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Intake of animal and plant proteins and risk of all-cause mortality in patients with type 2 diabetes: results from NHANES

European Journal of Clinical Nutrition volume 79, pages 214–223 (2025)Cite this article

Subjects

Abstract

Background/Objective

There is little and inconsistent data on the relationship between protein intake and mortality in patients with type 2 diabetes. Our goal was to look at the relationship between consuming plant- and animal-based proteins and the risk of all-cause death in patients with type 2 diabetes.

Subjects/Methods

We included 4646 patients with type 2 diabetes aged ≥20 years participating in continuous NHANES from 1999 to 2018. All-cause mortality was ascertained through linkage to National Death Index until December 31, 2019. Cox proportional hazard regression models were used to estimate multivariable-adjusted hazard ratios (HRs) and 95%CIs.

Results

Over an average follow-up of nine years, 969 deaths took place. The multivariable-adjusted HRs of all-cause mortality across quartiles of plant protein intake, were, respectively, 1.00 (reference), 0.77 (95%CI: 0.65, 0.93), 0.79 (95%CI: 0.64, 0.97), and 0.73 (95%CI: 0.58, 0.93) (Ptrend = 0.022). Intake of animal protein was not linked to all-cause mortality. The HR was 0.94 (95%CI: 0.81, 1.08) for replacing 5% of energy from animal protein with plant protein. Intake of protein from individual animal- and plant-based foods was not related to the risk of all-cause mortality, nor was replacing 5% of energy intake from red meat protein with those from other foods.

Conclusions

Among individuals with type 2 diabetes, a higher intake of plant protein is linked to a lower risk of death from all causes. Nevertheless, the results should be interpreted with caution because some subgroups did not show an inverse relationship, and observational studies have limitations.

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Fig. 1: Dose-response association between plant protein intake and risk of all-cause mortality in patients with type 2 diabetes participating in continuous NHANES from 1999 to 2018 (Pnonlinearity = 0.007).

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Data availability

Data described in the manuscript, code book, and analytic code will be made available upon reasonable request to the corresponding author.

References

  1. Zimmet P, Alberti KG, Magliano DJ, Bennett PH. Diabetes mellitus statistics on prevalence and mortality: facts and fallacies. Nat Rev Endocrinol. 2016;12:616–22.

    Article  PubMed  Google Scholar 

  2. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diab Res Clin Pract. 2022;183:109119.

    Article  Google Scholar 

  3. Forouhi NG, Misra A, Mohan V, Taylor R, Yancy W. Dietary and nutritional approaches for prevention and management of type 2 diabetes. Bmj. 2018;361.

  4. Zheng Y, Ley SH, Hu FB. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol. 2018;14:88–98.

    Article  PubMed  Google Scholar 

  5. Rodriguez NR. Introduction to Protein Summit 2.0: continued exploration of the impact of high-quality protein on optimal health. Am J Clin Nutr. 2015;101:1317s-1319s. https://doi.org/10.3945/ajcn.114.083980.

  6. Solon-Biet SM, McMahon AC, Ballard JWO, Ruohonen K, Wu LE, Cogger VC, et al. The ratio of macronutrients, not caloric intake, dictates cardiometabolic health, aging, and longevity in ad libitum-fed mice. Cell Metab. 2014;19:418–30.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Wycherley TP, Moran LJ, Clifton PM, Noakes M, Brinkworth GD. Effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2012;96:1281–98.

    Article  PubMed  CAS  Google Scholar 

  8. Santesso N, Akl E, Bianchi M, Mente A, Mustafa R, Heels-Ansdell D, et al. Effects of higher-versus lower-protein diets on health outcomes: a systematic review and meta-analysis. Eur J Clin Nutr. 2012;66:780–8.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  9. Dong JY, Zhang ZL, Wang PY, Qin LQ. Effects of high-protein diets on body weight, glycaemic control, blood lipids and blood pressure in type 2 diabetes: meta-analysis of randomised controlled trials. Br J Nutr. 2013;110:781–9. https://doi.org/10.1017/s0007114513002055.

    Article  PubMed  CAS  Google Scholar 

  10. Huth PJ, Fulgoni VL, Keast DR, Park K, Auestad N. Major food sources of calories, added sugars, and saturated fat and their contribution to essential nutrient intakes in the US diet: data from the National Health and Nutrition Examination Survey (2003-2006). Nutr J. 2013;12:1–10.

    Article  Google Scholar 

  11. O’Neil CE, Keast DR, Fulgoni VL, Nicklas TA. Tree nut consumption improves nutrient intake and diet quality in US adults: an analysis of National Health and Nutrition Examination Survey (NHANES) 1999-2004. Asia Pac J Clin Nutr. 2010;19:142–50.

