Egg consumption and risk of incident type 2 diabetes in men: the

Kuopio Ischaemic Heart Disease Risk Factor Study13

Jyrki K Virtanen, Jaakko Mursu, Tomi-Pekka Tuomainen, Heli EK Virtanen, and Sari Voutilainen

ABSTRACT Among dietary factors, egg consumption has been implicated

Background: The prevalence of type 2 diabetes (T2D) is increasing as one possible risk factor. Egg is a major source of dietary
around the world. Eggs are a major source of cholesterol, which has cholesterol (w200 mg/egg), which has been associated with
been associated with elevated blood glucose and an increased risk of impaired glucose metabolism (3) and increased inflammation
T2D. However, there are limited and conflicting data from prospec- (4) in animal models and with elevated fasting glucose (5) and
tive population studies on the association between egg consumption higher risk of T2D (6, 7) in humans. However, in randomized
and risk of T2D. controlled trials, the addition of eggs to the diet has reduced

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Objective: We investigated the association between egg consump- plasma insulin and insulin resistance (8), decreased inflammatory
tion and risk of incident T2D in middle-aged and older men from markers (911), and increased the formation of larger and less-
eastern Finland. dense LDL and HDL particles (8, 12). Both inflammation (13)
Design: The study included 2332 men aged 4260 y in 19841989 and certain lipoprotein subclasses characterized by small and dense
at the baseline examinations of the prospective, population-based LDL and HDL particles (14, 15) have been shown to predict the
Kuopio Ischaemic Heart Disease Risk Factor Study. Dietary intakes risk of T2D. There are, however, no trials of the effect of egg
were assessed with 4-d food records at baseline. Incident T2D was consumption on T2D incidence. In addition, the epidemiologic
assessed by self-administered questionnaires; by fasting and 2-h oral- data on the impact of egg consumption on the risk of T2D are
glucose-tolerance-test blood glucose measurement at re-examination scarce. Five prospective studies evaluated the association between
rounds 4, 11, and 20 y after baseline; and by record linkage to a egg consumption and risk of incident T2D and found either no
hospital discharge registry and reimbursement register of diabetes association (1619) or a direct association (20), whereas 1 cross-
medication expenses. Cox proportional hazards regression analyses
sectional (21) and 1 case-control study (22) both found a direct
were used to estimate associations with the risk of incident T2D.
association.
Associations with the metabolic risk markers at baseline and at the
Eggs are a common, affordable, and readily available food
4-y examinations were analyzed by ANCOVA.
item worldwide and, in addition to cholesterol, also a good source
Results: During an average follow-up of 19.3 y, 432 men developed
of many potentially beneficial nutrients, such as high-quality
T2D. After adjustment for potential confounders, those in the highest
protein, fatty acids, minerals, and vitamins, so it is important to
compared with the lowest egg intake quartile had a 38% (95% CI: 18%,
53%; P-trend across quartiles ,0.001) lower risk of incident T2D.
elucidate their impact on disturbances in glucose metabolism.
Analyses with metabolic risk markers also suggested an inverse associ- This is especially important because egg consumption does not
ation with fasting plasma glucose and serum C-reactive protein but not appear to increase the risk of cardiovascular disease in the general
with serum insulin. The associations between cholesterol intake and risk population but seems to increase the risk among diabetic patients
of T2D, plasma glucose, serum insulin, and C-reactive protein were (23, 24). Therefore, because the evidence on the impact of egg
mainly nonsignificant, especially after accounting for egg consumption. consumption on the risk of T2D is limited and mixed, we in-
Conclusion: Higher egg intake was associated with a lower risk of vestigated the association between egg consumption and risk of
T2D in this cohort of middle-aged and older men. Am J Clin Nutr incident T2D in middle-aged and older men from eastern Finland.
2015;101:108896. We previously showed that egg consumption was not associated
with carotid atherosclerosis or risk of myocardial infarction in
Keywords: diet, eggs, men, prospective study, type 2 diabetes
1
From the Institute of Public Health and Clinical Nutrition, University of
Eastern Finland, Kuopio, Finland.
INTRODUCTION 2
Supported by the University of Eastern Finland.
3
With the increasing prevalence of type 2 diabetes (T2D)4 Address correspondence to JK Virtanen, University of Eastern Finland,
around the world due mainly to the worsening obesity epidemic Institute of Public Health and Clinical Nutrition, PO Box 1627, FI-70211
Kuopio, Finland. E-mail: [email protected].
(1), there is a need to investigate modifiable factors that are 4
Abbreviations used: APOE4, apolipoprotein E4; CRP, C-reactive protein;
related to the risk of T2D to reduce its individual and societal KIHD, Kuopio Ischaemic Heart Disease Risk Factor Study; T2D, type 2
burden and its comorbidities. Evidence from observational and diabetes.
experimental studies suggests that dietary factors have a major Received November 27, 2014. Accepted for publication March 10, 2015.
role in the prevention and management of T2D (2). First published online April 1, 2015; doi: 10.3945/ajcn.114.104109.

