The Portfolio Diet and Incident Type 2 Diabetes: Findings From the Women’s Health Initiative Prospective Cohort Study

Type 2 diabetes continues to be a major burden globally, and a healthy diet plays a key role in the prevention of this chronic disease (1,2). Plant-based diets in particular are thought to be beneficial for the prevention of type 2 diabetes (3); however, findings from meta-analyses have found that the certainty of evidence for plant-based diets and incidence of type 2 diabetes is low, highlighting that more research on this topic is needed (4). The plant-based Portfolio Diet has been associated with lower cardiovascular disease (CVD) risk among U.S. postmenopausal women and lower mortality risk among Hong Kong older adults in two prospective cohort studies (5,6). We recently showed that greater adherence to the diet was associated with reductions in several risk factors for diabetes, including markers of glycemic control and adiposity in a population of older adults with metabolic syndrome (7); however, this dietary approach has yet to be assessed in the prevention of type 2 diabetes. Other well-known dietary patterns that are plant predominant and recommended for lowering CVD risk, and may also be beneficial for diabetes prevention, include the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets. While conducting a long-term randomized trial with type 2 diabetes as the primary outcome would be preferred, this type of trial is currently not feasible (8). Thus, high-quality and large prospective cohort studies remain the “alloyed gold” standard platform in evaluating the long-term effectiveness of diet for type 2 diabetes prevention. In this study, we examined the association of the Portfolio Diet, alongside the DASH and Mediterranean diets, with incident type 2 diabetes among postmenopausal women from the Women’s Health Initiative (WHI).

Between 1993 and 1998, postmenopausal women aged 50–79 years were recruited into the WHI clinical trials (CT) or a concomitant observational study (OS) if not assigned to a CT (n = 161,808). The design and methods of the WHI have previously been published (9–11), and recruitment and baseline data collection were previously reported (10). Written informed consent was obtained from all participants, and procedures were approved by institutional review boards at all participating institutions. We excluded participants who had a diagnosis of type 2 diabetes at baseline (n = 9,179), missing information on diet or lifestyle covariates (n = 2,732), or implausible caloric intake (<600 kcal or >5,000 kcal/day) (n = 4,598). Details regarding the implausible caloric intake can be found in the WHI protocol (12). For baseline diabetes status, participants were asked whether a physician had ever told them they had “sugar diabetes or high blood sugar” when they were not pregnant and about treatment with insulin or oral diabetes medications. Baseline type 2 diabetes was defined as a confirmatory answer to the above question or reported use of medication to treat diabetes. This current analysis includes follow-up through 6 March 2021 and 145,299 women. The WHI data are accessible to researchers, and requests to access the data set may be sent to the WHI Publications and Presentations Committee.

The primary exposure was diet as measured according to a Portfolio Diet score, previously developed and validated using a modified Willett food-frequency questionnaire (FFQ) against LDL cholesterol and 7-day diet records (13). The foods and nutrients included in this score were based on self-reported intake at enrollment and again at year 3 for the OS participants with use of the FFQ developed and validated for the WHI (14,15). We used an average score for those who completed the FFQ at baseline and year 3. Food items on the WHI FFQ were categorized into the six components of the diet (plant protein, nuts, viscous fiber, plant sterols, monounsaturated fatty acids (MUFAs), and high–saturated fat/dietary cholesterol sources). Intake was assessed as servings per day reported from the FFQ of targeted foods in all components except plant sterols, for which all FFQ food items were used to derive total intake (milligrams per day). For the six components, each was scored from 1 (least adherent) to 5 (most adherent) according to participant’s quintile of intake, resulting in a score range between 6 and 30. For the DASH and Mediterranean diets, we used diet scores widely applied in the epidemiology literature (16–18). The DASH score included eight components, with total scores ranging from 8 to 40. The Alternate Mediterranean Diet (aMED) score included nine components and total scores ranging from 0 to 9. Higher scores indicate higher adherence for each dietary pattern. The development of the Portfolio Diet score in the WHI has previously been described (5), and additional information on the DASH and aMED scores is included in Supplementary Material.

Only incident cases of type 2 diabetes were ascertained, defined as a self-report of physician-diagnosed diabetes treated with oral medication or insulin (19,20), determined at each semiannual (WHI CT) or annual (WHI OS) contact. Validation studies of the self-reported diabetes with use of both medical records and biomarkers indicated high accuracy and reliability (21,22). Time to diabetes was defined as the number of days from enrollment to the return of the questionnaire in which diabetes was first reported.