    PubMed  Google Scholar 

  12. Santarpia L, Contaldo F, Pasanisi F. Dietary protein content for an optimal diet: a clinical view. J Cachexia Sarcopenia Muscle. 2017;8:345–8. https://doi.org/10.1002/jcsm.12176.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Viguiliouk E, Stewart SE, Jayalath VH, Ng AP, Mirrahimi A, De Souza RJ, et al. Effect of replacing animal protein with plant protein on glycemic control in diabetes: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 2015;7:9804–24.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  14. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;393:447–92.

    Article  PubMed  Google Scholar 

  15. ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, et al. 5. Facilitating positive health behaviors and well-being to improve health outcomes: standards of Care in Diabetes—2023. Diab Care. 2023;46:S68–S96.

    Article  Google Scholar 

  16. Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diab Care. 2019;42:731.

    Article  Google Scholar 

  17. Dyson P, Twenefour D, Breen C, Duncan A, Elvin E, Goff L, et al. Diabetes UK evidence‐based nutrition guidelines for the prevention and management of diabetes. Diabet Med. 2018;35:541–7.

    Article  PubMed  CAS  Google Scholar 

  18. Barbaresko J, Lang A, Szczerba E, Baechle C, Beckhaus J, Schwingshackl L, et al. Dietary Factors and All-Cause Mortality in Individuals With Type 2 Diabetes: A Systematic Review and Meta-analysis of Prospective Observational Studies. Diab Care. 2023;46:469–77.

    Article  CAS  Google Scholar 

  19. Dunkler D, Dehghan M, Teo KK, Heinze G, Gao P, Kohl M, et al. Diet and kidney disease in high-risk individuals with type 2 diabetes mellitus. JAMA Intern Med. 2013;173:1682–92.

    PubMed  CAS  Google Scholar 

  20. Huang J, Liao LM, Weinstein SJ, Sinha R, Graubard BI, Albanes D. Association between plant and animal protein intake and overall and cause-specific mortality. JAMA Intern Med. 2020;180:1173–84.

    Article  PubMed  CAS  Google Scholar 

  21. Song M, Fung TT, Hu FB, Willett WC, Longo VD, Chan AT, et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Intern Med. 2016;176:1453–63.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Centers for Disease Control and Prevention. The National Health and Nutritional Examination Survey (NHANES) Analytic and Reporting Guidelines. Atlanta: CDC; 2006.

    Google Scholar 

  23. Qiu Z, Chen X, Geng T, Wan Z, Lu Q, Li L, et al. Associations of serum carotenoids with risk of cardiovascular mortality among individuals with type 2 diabetes: results from NHANES. Diab Care. 2022;45:1453–61.

    Article  CAS  Google Scholar 

  24. Rhee JJ, Sampson L, Cho E, Hughes MD, Hu FB, Willett WC. Comparison of methods to account for implausible reporting of energy intake in epidemiologic studies. Am J Epidemiol. 2015;181:225–33.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Willett W. Nutritional epidemiology. Oxford University Press: United States of America; 2013.

  26. U.S. Department of Agriculture. USDA National Nutrient Database for Standard Reference, Release 21 [updated March 12, 2009]. Available online at: http://www.ars.usda.gov/main/site_main.htm?modecode=12354500. Accessed March 31, 2009.

  27. Zipf G, Chiappa M, Porter KS, Ostchega Y, Lewis BG, Dostal J. National Health and Nutrition Examination Survey: Plan and operations, 1999–2010. National Center for Health Statistics. Vital Health Stat 2013;1:1-37.

  28. Food Surveys Research Group. Food Patterns Equivalents Database (FPED). 2017. Available at: https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/foodsurveys-research-group/docs/fped-databases/.

  29. McCance and Widdowson’s The Composition of Foods. 2015. Available at: https://www.nutrition.org.uk/nutritional-information/protein/.

  30. National Center for Health Statistics. The Linkage of National Center for Health Statistics Survey Data to the National Death Index — 2019 Linked Mortality File (LMF): Linkage Methodology and Analytic Considerations. Hyattsville, Maryland; National Center for Health Statistics: 2022.

  31. Beddhu S, Baird BC, Zitterkoph J, Neilson J, Greene T. Physical activity and mortality in chronic kidney disease (NHANES III). Clin J Am Soc Nephrology: CJASN. 2009;4:1901.

    Article  Google Scholar 

  32. Control CfD, Prevention. NHANES laboratory/medical technologists procedures manual. Atlanta, GA: Centers for Disease Control and Prevention; 2001. April

    Google Scholar 

  33. Chen Z, Glisic M, Song M, Aliahmad HA, Zhang X, Moumdjian AC et al. Dietary protein intake and all-cause and cause-specific mortality: results from the Rotterdam Study and a meta-analysis of prospective cohort studies. Springer; 2020. pp 411–29.