1088 Am J Clin Nutr 2015;101:108896. Printed in USA. 2015 American Society for Nutrition
 EGG CONSUMPTION AND RISK OF TYPE 2 DIABETES 1089
this study population (25). In secondary analyses we also in- confound the findings. In the subgroup analyses, data for the
vestigated the association of egg consumption with plasma glucose, APOE4 phenotype were available for 1193 men.
serum insulin, and serum C-reactive protein (CRP) at baseline and in
a subgroup after 4 y of follow-up. We also investigated these as-
sociations with cholesterol intake. In the subgroup analysis, we Other measurements
investigated the impact of the apolipoprotein E4 (APOE4) pheno- Fasting venous blood samples were collected between 0800
type, a major determinant in the response to dietary cholesterol and 1000 at baseline and at the follow-up examinations. Subjects
(26), on the association between egg and cholesterol intakes and were instructed to abstain from ingesting alcohol for 3 d and from
glucose metabolism. smoking and eating for 12 h before providing the sample. De-
tailed descriptions of the determination of serum lipids and li-
poproteins (28) and serum fatty acids (29) and the assessment of
METHODS medical history and medications (28), family history of diseases
(28), smoking (28), alcohol consumption (28), blood pressure
Study population (28), and physical activity (30) at baseline have been published.
The Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Education was assessed in years by using self-administered
Study was designed to investigate risk factors for cardiovascular questionnaires. Annual income was obtained from a self-ad-
disease, atherosclerosis, and related outcomes in a population- ministered questionnaire. Family history of diabetes was defined
based, randomly selected sample of men from eastern Finland as positive if a first-degree relative of the participant had a history
(27). The baseline examinations were carried out in 19841989 of diabetes. A diagnosis of hypertension was defined as systolic/
diastolic blood pressure .140/90 mm Hg or the use of hyper-

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(Figure 1). A total of 2682 men who were 42, 48, 54, or 60 y old
at baseline (83% of those eligible) were recruited in 2 cohorts. tension medication. BMI was computed as the ratio of weight in
The first cohort consisted of 1166 men who were 54 y old and kilograms to the square of height in meters. APOE4 phenotype
enrolled in 19841986, and the second cohort included 1516 was determined from plasma with isoelectric focusing and im-
men who were 42, 48, 54, or 60 y old and enrolled in 1986 munoblotting techniques. Subjects with 1 or 2 apolipoprotein e4
1989. The baseline examinations were followed by the 4-y ex- alleles were included in the APOE4 group. The diagnosis of
amination round (19911993) in which 1038 men from the metabolic syndrome was based on the definition by the National
second cohort (88% of those eligible) participated. At the 11-y Cholesterol Education Program Adult Treatment Panel III.
examination round (19982001), all of the men from the second
cohort were invited and 854 men (95% of those eligible) partic-
ipated. During the 20-y examination round, all eligible partici- Assessment of dietary intakes
pants from the first and second cohorts were invited to the study The consumption of foods at baseline was assessed with a guided
site. A total of 1241 men (80% of those eligible) participated. The food record of 4 consecutive days, one of which was a weekend day,
baseline characteristics of the entire study population were de- by household measures. A picture book of common foods and
scribed previously (27). The KIHD study protocol was approved dishes was used to help in the estimation of portion sizes and
by the Research Ethics Committee of the University of Kuopio. contained 126 of the most common foods and drinks consumed in
All subjects gave written informed consent for participation. Finland during the 1980s. For each food item, the participant could
Subjects with T2D (n = 167), impaired fasting glucose (n = choose from 3 to 5 commonly used portion sizes or describe the
127), or unknown diabetes status (n = 38) at baseline or those portion size in relation to those shown in the book. To further
with missing data on dietary intakes (n = 18) were excluded, improve accuracy, instructions were given and completed food
which left 2332 men for the analyses of incident T2D. Data on records were checked by a nutritionist together with the participant.
plasma glucose, serum insulin, and CRP were available for 2312 Nutrient intakes were estimated by using NUTRICA 2.5 software
men at baseline and for 880 men at the 4-y examinations. In the (Social Insurance Institution). The softwares databank is mainly
analyses with these biomarkers, participants with a diagnosis of based on Finnish values of nutrient composition of foods. The egg
T2D at the 4-y examinations were excluded from the analyses consumption variable used in this study represents total egg con-
with the 4-y data because the use of diabetes treatment could sumption, including eggs in mixed dishes and recipes.

FIGURE 1 Timeline of the Kuopio Ischaemic Heart Disease Risk Factor Study. The percentages in parentheses indicate the proportion of eligible
participants who participated in the study visits.
1090 VIRTANEN ET AL.

Measurement of plasma glucose, serum insulin, and serum the associations (,5% change in estimates). The cohort mean
CRP was used to replace missing values in covariates (,0.5%) (33).
Both at baseline and at the 4-y examinations, plasma glucose Tests of linear trend were conducted by assigning the median
was measured by using a glucose dehydrogenase method after values for each category of exposure variable and treating those
precipitation of proteins by trichloroacetic acid. The serum as a single continuous variable. The statistical significance of
samples for insulin determination were stored frozen at 808C. the interactions with BMI, APOE4 phenotype, and metabolic
Serum insulin was determined with a Novo Biolabs radioim- syndrome status on a multiplicative scale was assessed by
munoassay kit (Novo Nordisk). Serum CRP was measured with likelihood ratio tests with the use of a cross-product term. All P
an immunometric assay (Immulite High Sensitivity CRP Assay; values were 2-tailed (a = 0.05). Correlations were estimated by
Diagnostic Products Corporation). Spearman correlation coefficients. Data were analyzed by using
SPSS 21.0 for Windows (IBM Corporation).