Covariates that were included in our models were based on information on the participants’ lifestyle and risk factors for diabetes assessed at baseline, including age, region in the U.S, self-identified race and ethnicity, alcohol intake, physical activity, energy intake, hysterectomy history, BMI, hormone therapy (HT) use, personal history of hypertension and high cholesterol, family history of diabetes, smoking status, education, marital status, and CT/study arm. Detailed descriptions of the validity and reproducibility of baseline measurements have previously been published (11).

Baseline characteristics were described by quintile of each dietary pattern score with means and SDs for continuous variables and frequencies with percentages for categorical variables. Participants were categorized according to quintiles of the dietary scores, with the lowest quintile serving as the reference group. For our main analysis, we used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs for the association between the three dietary pattern score quintiles and incident type 2 diabetes. Three multivariable models were used. Covariates commonly examined in studies of dietary pattern indices and type 2 diabetes were included based on our a priori analysis plan. Model 1 included adjustment for age (continuous), region (Northeast, South, Midwest, West), smoking status (never, past, current), and study arm (HT arm, dietary modification [DM] arm, calcium and vitamin D [CaD] arm). Model 2 included model 1 adjustments plus adjustment for self-identified race and ethnicity (White, African American, Hispanic, Asian), education (college or above, below college), marital status (presently married, other), hysterectomy history (yes, no), physical activity (continuous), alcohol intake (≥7 drinks/week, <7 drinks/week), energy intake (continuous), hypertension status (yes, no), family history of diabetes (yes, no), postmenopausal hormone use (never, past, current), and cholesterol-lowering medication use (yes, no). Model 3 included model 2 adjustments plus adjustment for BMI (continuous), for examination of the potential role of obesity in the diet and type 2 diabetes relationship. We verified the proportional hazards model assumptions using Schoenfeld residuals method, and no violations of the assumption were found. Tests for linear trend were conducted through assigning the median value to each quintile. We further examined associations with incident type 2 diabetes per 1 SD increase in each score to facilitate comparisons across the scores, as they all have different score ranges. We used restricted cubic spline plots with four knots to explore the shape of the association between the dietary scores and incident type 2 diabetes. We also analyzed the Spearman rank correlation coefficients between the three dietary patterns.

We conducted several sensitivity and subgroup analyses to test the robustness of our Portfolio Diet findings, as this is the first time the Portfolio Diet score has been assessed with type 2 diabetes incidence. The sensitivity analyses include the following: 1) restricting the data to the OS participants only, 2) restricting analyses to the baseline diet score only, 3) excluding participants from the DM trial, as their diet may have changed over time, 4) excluding incident type 2 diabetes diagnosed within the first 3 years of follow-up to address possible reverse causation, and 5) excluding those with CVD or cancer at baseline, as these conditions may have resulted in dietary changes. In the subgroup analyses, we assessed associations between the Portfolio Diet score quintiles and incident type 2 diabetes according to age, BMI, family history of diabetes, self-identified race and ethnicity, and smoking status. P for interaction is for comparison of participants in quintile 1 (Q1) (low adherence) to Q5 (high adherence) of the Portfolio Diet score. Additional analyses included evaluation of associations between the six individual components of the Portfolio Diet and risk of type 2 diabetes. All statistical tests were two sided, and P < 0.05 was considered statistically significant. The statistical analyses were conducted with Stata statistical software (release 17; StataCorp, College Station, TX). Further information on methods can be found in Supplementary Material.

Participant characteristics by quintiles of the dietary pattern scores are shown in Table 1. Overall, women with higher scores in all three dietary patterns tended to be older, have a lower BMI, engage in more physical activity, and have a higher education and were less likely to smoke, among other characteristics. Mean intake for the Portfolio, DASH, and Mediterranean diet score components are shown in Table 2 and Supplementary Tables 1 and 2. The Spearman rank correlation coefficients between the three dietary pattern scores ranged from 0.54 to 0.68 (P < 0.001 for all), with the Portfolio Diet score having a stronger correlation with the aMED score (0.68) than the DASH score (0.54).

