked if diabetes more, participants were asked how often they consumed was diagnosed and, if so, in what year and which type. Only decaffeinated coffee with the following categories: always/ cases of type 2 diabetes that were verified were included as mostly (90%); often (65%); sometimes (35%); and seldom/ cases (88.6% of the potential incident cases were verified).
never (10%). These percentages were multiplied by total Information on vital status was obtained through linkage amount of coffee to determine how many cups of with the municipal administration registries.
decaffeinated coffee participants drank on average. Partic-ipants were also asked how many non-alcoholic drinks they Statistical analysis Follow-up time was calculated from the consumed and what percentage of these were caffeinated date of enrolment to the date of diabetes diagnosis or date soft drinks with identical answer categories. These percen- of death; all other participants were censored at the end of tages were multiplied by total amount of non-alcoholic follow up (January 2006). Baseline characteristics accord- drinks to obtain the number of glasses of caffeinated soft ing to category of daily coffee and tea consumption were drinks. Total fluid intake was calculated by adding up total evaluated using ANOVA for continuous variables and χ2 intake of juices, water, milk and carbonated drinks, and excluding coffee and tea intake. We used data from the To examine the association between coffee and tea validation study ] to estimate the reliability of the consumption and incidence of type 2 diabetes we used Cox assessment of coffee and tea consumption. We observed a proportional hazard regression. Hazard ratios and 95% Spearman correlation coefficient of 0.74 for coffee consump- confidence intervals for type 2 diabetes were calculated for tion and 0.87 for tea consumption between the FFQ and 12 each category of coffee or tea intake against a reference 24 h recalls. The coffee consumption was divided into six group of low consumers (for coffee) or non-consumers (for categories: 0–1.0 cups (reference group); 1.1–2.0 cups; 2.1– tea), corrected for age (continuous), sex (male or female) 3.0 cups; 3.1–4.0 cups; 4.1–6.0 cups; and >6.0 cups per day.
and cohort (Prospect or MORGEN). A second multivariate Because of a different distribution of tea consumption, tea model corrected for other known risk factors included consumption was divided into five groups: 0–1.0 cups smoking (present, former or never smokers), BMI (<20.0, (reference group); 1.1–2.0 cups; 2.1–3.0 cups; 3.1–5.0 cups; 20.0–24.9, 25.0–29.9 or ≥30.0 kg/m²), highest education and >5.0 cups per day. Finally, the number of cups of coffee level (low, intermediate or high), physical activity (inactive, and tea reported by an individual was added up and divided into moderately inactive, moderately active or active), family five categories: 0–1.0 cups (reference group); 1.1–3.0 cups; history of diabetes (present or not present), alcohol intake 3.1–5.0 cups; 5.1–7.0 cups; and >7.0 cups of coffee and tea (continuous), daily energy intake (continuous), energy- adjusted saturated fat intake (continuous), energy-adjustedintake of fibre and vitamin C (both continuous), hyperten- Assessment of type 2 diabetes The assessment of type 2 sion and hypercholesterolaemia (present or not). A third diabetes has been described in more detail elsewhere ].
model corrected for tea consumption (for coffee hazard The general questionnaire contained questions of whether ratios) and coffee consumption (for tea hazard ratios), or not a participant had been diagnosed with diabetes and, because participants who drank a lot of coffee tended to drink less tea and vice versa and both beverages have been likelihood ratio test. Furthermore, the association between associated with the development of type 2 diabetes.
several biomarkers for type 2 diabetes and coffee and tea Furthermore, we repeated the analysis with only four consumption has been examined by conducting a linear categories of coffee and tea to see if the observed regression analysis corrected for the same variables as used associations changed significantly. Also, hazard ratios were calculated for total consumption of coffee and tea, using the The Cox proportional hazards assumption was examined multivariate adjusted model. Because results may be by visually inspecting log–log plots with no deviations confounded by total fluid intake, this was checked by detected. p values<0.05 from two-tailed analyses were including it in the model with total coffee and tea considered statistically significant. All statistical analyses consumption. Total fluid intake consisted of total intake of were performed using SPSS for Windows version 14.0 juices, water, milk and carbonated soft drinks. To test for a linear trend, we calculated the median for each category ofcoffee and tea consumption and included this as acontinuous variable in the model. The square of this termwas used to test for a quadratic trend.