Diagnostic criteria for T2D

RESULTS
T2D was defined as a self-reported physician diagnosis of T2D
and/or fasting plasma glucose $7.0 mmol/L or 2-h oral-glucose- At baseline, men with a higher egg intake were more likely to
tolerance-test plasma glucose $11.1 mmol/L at the re-examination be younger and to have lower serum triglyceride and higher
rounds 4, 11, and 20 y after baseline and by record linkage to the serum apolipoprotein A-I concentrations (Table 1). They were
national hospital discharge registry and to the Social Insurance also less likely to smoke and less likely to have ischemic heart
Institution of Finland register for reimbursement of medicine ex- disease and hypertension. They also had higher intakes of energy,
unprocessed red meat, dairy, SFAs and MUFAs, linoleic acid,

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penses used for T2D for the entire study period until the end of the
follow-up on 31 December 2010. fiber, coffee, and cholesterol and lower intake of carbohydrates.
Impaired fasting glucose at baseline was defined by using the The average egg intake was 33 g/d [median (SD): 27 (26) g/d].
WHO criterion: fasting plasma glucose of 6.16.9 mmol/L. The Among participants, 377 (16.2%) consumed at least 55 g/d (equiv-
2-h oral-glucose-tolerance test was not performed at study baseline. alent to w1 medium egg). Only 22 participants did not consume
eggs at all during the 4-d food recording period and only 2 subjects
reported using egg whites. The average cholesterol intake was
Statistical analysis 396 mg/d [median (SD): 372 (153) mg/d]. The correlation coeffi-
The univariate relations between egg consumption and baseline cient between egg consumption and cholesterol intake was 0.66.
characteristics were assessed by means and linear regression (for During the average follow-up of 19.3 y (SD: 6.6 y; minimum
continuous variables) or by chi-square tests (for categorical var- maximum: 0.226.8 y; 45,008 person-years) a total of 432 T2D
iables). Cox proportional hazards regression models were used to events occurred. After adjustment for age, examination year, and
estimate HRs in quartiles of egg and cholesterol intakes, with the energy intake in the Cox regression model (Table 2, model 1),
lowest category as the reference. The validity of the proportional there was a lower risk of T2D with increasing egg intake (P-
hazards assumption was evaluated by using Schoenfeld residuals. trend across quartiles ,0.001). However, the lowest risk was
Absolute risk reduction was calculated by multiplying the absolute observed already in the third egg intake quartile (median intake:
risk in the reference group by the multivariable-adjusted HR re- 35 g/d or a little more than half a medium egg), and higher egg
duction in the comparison group. The mean values of plasma intake did not provide further reductions in risk. Compared with
glucose and serum insulin and CRP in quartiles of egg con- the lowest quartile (median intake: 9 g/d or w1 medium egg/wk),
sumption were analyzed by using ANCOVA, with adjustments for the relative risk reduction in the third quartile was 37% (95% CI:
potential confounders. The confounders were selected on the basis 17%, 52%; absolute risk in the lowest quartile: 21.0%; absolute
of established risk factors for T2D, previously published associ- risk reduction in the third quartile: 13.2%). When evaluated
ations with T2D in the KIHD study (29, 31, 32), or on associations continuously, each additional egg per day (55 g) was associated
with exposures or outcomes in the present analysis. Model 1 in- with a 30% lower risk (HR: 0.70; 95% CI: 0.55, 0.90). Further
cluded age (y), examination year, and energy intake (kcal/d). The multivariate adjustments for potential confounders (model 2) did
multivariate model (model 2) included the variables in model 1 and not have a major impact on the associations, but further adjust-
BMI (kg/m2), family history of T2D (yes or no), hypertension ment for cholesterol intake (model 3) slightly strengthened the
(yes or no), smoking (never smoker; previous smoker; current association.
smoker, ,20 cigarettes/d; and current smoker, $20 cigarettes/d), Cholesterol intake was not associated with the risk of T2D
education years, leisure-time physical activity (kcal/d), serum after adjustment for age, examination year, and energy intake
long-chain omega-3 PUFAs (percentage of all serum fatty acids), (Table 3, model 1). However, after further multivariate adjust-
and intakes of alcohol (g/d), linoleic acid (18:2n26; % of en- ment (model 2), cholesterol intake showed a pattern with risk
ergy), fiber (g/d), and fruit, berries, and vegetables (g/d). Model 3 similar to what was observed with egg consumptionthat is, the
included the variables in model 2 and either cholesterol intake risk was significantly lower already in the third tertile and little
(mg/d) in the analyses with egg consumption or egg consumption change was observed with a higher cholesterol intake. However,
(g/d) in the analyses with cholesterol intake. All quantitative vari- further adjustment for egg consumption (model 3) attenuated the
ables were entered in the models as continuous variables. Further association.
adjustments for waist-to-hip ratio, serum 25-hydroxyvitamin D, In the analyses with glucose metabolism markers, higher egg
glycemic load, or intakes of carbohydrates, saturated, mono- intake was associated with modestly lower plasma glucose
unsaturated, or trans fatty acids, processed or unprocessed red concentrations both at baseline and at the 4-y examinations,
meat, dairy, coffee, or magnesium had no appreciable impact on especially after cholesterol intake was accounted for (Table 4,
 EGG CONSUMPTION AND RISK OF TYPE 2 DIABETES 1091
TABLE 1
Baseline characteristics according to dietary egg intake1
Egg consumption quartile