  34. Wan Z, Shan Z, Geng T, Lu Q, Li L, Yin J, et al. Associations of Moderate Low-Carbohydrate Diets With Mortality Among Patients With Type 2 Diabetes: A Prospective Cohort Study. J Clin Endocrinol Metab. 2022;107:e2702–e2709. https://doi.org/10.1210/clinem/dgac235.

    Article  PubMed  Google Scholar 

  35. Wang X, Piantadosi S, Le-Rademacher J, Mandrekar SJ. Statistical considerations for subgroup analyses. J Thorac Oncol. 2021;16:375–80.

    Article  PubMed  Google Scholar 

  36. Hernández-Alonso P, Salas-Salvadó J, Ruiz-Canela M, Corella D, Estruch R, Fitó M, et al. High dietary protein intake is associated with an increased body weight and total death risk. Clin Nutr. 2016;35:496–506. https://doi.org/10.1016/j.clnu.2015.03.016.

    Article  PubMed  CAS  Google Scholar 

  37. Tharrey M, Mariotti F, Mashchak A, Barbillon P, Delattre M, Fraser GE. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol. 2018;47:1603–12.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Chan R, Leung J, Woo J. High Protein Intake Is Associated with Lower Risk of All-Cause Mortality in Community-Dwelling Chinese Older Men and Women. J Nutr Health Aging. 2019;23:987–96. https://doi.org/10.1007/s12603-019-1263-1.

    Article  PubMed  CAS  Google Scholar 

  39. Budhathoki S, Sawada N, Iwasaki M, Yamaji T, Goto A, Kotemori A, et al. Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality in a Japanese Cohort. JAMA Intern Med. 2019;179:1509–18. https://doi.org/10.1001/jamainternmed.2019.2806.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Papanikolaou Y, Fulgoni V III. Animal and plant protein usual intakes are not associated with mortality in US adults (P18-037-19). Curr Dev Nutr. 2019;3:nzz039. P018-037-019.

    Article  Google Scholar 

  41. Kelemen LE, Kushi LH, Jacobs DR Jr., Cerhan JR. Associations of dietary protein with disease and mortality in a prospective study of postmenopausal women. Am J Epidemiol. 2005;161:239–49. https://doi.org/10.1093/aje/kwi038.

    Article  PubMed  Google Scholar 

  42. Naghshi S, Sadeghi O, Willett WC, Esmaillzadeh A. Dietary intake of total, animal, and plant proteins and risk of all cause, cardiovascular, and cancer mortality: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ. 2020;370:m2412.

  43. Jayedi A, Soltani S, Abdolshahi A, Shab-Bidar S. Fish consumption and the risk of cardiovascular disease and mortality in patients with type 2 diabetes: a dose-response meta-analysis of prospective cohort studies. Crit Rev food Sci Nutr. 2021;61:1640–50. https://doi.org/10.1080/10408398.2020.1764486.

    Article  PubMed  Google Scholar 

  44. Djoussé L, Gaziano JM. Egg consumption in relation to cardiovascular disease and mortality: the Physicians’ Health Study. Am J Clin Nutr. 2008;87:964–9. https://doi.org/10.1093/ajcn/87.4.964.

    Article  PubMed  Google Scholar 

  45. Zhong VW, Van Horn L, Cornelis MC, Wilkins JT, Ning H, Carnethon MR, et al. Associations of Dietary Cholesterol or Egg Consumption With Incident Cardiovascular Disease and Mortality. JAMA. 2019;321:1081–95. https://doi.org/10.1001/jama.2019.1572

    Article  PubMed  PubMed Central  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran

    Ahmad Jayedi

  2. Department of Internal Medicine, Semnan University of Medical Sciences, Semnan, Iran

    Ali Gohari

  3. Department of Gastroenterology, Imam Hossein Center For Education, Research and Treatment, Shahroud University of Medical Sciences, Shahroud, Iran

    Ali Najafi

  4. Clinical Research Development Unit, Kowsar Educational, Research and Therapeutic Hospital, Semnan University of Medical Sciences, Semnan, Iran

    Mahdieh-Sadat Zargar

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  4. Mahdieh-Sadat Zargar
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Contributions

AJ conceived and designed the study; AJ and MSZ contributed to data verification, AJ and MSZ conducted statistical analyses; AJ, AG, AN, and MSZ wrote the first draft of the manuscript, contributed to the interpretation of the results and critically revised the manuscript for important intellectual content. AJ had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors have read and approved the final manuscript. AJ is the guarantor.

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Correspondence to Ahmad Jayedi.

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The authors declare no competing interests.

Ethics approval and consent to participate

NHANES received approval from the National Center for Health Statistics, and all participants gave their written informed consent.

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Jayedi, A., Gohari, A., Najafi, A. et al. Intake of animal and plant proteins and risk of all-cause mortality in patients with type 2 diabetes: results from NHANES. Eur J Clin Nutr 79, 214–223 (2025). https://doi.org/10.1038/s41430-024-01535-4

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