Mediating factors were included in the multivariate model to assess the differences in hazard ratio of the linear As coffee consumption increased, so did BMI, alcohol term. The mediating factors examined were systolic and consumption, energy intake and prevalence of smoking, but diastolic blood pressure and daily intake of magnesium, tea consumption decreased (Table Increasing tea consump- potassium and caffeine (both unadjusted and energy tion was associated with a reduction in alcohol consumption, adjusted), all as continuous variables. To further examine BMI, energy intake and physical activity (Table the effects of caffeine, hazard ratios with 95% confidence During a mean follow-up of 10 years, 918 incident cases intervals were calculated for decaffeinated coffee and of type 2 diabetes were documented. A U-shaped associ- caffeinated soft drinks. Interactions of coffee or tea ation between coffee consumption and risk of type 2 consumption with sex, age, BMI, caffeine and smoking diabetes was observed (Table ). Adjusting for tea were explored by including the interaction term of any of consumption lowered the hazard ratios, with the lowest these combinations in the multivariate model using a hazard ratio for 4.1–6.0 cups of coffee/day (0.74 [95% CI Table 1 Baseline characteristics by daily coffee and tea consumption in 38,176 participants a Energy-adjusted* All p values are <0.05 for the comparison between coffee consumption categories Table 2 Baseline characteristics by daily tea consumption in 38,176 participants a Energy-adjusted* All p values are <0.05 for the comparison between tea consumption categories 0.61–0.91], ptrend=0.019). A strong inverse association was or between caffeinated soft drinks and risk of type 2 diabetes observed between tea consumption and risk of type 2 (1.64 [0.60–4.49] for drinking >3.0 glasses of caffeinated soft diabetes (Table ). After multivariate adjustments and drink/day). Excluding hypertensive patients resulted in similar adjusting for coffee consumption the lowest hazard ratio hazard ratios for tea consumption and even stronger associa- was 0.68 (95% CI 0.52–0.89) for >5.0 cups of tea/day tions for coffee consumption (HR coffee 0.62 [95% CI 0.46– (ptrend=0.01). Substituting waist circumference for BMI did 0.83], HR tea 0.70 [95% CI 0.48–1.02]). Stronger associations not alter the results (HR coffee 0.74 [95% CI 0.61–0.91]).
were also observed when patients with hyperlipidaemia, There were 8,819 people who drank >1.0 cup of decaf- hypertension and prevalent cases of CVD were excluded feinated coffee/day and 228 participants in this group (HR coffee 0.55 [95% CI 0.40–0.77], HR tea 0.60 [95% CI developed type 2 diabetes. We found no association between 0.39–0.92]). Similar associations occurred when coffee and tea decaffeinated coffee intake and risk of type 2 diabetes (1.13 consumption were both divided into four categories (HR 0.75 [95% CI 0.76–1.67] for >1.0 cup of decaffeinated coffee/day) [95% CI 0.61–0.92] for >5.0 cups of coffee).
Table 3 Daily coffee consumption and hazard ratios (95% CI) for the risk of type 2 diabetes among 38,176 Dutch men and women 1.00 0.85 (0.67–1.07) 0.96 (0.77–1.19) 0.73 (0.59–0.90) 0.78 (0.64–0.94) 1.00 0.89 (0.70–1.12) 0.98 (0.79–1.22) 0.77 (0.62–0.95) 0.80 (0.65–0.97) 1.00 0.88 (0.69–1.11) 0.94 (0.75–1.17) 0.75 (0.60–0.92) 0.74 (0.61–0.910) 0.84 (0.65–1.08) 0.019 a Adjusted for cohort, sex, age, BMI, highest education, physical activity, family history of diabetes, smoking, alcohol intake, energy intake,energy-adjusted saturated fat intake, energy-adjusted fibre intake, energy-adjusted vitamin C intake, hypercholesterolaemia and hypertension Table 4 Daily tea consumption and hazard ratios (95% CI) for the risk of type 2 diabetes among 38,176 Dutch men and women a Adjusted for cohort, sex, age, BMI, highest education, physical activity, family history of diabetes, smoking, alcohol intake, energy intake,energy-adjusted saturated fat Using the data on total amount of coffee and tea consumed (HR 0.64 [95% CI 0.46–0.89]) and lowered the hazard ratio resulted in a stronger inverse association with the risk of type 2 for coffee further (HR 0.72 [95% CI 0.57–0.90]).