Characteristic 1 (,14 g/d) 2 (1426 g/d) 3 (2745 g/d) 4 (.45 g/d) P-trend

Subjects, n 585 579 586 582

Age, y 53.4 6 5.22 52.9 6 5.3 53.0 6 5.1 52.7 6 5.0 0.03
BMI, kg/m2 26.7 6 3.6 26.5 6 3.2 26.6 6 3.3 26.6 6 3.3 0.83
Leisure-time physical activity, kcal/d 135 6 166 138 6 166 158 6 210 131 6 148 0.79
Income, V 12,840 6 9675 13,635 6 9060 13,545 6 8265 13,170 6 8755 0.80
Education, y 8.4 6 3.4 8.9 6 3.6 8.8 6 3.4 8.7 6 3.5 0.43
Serum EPA + DPA3 + DHA, % 4.67 6 1.64 4.61 6 1.55 4.66 6 1.52 4.76 6 1.60 0.21
Serum LDL cholesterol, mmol/L 4.07 6 1.09 4.09 6 1.02 4.03 6 1.01 4.00 6 0.96 0.16
Serum HDL cholesterol, mmol/L 1.30 6 0.32 1.29 6 0.31 1.28 6 0.27 1.33 6 0.31 0.16
Serum apolipoprotein B, g/L 1.04 6 0.25 1.04 6 0.24 1.03 6 0.24 1.02 6 0.24 0.06
Serum apolipoprotein A-I, g/L 1.33 6 0.27 1.33 6 0.26 1.33 6 0.24 1.36 6 0.26 0.02
Serum triglycerides, mmol/L 1.34 6 0.79 1.30 6 0.76 1.24 6 0.66 1.19 6 0.79 ,0.001
Systolic blood pressure, mm Hg 134 6 17 133 6 17 133 6 17 133 6 16 0.80
Diastolic blood pressure, mm Hg 89 6 10 88 6 10 88 6 10 88 6 10 0.40
Alcohol intake, g/wk 83 6 145 63 6 94 60 6 92 85 6 176 0.35
Current smoker, % 39 32 27 30 0.002

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Hypertension, % 63 57 58 55 0.02
Ischemic heart disease, % 30 23 22 19 ,0.001
Stroke, % 3 3 2 2 0.24
Family history of type 2 diabetes, % 24 27 30 26 0.58
Dietary intakes
Energy, kcal/d 2151 6 582 2348 6 592 2414 6 554 2619 6 674 ,0.001
Cholesterol, mg/d 291 6 110 342 6 106 406 6 107 545 6 148 ,0.001
Protein, % of energy 15.7 6 2.9 15.4 6 2.5 15.7 6 2.7 15.5 6 2.5 0.30
SFAs, % of energy 17.9 6 4.9 17.7 6 4.1 18.0 6 4.0 18.8 6 4.0 ,0.001
PUFAs, % of energy 4.5 6 1.6 4.6 6 1.6 4.5 6 1.5 4.4 6 1.3 0.06
Linoleic acid, % of energy 3.3 6 1.4 3.5 6 1.5 3.3 6 1.2 3.2 6 1.2 0.02
MUFAs, % of energy 10.7 6 2.3 10.9 6 2.3 10.9 6 2.3 11.2 6 2.0 ,0.001
trans Fatty acids, % of energy 1.1 6 0.4 1.1 6 0.4 1.0 6 0.4 1.1 6 0.4 0.96
Carbohydrates, % of energy 43.6 6 7.0 44.4 6 6.6 44.1 6 6.0 42.1 6 6.7 ,0.001
Glycemic load 140 6 30 144 6 30 139 6 35 142 6 31 0.43
Glycemic index 56 6 8 56 6 7 56 6 7 56 6 7 0.15
Fiber, g/d 23.7 6 9.0 25.7 6 8.8 25.7 6 8.5 25.9 6 9.0 ,0.001
Unprocessed red meat, g/d 62 6 46 69 6 49 68 6 44 72 6 51 0.001
Processed red meat, g/d 70 6 61 69 6 63 67 6 56 73 6 61 0.33
Dairy, g/d 727 6 378 733 6 363 745 6 352 806 6 382 ,0.001
Fruit, berries, and vegetables, g/d 232 6 161 261 6 156 260 6 147 253 6 147 0.11
Coffee, mL/d 545 6 285 545 6 292 585 6 290 592 6 311 0.001
1
P-trend was assessed by using linear regression (continuous variables) or by chi-square test (categorical variables). 1
medium egg weighs w55 g.
2
Mean 6 SD (all such values).
3
DPA, docosapentaenoic acid (22:5n3).

