Dietary Acid Load and Risk of Type 2 Diabetes: The E3N-EPIC Cohort Study

Study Questions:

Is there an association between dietary acid load, assessed with both the potential renal acid load (PRAL) and the net endogenous acid production (NEAP) scores, and type 2 diabetes risk?


A total of 66,485 women from the E3N-EPIC cohort were followed for incident diabetes over 14 years. PRAL and NEAP scores were derived from nutrient intakes. Hazard ratios (HRs) for type 2 diabetes risk across quartiles of the baseline PRAL and NEAP scores were estimated with multivariate Cox regression models.


During follow-up, 1,372 cases of incident type 2 diabetes were validated. In the overall population, the highest PRAL quartile, reflecting a greater acid-forming potential, was associated with a significant increase in type 2 diabetes risk, compared with the first quartile (HR, 1.56; 95% confidence interval [CI], 1.29-1.90). The association was stronger among women with body mass index <25 kg/m2 (HR, 1.96; 95% CI, 1.43-2.69) than in overweight women (HR, 1.28; 95% CI, 1.00-1.64); statistically significant trends in risk across quartiles were observed in both groups (p trend <0.0001 and p trend = 0.03, respectively). The NEAP score provided similar findings.


In a large prospective study, dietary acid load was positively associated with type 2 diabetes risk, independently of other known risk factors for diabetes. The results need to be validated in other populations, and may lead to promotion of diets with a low acid load for the prevention of diabetes.


A high-PRAL diet includes more meat, fish, cheese, bread, and drinks with artificial sweetened beverages, and a low-PRAL diet has more dairy products, fruit, vegetables, and coffee. The findings, which seem related to glycemic index and dietary fat, were independent of dietary patterns, suggesting a contribution of dietary acidity.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Diet

Keywords: Dietary Fats, Overweight, Diabetes Mellitus, Type 2, Risk Factors, Glycemic Index, Metabolic Syndrome X, Fruit, Bread, Body Mass Index, Dairy Products, Vegetables, Sweetening Agents, Cheese, Diet, Confidence Intervals, Coffee, Meat

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