diabetes (Fig. Consumption of at least three cups of coffee Adjusting for several mediating factors did not alter the and/or tea per day was associated with a reduced risk of type results. The hazard ratios for 4.1–6.0 cups of coffee were 2 diabetes of approximately 42% (HR 0.58 [95% CI 0.42– similar after adjusting for diastolic and systolic blood 0.80], ptrend <0.001). Drinking more than three cups of pressure (0.76 [95% CI 0.62–0.94]), for magnesium and coffee and/or tea did not substantially lower the hazard ratio potassium (0.75 [95% CI 0.62–0.93]) and for caffeine (0.73 any further. The relative amount of coffee vs tea did not [95% CI 0.50–1.07]). The hazard ratio for >6.0 cups of tea affect the associations for total consumption.
was 0.64 (95% CI 0.47–0.86) after adjusting for diastolic Similar associations were observed when we adjusted for blood pressure and potassium, 0.63 (95% CI 0.47–0.86) total fluid consumption, the hazard ratio for type 2 diabetes after adjusting for systolic blood pressure and magnesium, was 0.53 (95% CI 0.39–0.73) for consumption of >7.0 cups and for caffeine 0.61 (95% CI 0.42–0.90). No significant of coffee and tea/day (ptrend <0.001). Excluding cases interactions of coffee or tea consumption with sex, age, obtained in the first 4 years, to prevent reverse causation, BMI and smoking were observed. We observed no did not significantly alter the observed associations for tea significant association between coffee or tea consumptionand any of the examined biomarkers.
In this cohort of 38,176 men and women, both coffee and tea consumption were associated with a lowered risk oftype 2 diabetes. Consumption of at least three cups of coffee and/or tea was associated with a lowered risk of type 2 diabetes. Blood pressure and intake of magnesium,potassium and caffeine did not explain these associations.
The strengths of this study are its large sample size, prospective design, validation of diabetes cases and extensive information about lifestyle and diet of the participants, but some limitations need to be addressed.
First, we relied on self-reported coffee and tea consumption and therefore misclassification may have occurred. How-ever, we validated the assessment of coffee and tea Fig. 1 Hazard ratios (95% CI) for the risk of type 2 diabetes by dailytotal consumption of coffee and tea among 38,176 Dutch men and consumption, showing correlations over 0.75. A second women. Adjusted for cohort, sex, age, BMI, highest education, limitation of our study is the assessment of decaffeinated physical activity, family history of diabetes, smoking, alcohol intake, coffee. Participants could only indicate in categories how energy intake, energy-adjusted saturated fat intake, energy-adjusted much decaffeinated coffee they consumed. Therefore, we fibre intake, energy-adjusted vitamin C intake, hypercholesterolaemiaand hypertension could not accurately assess the effect of decaffeinated coffee. Similarly, no specific information on green tea We observed an inverse association between tea con- consumption was available. However, only 4.6% of the total sumption and type 2 diabetes over the entire range, even amount of tea consumed in the Netherlands is green tea ].
though the hazard ratio for two to three cups/day was Second, the presence of type 2 diabetes is often undetected, slightly higher. Although we could not differentiate and may remain preclinical for up to 9–12 years []. Patients between black and green tea, an estimated 95% of the total with undetected type 2 diabetes in our cohort may have been tea consumption is black tea in the Netherlands [ misclassified as people without diabetes, resulting in attenu- Recently, a study reported that both black and green tea ation of associations. As a sensitivity analysis we excluded lower blood glucose concentrations [Combined with prevalent cases of cardiovascular disease, hypertension or our results, it seems likely that the association between tea hyperlipidaemia, which resulted in slightly stronger estimates.
consumption and type 2 diabetes is not solely due to Third, participants may have changed their coffee and tea consumption over the years because of their health.