model 3). No association was found with serum insulin (Table may be attenuated by a long follow-up period. The multivariate-
4). Higher egg intake was also associated with lower CRP, but adjusted HRs for T2D (72 cases) in quartiles of egg consumption
the association was significant only with the 4-y examination were 1, 0.79, 0.69, and 0.41 (95% CI: 0.19, 0.89; P-trend = 0.02;
data (Table 4) and was attenuated after further adjustment for model 2). After further adjustment for cholesterol intake, HRs
cholesterol intake. Dietary cholesterol intake was associated were 1, 0.76, 0.58, and 0.29 (95% CI: 0.11, 0.74; P-trend = 0.01).
with higher glucose and insulin concentrations at baseline, es- For cholesterol intake, the multivariate-adjusted HRs were 1,
pecially after adjustment for egg intake (Table 5, model 3). No 1.20, 1.16, and 0.76 (95% CI: 0.29, 1.97; P-trend = 0.54; model
significant associations were observed with glucose or insulin at 2), and after further adjustment for egg consumption HRs were 1,
the 4-y examinations. The associations with CRP were generally 1.48, 1.72, and 1.62 (95% CI: 0.52, 5.07; P-trend = 0.41). We also
nonsignificant, except for the inverse association at the 4-y exam- investigated the impact of excluding participants with coronary
inations after multivariate adjustment (model 2). However, further heart disease at baseline (n = 545), because those who had ex-
adjustment for egg intake attenuated the association (model 3). perienced a coronary heart disease event might have changed
In the sensitivity analyses, we evaluated the associations of egg their dietary habits. This could explain the lower frequency of
and cholesterol intakes with T2D incidence after 10 y of follow-up, participants with a history of coronary heart disease among those
because the associations with a single measurement at baseline with a higher egg intake (Table 1). After exclusion, the associations
1092 VIRTANEN ET AL.
TABLE 2
Incident type 2 diabetes in 2332 men according to egg consumption at baseline in 198419891
Egg consumption quartile

1 (,14 g/d) 2 (1426 g/d) 3 (2745 g/d) 4 (.45 g/d) P-trend

Subjects, n 585 579 586 582

Incidence rate/1000 person-years 12.0 10.9 8.0 7.9
Model2
1 1 0.86 (0.67, 1.11) 0.63 (0.48, 0.83) 0.63 (0.47, 0.83) ,0.001
2 1 0.91 (0.71, 1.18) 0.63 (0.48, 0.83) 0.62 (0.47, 0.82) ,0.001
3 1 0.90 (0.69, 1.16) 0.59 (0.44, 0.80) 0.55 (0.38, 0.79) 0.001
1
One medium egg weighs w55 g.
2
Values are HRs (95% CIs) derived by Cox proportional hazards regression models. Model 1 was adjusted for age,
examination year, and energy intake (kcal/d). Model 2 was adjusted as for model 1 plus BMI (kg/m2), family history of type
2 diabetes (yes or no), hypertension (yes or no), smoking (never smoker; previous smoker; current smoker, ,20 cigarettes/
d; current smoker, $20 cigarettes/d), education years, leisure-time physical activity (kcal/d), serum long-chain omega-3
PUFAs (percentage of all serum fatty acids), and intakes of alcohol (g/d), linoleic acid (% of energy), fiber (g/d), and fruit,
berries, and vegetables (g/d). Model 3 was adjusted as for model 2 and dietary cholesterol intake (mg/d).

with egg consumption remained similar but were attenuated with 0.001; model 2) than in those with a BMI equal to or greater than

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cholesterol intake. The multivariate-adjusted HR in the highest vs. the median (extreme quartile HR: 0.74; 95% CI: 0.52, 1.04; P-
the lowest egg intake quartile was 0.69 (95% CI: 0.50, 0.96; P- trend = 0.03), there was no evidence for statistical interaction
trend = 0.01; model 2) and after further adjustment for cholesterol (P-interaction = 0.21). There was also no evidence for effect
intake the HR was 0.58 (95% CI, 0.38, 0.90; P-trend = 0.01; model modification by baseline BMI in the analyses with plasma glucose,
3). For cholesterol intake, the multivariate-adjusted HR in the serum insulin, and serum CRP (P-interaction . 0.05). Adjustment
highest vs. the lowest quartile was 0.81 (95% CI: 0.53, 1.24; P- of the models for the 4-y change in BMI instead of the baseline
trend = 0.15) and after further adjustment for egg consumption the BMI did not have an appreciable effect on the associations (data
HR was 0.95 (95% CI: 0.56, 1.61; P-trend = 0.54). We also ex- not shown). Cholesterol intake showed a similar direct, but weaker,
cluded from the analyses the T2D events that occurred during the association with the 4-y change in BMI (unadjusted difference
first 2 y of follow-up (n = 3) but that had no effect on the asso- between the extreme quartiles: 0.12; 95% CI: 20.43, 0.20; P-trend
ciations (data not shown). Finally, because adiposity is a major risk = 0.84). Adjustment for the 4-y change in BMI instead of the
factor for T2D, and weight gain could potentially have an effect on baseline BMI in the analyses with glucose metabolism markers
glucose metabolism markers such as plasma glucose, we also in- (Table 5) did not appreciably change the associations (data not
vestigated whether higher egg intake was associated with better shown). Baseline BMI also did not modify the association between
weight management between the baseline and the 4-y examina- cholesterol intake and risk of T2D (P-interaction = 0.84) or glucose
tions. However, the 4-y change in BMI was greater in those with metabolism markers (P-interaction . 0.05). Because participants
a higher baseline egg intake [unadjusted difference between the with metabolic syndrome (n = 156) are more likely to develop T2D
highest and the lowest quartile (in kg/m2): 0.26, 95% CI: 20.05, during follow-up, we also evaluated whether metabolic syndrome
0.58; P-trend = 0.03]. Furthermore, although the inverse associa- could modify the associations between egg or cholesterol intake
tion between egg consumption and risk of T2D was stronger in and risk of T2D. However, we found no evidence for effect
those with a baseline BMI below the median of 26.3 (multivariate- modification by metabolic syndrome status (P-interaction . 0.05).
adjusted extreme quartile HR: 0.43; 95% CI: 0.26, 0.72; P-trend = Finally, in the subgroup of 1193 men for whom APOE4 phenotype

