Roberto Segura
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Children’s National Hospital, San José, Costa Rica
Angela Quinche
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; University of El Rosario, Bogotá, Colombia
Alanna Michel Zorrilla Marte
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Universidad Nacional Pedro Henriquez Ureña (UNPHU), Dominican Republic
Aarti Garg
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; University of Regina, Saskatchewan, Canada
Anushka Verma
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Smt. N.H.L. Municipal Medical College, India
Arthur de Ávila
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
Arthur Gomes Oliveira Braga
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; A.C.Camargo Cancer Center, São Paulo, Brazil
Brian Villafuerte-Trisolini
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Design Neuroscience Center, Larkin Community Hospital Neurology Residency Program, HCA Kendall Hospital Residency Program, Florida, USA
Drumadala Gajbhiye
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Government Medical College & Hospital, Akola, India
Elif Kortan
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
Enkhtuul Iderjavkhlan
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Macquarie University, Australia
Fernanda Mishelly Yánez Llerena
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; University of Guayaquil, Ecuador
Gabrielle Sigaki
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Faculty of Medicine (FMUSP), University of São Paulo, São Paulo, Brazil
Giulia Soares
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Einstein Hospital Israelita, São Paulo, Brazil
Josefina Maria Bran
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Austral University Hospital, Buenos Aires, Argentina
Lucas Caro Herrera
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Clínica Dávila, Santiago, Chile
Manuela Neira
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA
Maria Guadalupe Gomez-Castano
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; University of El Rosario, Bogotá, Colombia
Nathalia Serrato
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Instituto D’Or de Pesquisa e Ensino (IDOR), DF Star Hospital, Brasília, Brazil
Nicole Schleicher
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Klinikum Chemnitz, Germany
Pedro Jara-Guajardo
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Clínica Alemana de Santiago, Chile
Renzo Villagra
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Hospital de Clínicas, National University of Asunción, Paraguay
Ruzika Puljic
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Abbott Diabetes Care GmbH, Medical Affairs DACH, Baar, Switzerland
Sherin Rahim
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Hamad Medical Corporation, Doha, Qatar
Stefano Doronzio
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA; IRCCS Fondazione Don Carlo Gnocchi ONLUS, Italy
Sulaiman Abubakar
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
Waleed El Harith
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
Walter Marrou
Principles and Practice of Clinical Research Program, Harvard T.H. Chan School of Public Health, Boston, MA, USA
Abstract
Background: High levels of low-density lipoprotein cholesterol (LDL-C) and diabetes are major cardiovascular risk factors. Dietary modifications are commonly recommended as part of diabetes management. However, in real-world populations, the association between self-reported adherence to a diabetes-focused diet and LDL-C levels remains unclear.
Objective: To examine the cross-sectional association between a self-reported diabetic diet (SRDD) and LDL-C levels in U.S. overweight and obese adults, and to explore potential mediators and effect modifiers of this relationship using nationally representative data.
Methods: We performed a cross-sectional analysis of 2,150 adults aged ≥18 years, overweight and obese, from the 2017–2018 National Health and Nutrition Examination Survey (NHANES). Exposure was SRDD and the outcome was laboratory-measured LDL-C. Linear regression models were used to assess associations. Multivariable models included age, statin use, diabetes diagnosis, and HbA1c to evaluate whether the observed association persisted after accounting for metabolic status and treatment-related factors. NHANES survey weights were applied.
Results: Of the 2,150 adults, 52 participants reported following a diabetic diet. In unadjusted analyses, SRDD was associated with significantly lower LDL-C levels (mean difference = –18.6 mg/dL; 95% CI –28.4 to –8.8; p < 0.001). After adjustment for metabolic and treatment-related variables, including diabetes status, statin use, and HbA1c, the association was attenuated and no longer statistically significant (β = –8.4; p = 0.3). Statin use showed the strongest association with lower LDL-C levels (β = –26.6 mg/dL; 95% CI –30.7 to –22.4; p < 0.001). Effect modification analysis indicated that diabetes status significantly modified the association between diet and LDL-C (p for interaction = 0.024), with an inverse association observed primarily among participants with diabetes. Mediation analyses indicated that body mass index (BMI) significantly mediated the association between diet and LDL-C (p = 0.007), whereas HbA1c did not demonstrate evidence of mediation.
Conclusions: While adherence to a self-reported diabetic diet was associated with lower LDL-C levels in unadjusted analyses, this association was attenuated after accounting for metabolic and treatment-related factors. Mediation analyses suggest that body mass index may partially explain this relationship, indicating that the association between diet and LDL-C could operate through broader metabolic mechanisms. In contrast, HbA1c did not appear to mediate the association. Overall, these findings highlight the complex interplay between dietary behaviors, metabolic status, and clinical management in cross-sectional populations and underscore the need for longitudinal studies to clarify causal pathways.
