{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,3]],"date-time":"2026-11-03T13:10:03Z","timestamp":1793711403278,"version":"4.6.1"},"reference-count":43,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2019,5,31]],"date-time":"2019-05-31T00:00:00Z","timestamp":1559260800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Swedish Research Council (Swedish Development Grant)","award":["No number assigned"],"award-info":[{"award-number":["No number assigned"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>The dietary inflammatory index (DII\u00ae), a validated tool used to measure the inflammatory potential of the diet, has been associated with metabolic disorders in various settings, but not in African populations. The aim of this study was to investigate whether the DII is associated with markers of type 2 diabetes (T2D) risk, and if this association is mediated by adiposity and\/or low-grade inflammation, in black South Africa women. Energy-adjusted-DII (E-DII) scores were calculated in 190 women (median age, 53 years) from the Birth-to-Twenty plus cohort using a validated food frequency questionnaire. Fasting glucose, insulin, HbA1c, and inflammatory cytokines were measured, and an oral glucose tolerance test performed. Basic anthropometry and dual-energy x-ray absorptiometry-derived body fat, including estimate of visceral adipose tissue (VAT) area, were measured. E-DII scores were associated with all markers of T2D risk, namely, fasting glucose and insulin, HbA1c, HOMA2-IR, two-hour glucose and Matsuda index (all p &lt; 0.05). After adjusting for age, measures of adiposity, but not inflammatory cytokines, mediated the association between E-DII and markers of T2D risk (p &lt; 0.05). Measures of central obesity had proportionally higher (range: 23.5\u2013100%) mediation effects than total obesity (range: 10\u201360%). The E-DII is associated with T2D risk through obesity, in particular central obesity, among black middle-aged South African women.<\/jats:p>","DOI":"10.3390\/nu11061246","type":"journal-article","created":{"date-parts":[[2019,5,31]],"date-time":"2019-05-31T11:59:56Z","timestamp":1559303996000},"page":"1246","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":46,"title":["Adiposity Mediates the Association between the Dietary Inflammatory Index and Markers of Type 2 Diabetes Risk in Middle-Aged Black South African Women"],"prefix":"10.3390","volume":"11","author":[{"given":"Asanda","family":"Mtintsilana","sequence":"first","affiliation":[{"name":"South African Medical Research Council\/University of the Witwatersrand Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4994-0779","authenticated-orcid":false,"given":"Lisa K.","family":"Micklesfield","sequence":"additional","affiliation":[{"name":"South African Medical Research Council\/University of the Witwatersrand Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa"},{"name":"Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7725, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elin","family":"Chorell","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 University, SE-901 87 Ume\u00e5, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7768-1076","authenticated-orcid":false,"given":"Tommy","family":"Olsson","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 University, SE-901 87 Ume\u00e5, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nitin","family":"Shivappa","sequence":"additional","affiliation":[{"name":"Cancer Prevention and Control Program, University of South Carolina, 915 Greene Street, Suite 200, Columbia, SC 29208, USA"},{"name":"Department of Epidemiology and Biostatistics, University of South Carolina, 915 Greene Street, Suite 400, Columbia, SC 29208, USA"},{"name":"Connecting Health Innovations, LLC, 1417 Gregg Street, Columbia, SC 29201, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0677-2672","authenticated-orcid":false,"given":"James R","family":"Hebert","sequence":"additional","affiliation":[{"name":"Cancer Prevention and Control Program, University of South Carolina, 915 Greene Street, Suite 200, Columbia, SC 29208, USA"},{"name":"Department of Epidemiology and Biostatistics, University of South Carolina, 915 Greene Street, Suite 400, Columbia, SC 29208, USA"},{"name":"Connecting Health Innovations, LLC, 1417 Gregg Street, Columbia, SC 29201, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5183-131X","authenticated-orcid":false,"given":"Andre P.","family":"Kengne","sequence":"additional","affiliation":[{"name":"Non-Communicable Diseases Research Unit, South African Medical Research Council, Francie Van Zijl, Parow Valley, Cape Town 7505, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6795-4771","authenticated-orcid":false,"given":"Julia H.","family":"Goedecke","sequence":"additional","affiliation":[{"name":"South African Medical Research Council\/University of the Witwatersrand Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa"},{"name":"Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7725, South Africa"},{"name":"Non-Communicable Diseases Research Unit, South African Medical Research Council, Francie Van Zijl, Parow Valley, Cape Town 7505, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2019,5,31]]},"reference":[{"key":"ref_1","unstructured":"World Health Organisation (2014). Global Status Report on Noncommunicable Diseases 2014, World Health Organization."},{"key":"ref_2","unstructured":"Statistics South Africa (2018). Mortality and Causes of Death in South Africa, 2016: Findings from Death Notification, Statistics South Africa. Available online: https:\/\/doi.org\/StatisticalreleaseP0309.3."