TABLE 3
Incident type 2 diabetes in 2332 men according to cholesterol intake at baseline in 19841989
Cholesterol intake quartile

1 (,291 mg/d) 2 (291371 mg/d) 3 (372478 mg/d) 4 (.478 mg/d) P-trend

Subjects, n 583 583 583 583

Incidence rate/1000 person-years 10.3 11.4 8.2 8.7
Model1
1 1 1.13 (0.86, 1.47) 0.78 (0.58, 1.06) 0.84 (0.59, 1.20) 0.12
2 1 1.06 (0.81, 1.39) 0.67 (0.49, 0.91) 0.66 (0.46, 0.96) 0.01
3 1 1.12 (0.85, 1.49) 0.75 (0.53, 1.05) 0.84 (0.53, 1.34) 0.20
1
Values are HRs (95% CIs) derived by Cox proportional hazards regression models. Model 1 was adjusted for age,
examination year, and energy intake (kcal/d). Model 2 was adjusted as for model 1 plus BMI (kg/m2), family history of type
2 diabetes (yes or no), hypertension (yes or no), smoking (never smoker; previous smoker; current smoker, ,20 cigarettes/
d; current smoker, $20 cigarettes/d), education years, leisure-time physical activity (kcal/d), serum long-chain omega-3
PUFAs (percentage of all serum fatty acids), and intakes of alcohol (g/d), linoleic acid (% of energy), fiber (g/d), and fruit,
berries, and vegetables (g/d). Model 3 was adjusted as for model 2 and egg consumption (g/d).
 EGG CONSUMPTION AND RISK OF TYPE 2 DIABETES 1093
TABLE 4
Markers of glucose homeostasis and inflammation at baseline and after 4 y of follow-up according to egg consumption at baseline in 198419891
Egg consumption quartile

1 2 3 4 P-trend

Fasting plasma glucose, mmol/L

Baseline number of participants (intake, g/d) 579 (,14) 577 (1426) 578 (2745) 578 (.45)
Model 1 4.55 (4.52, 4.58) 4.51 (4.48, 4.57) 4.50 (4.47, 4.54) 4.52 (4.49, 4.56) 0.40
Model 2 4.55 (4.52, 4.58) 4.52 (4.49, 4.55) 4.50 (4.47, 4.54) 4.52 (4.49, 4.55) 0.27
Model 3 4.57 (4.54, 4.61) 4.53 (4.50, 4.57) 4.50 (4.47, 4.53) 4.48 (4.44, 4.52) 0.002
Number of participants at 4 y (intake, g/d) 220 (,14) 222 (1425) 218 (2541) 220 (.41)
Model 1 4.88 (4.83, 4.95) 4.85 (4.79, 4.91) 4.83 (4.77, 4.89) 4.80 (4.74, 4.85) 0.03
Model 2 4.88 (4.83, 4.94) 4.86 (4.81, 4.92) 4.82 (4.77, 4.88) 4.79 (4.74, 4.85) 0.02
Model 3 4.90 (4.83, 4.96) 4.87 (4.81, 4.93) 4.82 (4.77, 4.88) 4.78 (4.71, 4.84) 0.02
Fasting serum insulin, mU/L
Baseline number of participants (intake, g/d) 579 (,14) 577 (1426) 578 (2745) 578 (.45)
Model 1 10.95 (10.44, 11.45) 10.84 (10.35, 11.34) 10.62 (10.12, 11.11) 11.07 (10.56, 11.57) 0.73
Model 2 10.96 (10.53, 11.40) 10.91 (10.48, 11.34) 10.57 (10.14, 11.00) 11.03 (10.59, 11.47) 0.88
Model 3 11.12 (10.64, 11.60) 11.00 (10.56, 11.45) 10.55 (10.13, 10.98) 10.79 (10.26, 11.33) 0.35
Number of participants at 4 y (intake, g/d) 220 (,14) 222 (1425) 218 (2541) 220 (.41)
Model 1 7.66 (6.98, 8.33) 6.98 (6.31, 7.64) 7.42 (6.75, 8.09) 7.36 (5.58, 8.05) 0.86

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Model 2 7.31 (6.73, 7.89) 7.30 (6.73, 7.87) 7.33 (6.76, 7.91) 7.47 (6.88, 8.06) 0.68
Model 3 7.52 (6.89, 8.15) 7.42 (6.83, 8.00) 7.32 (6.75, 7.89) 7.15 (6.45, 7.85) 0.49
C-reactive protein, mg/L
Baseline number of participants (intake, g/d) 579 (,14) 577 (1426) 578 (2745) 578 (.45)
Model 1 2.54 (2.21, 2.87) 2.37 (2.04, 2.70) 2.18 (1.85, 2.50) 2.17 (1.84, 2.51) 0.13
Model 2 2.40 (2.07, 2.73) 2.43 (2.11, 2.75) 2.28 (1.96, 2.60) 2.14 (1.81, 2.47) 0.20
Model 3 2.42 (2.06, 2.79) 2.45 (2.11, 2.78) 2.28 (1.96, 2.60) 2.11 (1.71, 2.51) 0.26
Number of participants at 4 y (intake, g/d) 220 (,14) 222 (1425) 218 (2541) 220 (.41)
Model 1 3.38 (2.50, 4.26) 3.93 (3.06, 4.79) 3.15 (2.28, 4.02) 2.27 (1.38, 3.17) 0.03
Model 2 3.21 (2.33, 4.09) 4.09 (3.23, 4.95) 3.14 (2.30, 4.03) 2.26 (1.36, 3.15) 0.04
Model 3 3.07 (2.11, 4.03) 4.01 (3.12, 4.90) 3.17 (2.30, 4.04) 2.47 (1.41, 3.54) 0.26
1
Values are means (95% CIs) obtained by using ANCOVA unless otherwise indicated. Model 1 was adjusted for age, examination year, and energy intake
(kcal/d). Model 2 was adjusted as for model 1 plus BMI (kg/m2), family history of type 2 diabetes (yes or no), hypertension (yes or no), smoking (never
smoker; previous smoker; current smoker, ,20 cigarettes/d; current smoker, $20 cigarettes/d), education years, leisure-time physical activity (kcal/d), serum
long-chain omega-3 PUFAs (percentage of all serum fatty acids), and intakes of alcohol (g/d), linoleic acid (% of energy), fiber (g/d), and fruit, berries, and
vegetables (g/d). Model 3 was adjusted as for model 2 and dietary cholesterol intake (mg/d). One medium egg weighs w55 g.