There were 13,943 cases reported of incident type 2 diabetes over a mean follow-up of 16.0 years. When comparing highest versus lowest quintiles in model 2, we observed an inverse association with incident type 2 diabetes for the Portfolio Diet (HR 0.77 [95% CI 0.72, 0.82], P < 0.001 for trend); DASH diet (0.69 [0.64, 0.73], P < 0.001 for trend); and aMED diet (0.78 [0.74, 0.83], P < 0.001 for trend) (Table 3). Additional adjustment for BMI in model 3 attenuated the risk by ∼10% but did not eliminate the inverse association for the Portfolio Diet (0.87 [0.82, 0.93], P < 0.001 for trend), DASH diet (0.78 [0.72, 0.83], P < 0.001 for trend), and aMED diet (0.88 [0.83, 0.94], P < 0.001 for trend). In addition, a 1-SD increase in the dietary scores was associated with a 6–8% lower risk of type 2 diabetes (0.94 [0.93, 0.96] for the Portfolio Diet, 0.92 [0.90, 0.93] for the DASH diet, and 0.94 [0.93, 0.96] for aMED diet), in the most adjusted models (Table 3). No significant nonlinear relationships were found between the three dietary pattern scores and risk of type 2 diabetes (Fig. 1 and Supplementary Figs. 1 and 3).

The significant inverse associations between the Portfolio Diet score and incident type 2 diabetes remained similar (13–18% reduction comparing highest with lowest quintiles in model 3) in all sensitivity analyses, including when we excluded the CT participants (Supplementary Table 3).

The results remained largely consistent in each of the subgroup analyses, apart from smoking status, in which the inverse association was stronger but less precise in current smokers comparing the lowest and highest quintiles (Supplementary Fig. 3).

When we individually assessed the six components of the diet with incidence of type 2 diabetes, higher intake of viscous fiber sources (HR 0.93 [95% CI 0.87, 0.99]) and plant sterols (0.85 [0.78, 0.92]), and lower intake of saturated fat and dietary cholesterol sources (0.83 [0.77, 0.88]), were inversely associated with risk of type 2 diabetes in the most adjusted models (Supplementary Table 4). No significant associations were seen with plant protein, nuts, and MUFAs in relation to type 2 diabetes risk, although nut intake pointed in the direction of an inverse association (Supplementary Table 4).

In this large prospective cohort study of 145,299 postmenopausal women, comparing highest to lowest adherence, the Portfolio Diet score was associated with a 13% lower risk of type 2 diabetes. These findings remained generally consistent across all sensitivity and subgroup analyses, including when we excluded the WHI CT participants, highlighting the robustness of our findings. In addition, we found that comparing highest to lowest adherence of the DASH and aMED diets were associated with a 12–22% lower risk of type 2 diabetes.

The three dietary patterns scores were moderately to highly correlated, likely due to the overlap in many healthy food items between the dietary patterns, with the Portfolio and aMED diets showing the highest correlation (r = 0.68). The Portfolio and aMED diets may be more closely related due to the higher emphasis on MUFAs compared with saturated fat than the DASH diet. However, none of the scores were perfectly correlated, highlighting that each dietary pattern reflects some unique combination of foods. As each dietary pattern is scored differently, it is difficult to conclude that one pattern is better than another; however, the per 1 SD increase in the scores were all similarly (6–8%) associated with lower risk of incident type 2 diabetes. As adherence to diet is the most important determinant for patient success, health professionals should recommend evidence-based dietary patterns that best align with a patient’s values and preferences (2).

We are unaware of other studies with examination of the association of the Portfolio Diet with incident type 2 diabetes. Our findings are, however, consistent with previous research in which greater adherence to the Portfolio Diet was associated with reductions in intermediate risk factors for type 2 diabetes (23,24), including fasting plasma glucose, glycated hemoglobin (HbA_1c), BMI, and waist circumference, in patients with metabolic syndrome over 1 year in the Prevención con Dieta Mediterránea (PREDIMED)-Plus cohort (7). The Portfolio Diet trials did not include assessment of markers of glycemic control and were not designed as weight loss studies (25); therefore, comparison with these trial results is difficult. Investigators of the Portfolio Diet trials did, however, observe a major reduction in a marker of inflammation, CRP (25), which has been associated with development of type 2 diabetes in prospective cohort studies, including the WHI (22,26). The results of the 3-year PortfolioEX trial (ClinicalTrials.gov identifier NCT02481466) of the effect of the Portfolio Diet plus exercise on a surrogate marker of atherosclerotic CVD risk (MRI of atherosclerosis [plaque volume]) will be of great interest once available, as this trial includes measurement of markers of glycemic control and will provide additional insight into the role of this diet regarding risk factors for type 2 diabetes.