Moreover, consumption of at least three cups of coffee Excluding cases obtained in the first 4 years did not alter and/or tea was associated with a lowered risk of type 2 diabetes. A similar inverse relation for combined consump- Last, coffee and tea drinkers have very different—almost tion of coffee and tea has been observed in the Whitehall II opposite—health behaviour. Coffee drinkers tend to smoke study []. Unfortunately, these analyses were limited by more and have a less healthy diet, while tea consumption is small sample size (n=2,300), and coffee and tea consump- associated with a healthier lifestyle. Such confounding tion was divided into only two categories, therefore no could attenuate the observed relation, particularly for tea effect of consuming a greater amount of coffee and tea consumption, while it could partly explain the increased risks in the higher-intake categories for coffee consumption.
Blood pressure and intake of magnesium, potassium and Although we have adjusted for several lifestyle and dietary caffeine were included in our model to assess whether these factors, we cannot exclude residual confounding.
factors mediated the observed association, but none affected The observed reduction in risk of type 2 diabetes with the associations substantially. One study observed a higher coffee consumption is in line with previous studies borderline inverse association between magnesium intake –although our study did not indicate a strong and risk of type 2 diabetes. However, magnesium did not dose-response relation. In our study population, high coffee explain the relation between coffee and type 2 diabetes in consumption was strongly related to low tea consumption.
our study, similar to other studies , ]. In our study Associations unadjusted for tea consumption could there- up to three cups of coffee was associated with higher blood fore be confounded by lower consumption of tea in the pressure, but more than four cups of coffee was associated high-intake groups, leading to higher risks. These results with a lowered blood pressure. However, the inclusion of could then reflect the effect of lower tea consumption blood pressure in the model did not explain the association instead of higher coffee consumption. Most studies on between coffee or tea consumption and type 2 diabetes.
coffee consumption did not account for tea consumption Caffeine intake only slightly attenuated the relation be- –However, this cannot solely explain the increased tween coffee consumption and type 2 diabetes, but the risks in the higher categories of coffee consumption.
correlation between coffee and caffeine was 0.86, making it Another explanation could be residual confounding by difficult to distinguish the effects of coffee and caffeine.
unhealthy lifestyles in the categories of higher coffee Furthermore, no association between several biomarkers consumption. In addition, it could be explained by higher and coffee and tea consumption has been observed.
intake of ingredients associated with increased risks of type These results suggest that other factors may be more 2 diabetes, such as kahweol and cafestol [ important to explain the relation of coffee and tea Several studies have investigated the associations between consumption with type 2 diabetes. The effect of total coffee tea consumption and type 2 diabetes. Some of these studies did and tea consumption could indicate that the beneficial effect not find any associations [, , ], while one study of coffee and tea consumption is due to their antioxidant observed an inverse relation for both coffee and black tea content. Coffee is rich in the antioxidant chlorogenic acid consumption and type 2 diabetes but not for green tea [].
and tea contains flavonols and flavones as antioxidants [ Another study found an association only for green tea, not ]. Antioxidants may reduce the amount of reactive for black or oolong tea [A recent meta-analysis oxygen species, which activate stress-sensitive pathways.
summarised these studies and concluded that consumption These pathways can lead to insulin resistance, impaired of at least four cups of tea may lower the risk of type 2 insulin secretion and beta cell dysfunction [ diabetes, but a reduced risk was not observed for one to three This relation is still controversial, as studies examining cups of tea per day In addition, they were unable to dietary and serum antioxidants with type 2 diabetes show distinguish between black and green tea in this meta-analysis.
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