data were available, APOE4 phenotype (n = 394) did not modify found either a direct association (2022) or no association (16
the associations with either egg or cholesterol intake (P-interaction 19) with higher intake. However, one of these studies was
. 0.05). a cross-sectional analysis (21) and one was a case-control study
(22). The limitations of case-control and cross-sectional study
designs in nutrition research, such as reverse causation and re-
DISCUSSION call and selection biases, warrant caution in interpreting the
In this prospective, population-based cohort study in middle- results from these studies. These limitations are largely avoided
aged and older men, higher egg intake was associated with lower with a prospective study design, in which the information on
risk of incident T2D. The analyses with metabolic risk markers dietary intakes is collected before the occurrence of disease. The
for T2D suggested an inverse association with fasting plasma association between egg consumption and risk of T2D has been
glucose and serum CRP but not with serum insulin. The asso- investigated in 5 prospective studies (1620) and only one found
ciation between cholesterol intake and risk of T2D was similar to a direct association (20).
that of egg consumption but was attenuated after adjusting for egg Most studies have assessed egg intake by using food-frequency
consumption. Cholesterol intake also had an unfavorable asso- questionnaires, which do not usually contain detailed information
ciation with plasma glucose and serum insulin, although most about egg consumption, such as eggs in mixed dishes or eggs used
associations were not significant. in baking. However, this would add random error to the estimates
The average egg intake in our study was similar to the average of egg intake, which would attenuate the true associations. One
intake in another study population from Finland (16) and in potential explanation for the opposite findings is that eggs are
studies from China (21) and Japan (19) and in the Adventist seldom consumed in isolation but are usually eaten as part of
Health Studies in the United States (17) but was higher than in a mixed dish. For example, in many countries, eggs are com-
other study cohorts from the United Statesthe Cardiovascular monly consumed with processed red meat, such as bacon, sau-
Health Study (18) and the Physicians Health Study and the sages, or burgers, and processed red meat has been associated
Womens Health Study (20). Our finding of a lower T2D risk with a higher risk of T2D (34). Also, in many studies that found
with higher egg intake is in contrast with these studies, which a positive association between higher egg intake and risk of T2D
1094 VIRTANEN ET AL.
TABLE 5
Markers of glucose homeostasis and inflammation at baseline and after 4 y of follow-up according to cholesterol intake at baseline in 198419891
Cholesterol intake quartile

1 2 3 4 P-trend

Fasting plasma glucose, mmol/L

Baseline number of participants (intake, mg/d) 578 (,291) 578 (291371) 578 (372478) 578 (.478)
Model 1 4.51 (4.47, 4.55) 4.49 (4.46, 4.52) 4.51 (4.47, 4.54) 4.58 (4.54, 4.62) 0.01
Model 2 4.52 (4.49, 4.56) 4.50 (4.47, 4.53) 4.50 (4.47, 4.53) 4.56 (4.52, 4.60) 0.13
Model 3 4.51 (4.46, 4.55) 4.49 (4.46, 4.52) 4.50 (4.47, 4.54) 4.59 (4.54, 4.63) 0.03
Number of participants at 4 y (intake, mg/d) 220 (,277) 220 (277347) 220 (348455) 220 (.455)
Model 1 4.88 (4.82, 4.94) 4.82 (4.77, 4.88) 4.84 (4.78, 4.90) 4.83 (4.76, 4.89) 0.45
Model 2 4.90 (4.83, 4.96) 4.83 (4.77, 4.89) 4.83 (4.78, 4.89) 4.81 (4.74, 4.87) 0.16
Model 3 4.88 (4.81, 4.95) 4.82 (4.76, 4.88) 4.83 (4.78, 4.89) 4.83 (4.75, 4.91) 0.56
Fasting serum insulin, mU/L
Baseline number of participants (intake, mg/d) 578 (,291) 578 (291371) 578 (372478) 578 (.478)
Model 1 10.45 (9.89, 11.02) 10.47 (9.97, 10.97) 10.99 (10.49, 11.49) 11.56 (10.98, 12.14) 0.01
Model 2 10.54 (10.04, 11.04) 10.65 (10.21, 11.08) 10.91 (10.48, 11.34) 11.38 (10.86, 11.90) 0.03
Model 3 10.35 (9.78, 10.92) 10.56 (10.12, 11.01) 10.93 (10.50, 11.35) 11.63 (11.00, 12.26) 0.01
Number of participants at 4 y (intake, mg/d) 220 (,277) 220 (277347) 220 (348455) 220 (.455)
Model 1 6.99 (6.23, 7.74) 6.82 (6.14, 7.50) 7.73 (7.06, 8.40) 7.88 (7.10, 8.65) 0.07