Our findings are in line with previous literature assessing other healthy plant-based dietary patterns and type 2 diabetes risk (27,28). In a recent systematic review and meta-analysis of prospective cohort studies investigators found that plant-based diets were associated with 23% lower risk of type 2 diabetes—similar to our findings (27). In addition, the Mediterranean diet was shown to reduce incidence of type 2 diabetes in the PREDIMED-Reus trial (29). The Mediterranean diet and DASH diets have also been associated with an 18–19% reduction in type 2 diabetes risk in prospective cohort studies, which is similar to our findings for these two dietary patterns (30,31). Specifically, in the WHI, the DASH diet, Mediterranean diet, and Alternative Healthy Eating Index (AHEI) were previously associated with a 15–26% lower risk of type 2 diabetes in the OS participants only, and similar to our findings, BMI attenuated the risk estimates by ∼10%, highlighting that BMI could serve as a both a confounder and mediator in the relationship with type 2 diabetes (32).

Many of the individual components of the Portfolio Diet have also been associated with lower risk of type 2 diabetes in prospective cohort studies, including soy foods (33), viscous fiber sources such as oats (34), and peanut butter (35). However, the inverse association of increasing plant sterol intake from natural sources with incident type 2 diabetes has not been shown previously to the best of our knowledge. Interestingly, plant sterols have been shown to reduce adipose tissue and improve insulin sensitivity in animal models (36); further research in humans, however, is needed. The individual components of the Portfolio Diet have likewise been shown to improve intermediate risk factors for type 2 diabetes, including markers of glycemic control, insulin resistance, inflammation, body weight, and metabolic syndrome (37–41). The high viscous fiber content, low glycemic index, reduced intake of saturated fat, higher intake of plant MUFAs, increased intake of antioxidants and plant sterols, and higher intake of plant protein may contribute to the cardiometabolic benefits of the Portfolio Diet (3). In addition, the displacement of carbohydrates with MUFAs (as in the case of the Portfolio Diet + MUFA trial [42]) or nuts (43) may also improve intermediate risk factors for type 2 diabetes.

Strengths of our study include the prospective cohort design, large sample size, and long follow-up for incident type 2 diabetes. Nonetheless, our study has some limitations. Our study only included one or two self-reported dietary FFQ measurements, and therefore we could not measure dietary change. The population also included only postmenopausal women, and, thus, the results may not be generalizable to men or premenopausal women. Incident diabetes was also self-reported, and although this method has been shown to be valid with use of medical records and biomarkers (21,22), some cases may have been missed, as only medication-treated diabetes was determined. Moreover, as in all observational studies, residual confounding cannot be completely ruled out, even though we conducted a comprehensive assessment of the known diabetes risk factors in the WHI; however, this limitation will tend to attenuate the results. Lastly, consumption of some Portfolio Diet foods appeared low, particularly plant protein and MUFAs, which could have resulted in underestimation of the magnitude of the association between the Portfolio Diet foods and diabetes risk, and a stronger inverse association with type 2 diabetes risk may be seen with greater consumption of the Portfolio Diet foods, as shown in previous studies of healthy plant-based dietary patterns (27). This finding of low level of consumption of certain foods suggests an opportunity for individuals to achieve cardiometabolic benefits of the Portfolio Diet and important implications for public health initiatives to help mitigate the global burden of type 2 diabetes and CVD, for which patients with type 2 diabetes are at higher risk. Despite this low consumption of some Portfolio Diet foods in the WHI population, we still observed a protective association with type 2 diabetes risk, alongside the DASH and aMED diets. This finding provides evidence that even small additions of Portfolio Diet foods to the diet may help lower the risk of diabetes, which may be a useful strategy for individuals who find consuming some components of the Portfolio Diet particularly challenging.

Greater adherence to the Portfolio, DASH, and aMED diets was significantly associated with a lower risk of type 2 diabetes in postmenopausal women. These findings represent the first prospective evidence showing the potential long-term benefits of a portfolio of plant-based foods known to lower circulating levels of cholesterol and CVD risk in the primary prevention of type 2 diabetes, although the findings need to be confirmed in other populations and randomized trials are needed. Overall, our results support the plant-based Portfolio Diet as another dietary approach for reducing type 2 diabetes risk among postmenopausal women along with the DASH and Mediterranean diets.

Acknowledgments. The authors thank all participants, investigators, and staff from the WHI CTs and cohort for their invaluable contributions. The WHI investigator short list can be found in Supplementary Material.