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Model 2 7.04 (6.27, 7.71) 6.96 (6.38, 7.54) 7.65 (7.08, 8.22) 7.76 (7.07, 8.45) 0.12
Model 3 7.05 (6.31, 7.78) 6.96 (6.36, 7.55) 7.65 (7.08, 8.22) 7.75 (7.07, 8.57) 0.19
C-reactive protein, mg/L
Baseline number of participants (intake, mg/d) 578 (,291) 578 (291371) 578 (372478) 578 (.478)
Model 1 2.25 (1.88, 2.63) 2.37 (2.03, 2.70) 2.17 (1.84, 2.50) 2.46 (2.08, 2.85) 0.60
Model 2 2.40 (2.02, 2.78) 2.42 (2.10, 2.75) 2.19 (1.87, 2.51) 2.24 (1.85, 2.63) 0.49
Model 3 2.25 (1.82, 2.68) 2.36 (2.02, 2.70) 2.20 (1.88, 2.53) 2.44 (1.97, 2.91) 0.75
Number of participants at 4 y (intake, mg/d) 220 (,277) 220 (277347) 220 (348455) 220 (.455)
Model 1 3.34 (2.36, 4.32) 3.76 (2.87, 4.64) 2.91 (2.03, 3.78) 2.73 (1.72, 3.73) 0.27
Model 2 3.69 (2.67, 4.71) 3.95 (3.06, 4.83) 2.80 (1.93, 3.66) 2.30 (1.25, 3.35) 0.05
Model 3 3.48 (2.37, 4.60) 3.85 (2.95, 4.76) 2.80 (1.93, 3.66) 2.60 (1.36, 3.84) 0.24
1
Values are means (95% CIs) obtained by using ANCOVA unless otherwise indicated. Model 1 was adjusted for age, examination year, and energy intake
(kcal/d). Model 2 was adjusted as for model 1 plus BMI (kg/m2), family history of type 2 diabetes (yes or no), hypertension (yes or no), smoking (never
smoker; previous smoker; current smoker, ,20 cigarettes/d; current smoker, $20 cigarettes/d), education years, leisure-time physical activity (kcal/d), serum
long-chain omega-3 PUFAs (percentage of all serum fatty acids), and intakes of alcohol (g/d), linoleic acid (% of energy), fiber (g/d), and fruit, berries, and
vegetables (g/d). Model 3 was adjusted as for model 2 and egg consumption (g/d).

(20, 21) or cardiovascular disease (3537), those who consumed HDL-cholesterol ratio (40), the addition of eggs has also been
more eggs were also more likely to smoke and have lower lei- found to increase the formation of larger and less-dense LDL and
sure-time physical activity. This was not observed in our study HDL particles, at least when accompanied with a low-carbohydrate
cohort (Table 1). On the other hand, higher egg intake was also diet (8, 12). Egg intake may also increase plasma adiponectin
not uniformly associated with healthier lifestyle or dietary fac- concentrations (9), and low plasma adiponectin has been suggested
tors (Table 1), and adjustment for potential risk factors in the as a risk factor for insulin resistance and T2D (41). Although we
multivariate-adjusted model did not have a major impact on the did not find an association between egg consumption and serum
associations. This suggests that, in our study cohort, egg con- insulin, we did find an inverse association with plasma glucose and
sumption was not just a surrogate for some other factors that a suggestive inverse association with serum CRP, which provide
could explain the inverse association between egg intake and possible mechanisms for the observed lower risk of T2D. Un-
risk of T2D. fortunately, we did not have data on lipoprotein particle sizes or
Several small randomized trials that investigated the effect of plasma adiponectin.
additional egg intake on various risk markers support our find- One medium egg contains w200 mg cholesterol, so eggs are
ings. In these trials, compared with a yolk-free substitute, the a major contributor to cholesterol intake. In rats, an egg yolk
consumption of 3 eggs/d for 12 wk as a part of a carbohydrate- enriched diet increased plasma glucose (3); and in studies in
restricted diet reduced plasma insulin concentrations and insulin humans, egg or cholesterol intakes correlated with elevated
resistance among subjects with metabolic syndrome (8), although fasting glucose (5). Higher cholesterol intake was also associ-
no effect was found on fasting glucose among overweight men ated with increased risk of incident T2D in some (6, 7, 42) but
(38). Also, the consumption of 3 eggs/d was found to decrease not all (18, 19) studies. In our analyses, both egg and cholesterol
inflammatory markers (911). The opposite was observed in intakes had a similar inverse association with T2D risk after
another trial, in which the addition of 4 eggs/d for 4 wk in- multivariate adjustment. However, the association with choles-
creased inflammatory markers in lean insulin-sensitive subjects, terol intake was attenuated after further adjustment for egg intake,
although this was not observed in lean or obese insulin-resistant suggesting that the inverse association with cholesterol intake
subjects (39). Although egg intake may increase the total- to mainly reflected the inverse association of egg consumption. This
 EGG CONSUMPTION AND RISK OF TYPE 2 DIABETES 1095
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