Funding. The WHI program is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), U.S. Department of Health and Human Services, through 75N92021D00001, 75N92021D00002, 75N92021D00003, and 75N92021D00004, 75N92021D00005. A.J.G. is supported by a Canadian Institutes of Health Research (CIHR) Postdoctoral Fellowship. J.L.S. was funded by a Diabetes Canada Clinician Scientist Award. S.L. is a WHI principal investigator (PI) and PI of an ancillary study of diabetes in the WHI, supported by NIH R01DK125403 and R01ES031391.

Duality of Interest. A.J.G. has received consulting fees from SoLo GI Nutrition and has received an honorarium from the Soy Nutrition Institute. D.J.A.J. has received research grants from Saskatchewan Pulse Growers, the Agricultural Bioproducts Innovation Program through the Pulse Research Network, the Advanced Foods and Material Network, Loblaw Companies Ltd., Unilever, Barilla, the Almond Board of California, Agriculture and Agri-Food Canada, Pulse Canada, Kellogg Canada, Quaker Oats, Canada, Procter & Gamble Technical Centre Ltd., Bayer Consumer Care (Springfield, NJ), PepsiCo/Quaker Oats, Soyfoods Association of North America, Coca-Cola Company (investigator-initiated, unrestricted grant), Solae, Haine Celestial, Sanitarium, Orafti, the Canola Council of Canada and Flax Council of Canada, and the Ontario Research Fund. D.J.A.J. has been on the speakers panel and/or served on the scientific advisory board for and/or received travel support and/or honoraria from the Saint Barnabas Medical Center, The University of Chicago, 2020 China Glycemic Index (GI) International Conference, Atlantic Pain Conference, Academy of Life Long Learning, Almond Board of California, Canadian Agri-Food Policy Institute, Loblaw Companies Ltd., Griffin Hospital (for the development of the NuVal scoring system), Coca-Cola Company, EPICURE, Danone, Dietary Quality Photo Navigation (DQPN), Better Therapeutics (FareWell), Verywell, True Health Initiative, Institute of Food Technologists, Saskatchewan Pulse Growers, Sanitarium, Orafti, the Almond Board of California, the American Peanut Council, Herbalife International, PacificHealth Laboratories, Nutritional Fundamentals for Health, Barilla, Metagenics, Bayer Consumer Care, Unilever Canada and Netherlands, Solae, Kellogg, Quaker Oats, Procter & Gamble, Coca-Cola Company, Griffin Hospital, Abbott Laboratories, the Canola Council of Canada, Dean Foods, the California Strawberry Commission, Haine Celestial, PepsiCo, the Alpro Foundation, Pioneer Hi-Bred International, DuPont Nutrition and Health, Spherix Consulting, WhiteWave Foods, the Advanced Foods and Material Network, Flax Council of Canada, Nutritional Fundamentals for Health (NFH)-Nutramedica, Agriculture and Agri-Food Canada, the Canadian Agri-Food Policy Institute, Pulse Canada, the Saskatchewan Pulse Growers, Soyfoods Association of North America, the Nutrition Foundation of Italy, Nutrasource Diagnostics, the McDougall Program, the Toronto Knowledge Translation Group (St. Michael’s Hospital), the Canadian College of Naturopathic Medicine, The Hospital for Sick Children, the Canadian Nutrition Society, Arizona State University, Paolo Sorbini Foundation, and the Institute of Nutrition, Metabolism and Diabetes. D.J.A.J. received an honorarium from the U.S. Department of Agriculture to present the 2013 W.O. Atwater Memorial Lecture. D.J.A.J. received funding and travel support from the Canadian Society of Endocrinology and Metabolism to produce mini cases for the Canadian Diabetes Association. D.J.A.J. is a member of the International Carbohydrate Quality Consortium (ICQC). His wife, Alexandra L. Jenkins, is a director and partner of INQUIS Clinical Research for the Food Industry; his two daughters, Wendy Jenkins and Amy Jenkins, have published a vegetarian book that promotes the use of the foods described here, The Portfolio Diet for Cardiovascular Risk Reduction (Academic Press/Elsevier 2020 ISBN:978-0-12-810510-8); and his sister received funding through a grant from the St. Michael’s Hospital Foundation to develop a cookbook for one of his studies. A.J.H. received independent investigator-initiated research funding from Dairy Farmers of Canada. C.W.C.K. has received grants or research support from the Advanced Food Materials Network, Agriculture and Agri-Foods Canada (AAFC), Almond Board of California, Barilla, Canadian Institutes of Health Research (CIHR), Canola Council of Canada, International Nut and Dried Fruit Council, International Tree Nut Council Research and Education Foundation, Loblaw Brands Ltd., the Peanut Institute, Pulse Canada and Unilever. He has received in-kind research support from the Almond Board of California, Barilla, California Walnut Commission, Kellogg Canada, Loblaw Companies, Nutrartis, Quaker (PepsiCo), the Peanut Institute, Primo, Unico, Unilever, and WhiteWave Foods/Danone. He has received travel support and/or honoraria from the Barilla, California Walnut Commission, Canola Council of Canada, General Mills, International Nut and Dried Fruit Council, International Pasta Organization, Lantmannen, Loblaw Brands Ltd., Nutrition Foundation of Italy, Oldways Preservation Trust, Paramount Farms, the Peanut Institute, Pulse Canada, Sun-Maid, Tate & Lyle, Unilever, and WhiteWave Foods/Danone. He has served on the scientific advisory board for the International Tree Nut Council, International Pasta Organization, McCormick Science Institute, and Oldways Preservation Trust. He is a founding member of the International Carbohydrate Quality Consortium (ICQC), is the Chair of the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD), is on the Clinical Practice Guidelines Expert Committee for Nutrition Therapy of the EASD, and is a Director of Glycemia Consulting and the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. J.L.S. has received research support from the Canadian Foundation for Innovation, Ontario Research Fund, Province of Ontario Ministry of Research and Innovation and Science, Canadian Institutes of Health Research (CIHR), Diabetes Canada, American Society for Nutrition (ASN), International Nut and Dried Fruit Council (INC) Foundation, National Honey Board (U.S. Department of Agriculture [USDA] honey “Checkoff” program), Institute for the Advancement of Food and Nutrition Sciences (IAFNS; formerly ILSI North America), Pulse Canada, Quaker Oats Center of Excellence, The United Soybean Board (USDA soy “Checkoff” program), The Tate and Lyle Nutritional Research Fund at the University of Toronto, The Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), The Plant Protein Fund at the University of Toronto (a fund which has received contributions from IFF), and The Nutrition Trialists Network Fund at the University of Toronto (a fund established by an inaugural donation from the Calorie Control Council). He has received food donations to support randomized controlled trials from the Almond Board of California, California Walnut Commission, Peanut Institute, Barilla, Unilever/Upfield, Unico/Primo, Loblaw Companies, Quaker, Kellogg Canada, WhiteWave Foods/Danone, Nutrartis, and Dairy Farmers of Canada. He has received travel support, speaker fees and/or honoraria from ASN, Danone, Dairy Farmers of Canada, FoodMinds LLC, Nestlé, Abbott, General Mills, Nutrition Communications, International Food Information Council (IFIC), Calorie Control Council, International Sweeteners Association, and International Glutamate Technical Committee. He has or has had ad hoc consulting arrangements with Perkins Coie LLP, Tate & Lyle, Phynova, and Inquis Clinical Research. He is a former member of the European Fruit Juice Association Scientific Expert Panel and former member of the Soy Nutrition Institute (SNI) Scientific Advisory Committee. He is on the Clinical Practice Guidelines Expert Committees of Diabetes Canada, European Association for the study of Diabetes (EASD), Canadian Cardiovascular Society (CCS), and Obesity Canada/Canadian Association of Bariatric Physicians and Surgeons. He serves or has served as an unpaid member of the Board of Trustees and an unpaid scientific advisor for the Carbohydrates Committee of IAFNS. He is a member of the International Carbohydrate Quality Consortium (ICQC), Executive Board Member of the Diabetes and Nutrition Study Group (DNSG) of the EASD, and Director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. His spouse is an employee of AB InBev. S.D.C. is an employee of Ascendis Pharma. No other potential conflicts of interest relevant to this article were reported.

Author Contributions. A.J.G., K.L., D.J.A.J., C.W.C.K., S.L., and J.L.S. designed the study. A.J.G. wrote the first draft of the manuscript. A.J.G., K.L., and S.L. conducted the statistical analysis. S.L. and J.L.S. supervised the study, and all authors were responsible for acquisition, analysis, and interpretation of data and critical revision of the manuscript and approved the final version of the manuscript. S.L. and J.L.S. are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Prior Presentation. Parts of this study were presented in abstract form at the American Society for Nutrition annual meeting NUTRITION 2021 LIVE ONLINE, 7–10 June 2021, and the 38th International Symposium on Diabetes and Nutrition, Diabetes Nutrition Study Group of the European Association for the Study of Diabetes, Virtual, 21–24 June 2021.