},{"key":"ref_3","unstructured":"Cho, N.H., Kirigia, J., Claude, J., Ogurstova, M.K., Guariguata, L., Rathmann, W., Roglic, G., Forouhi, N., Dajani, R., and Esteghamati, A. (2017). Diabetes Atlas, IDF. [8th ed.]."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1340","DOI":"10.1038\/sj.ijo.0801416","article-title":"Evidence for Insulin Resistance in Black Women from South Africa","volume":"24","author":"Crowther","year":"2000","journal-title":"Int. J. Obes. Relat. Metab. Disord."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"860","DOI":"10.2337\/dc08-2048","article-title":"Insulin Response in Relation to Insulin Sensitivity- An Appropriate Beta-Cell Response in Black South African Women","volume":"32","author":"Goedecke","year":"2009","journal-title":"Diabetes Care"},{"key":"ref_6","unstructured":"National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research (SAMRC), and ICF (2017). South African Demographic and Health Survey (SADHS) 2016: Key Indicators, Statistics South Africa."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Peer, N., Steyn, K., Lombard, C., Lambert, E.V., Vythilingum, B., and Levitt, N.S. (2012). Rising Diabetes Prevalence among Urban-Dwelling Black South Africans. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0043336"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1479","DOI":"10.3945\/ajcn.113.069005","article-title":"Added Sugar Intake in South Africa: Findings from the Adult Prospective Urban and Rural Epidemiology Cohort Study","volume":"99","author":"Vorster","year":"2014","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3402\/gha.v6i0.19216","article-title":"Urban-Rural and Gender Differences in Tobacco and Alcohol Use, Diet and Physical Activity among Young Black South Africans between 1998 and 2003","volume":"6","author":"Peer","year":"2013","journal-title":"Glob. Health Action"},{"key":"ref_10","first-page":"1","article-title":"The Use of Predefined Diet Quality Scores in the Context of CVD Risk during Urbanization in the South African Prospective Urban and Rural Epidemiological (PURE) Study","volume":"17","author":"Dolman","year":"2013","journal-title":"Public Health Nutr."},{"key":"ref_11","first-page":"1","article-title":"Accelerated Nutrition Transition in the North West Province of South Africa: Results from the Prospective Urban and Rural Epidemiology (PURE-NWP-SA) Cohort Study, 2005 to 2010","volume":"2003","author":"Lee","year":"2018","journal-title":"Public Health Nutr."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1007\/s00394-012-0340-6","article-title":"Consumption of Red Meat and Whole-Grain Bread in Relation to Biomarkers of Obesity, Inflammation, Glucose Metabolism and Oxidative Stress","volume":"52","author":"Montonen","year":"2013","journal-title":"Eur. J. Nutr."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"984","DOI":"10.1017\/S0007114514004401","article-title":"Dietary Inflammatory Index and Anthropometric Measures of Obesity in a Population Sample at High Cardiovascular Risk from the PREDIMED (PREvenci\u00f3n Con DIeta MEDiterr\u00e1nea) Trial","volume":"113","author":"Zazpe","year":"2015","journal-title":"Br. J. Nutr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1689","DOI":"10.1017\/S1368980013002115","article-title":"Designing and developing a literature-derived, population-based dietary inflammatory index","volume":"17","author":"Shivappa","year":"2014","journal-title":"Public Health Nutr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"3218","DOI":"10.1080\/10408398.2015.1107021","article-title":"A Comprehensive Meta-Analysis on Evidence of Mediterranean Diet and Cardiovascular Disease: Are Individual Components Equal?","volume":"57","author":"Grosso","year":"2017","journal-title":"Crit. Rev. Food Sci. Nutr."},{"key":"ref_16","first-page":"1796","article-title":"Obesity Is Associated with Macrophage Accumulation in Adipose Tissue","volume":"112","author":"Weisberg","year":"2003","journal-title":"Anaesth. Intensive Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1347","DOI":"10.1038\/sj.ijo.0803259","article-title":"Circulating Levels of MCP-1 and IL-8 Are Elevated in Human Obese Subjects and Associated with Obesity-Related Parameters","volume":"30","author":"Kim","year":"2006","journal-title":"Int. J. Obes."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1007\/s12603-016-0775-1","article-title":"Construct Validation of the Dietary Inflammatory Index among African Americans","volume":"21","author":"Wirth","year":"2017","journal-title":"J. Nutr. Heal. Aging"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1533","DOI":"10.3945\/ajcn.112.056333","article-title":"Adapted Dietary Inflammatory Index and Its Association with a Summary Score for Low-Grade Inflammation and Markers of Glucose Metabolism: The Cohort Study on Diabetes and Atherosclerosis Maastricht (CODAM) and the Hoorn Study1-4","volume":"98","author":"Theofylaktopoulou","year":"2013","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1139\/apnm-2016-0395","article-title":"Association between Dietary Inflammatory Index (DII) and Risk of Prediabetes: A Case-Control Study","volume":"42","author":"Vahid","year":"2017","journal-title":"Appl. Physiol. Nutr. Metab."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Denova-Guti\u00e9rrez, E., Mu\u00f1oz-Aguirre, P., Shivappa, N., H\u00e9bert, J.R., Tolentino-Mayo, L., Batis, C., and Barquera, S. (2018). Dietary Inflammatory Index and Type 2 Diabetes Mellitus in Adults: The Diabetes Mellitus Survey of Mexico City. Nutrients, 10.","DOI":"10.3390\/nu10040385"},{"key":"ref_22","first-page":"89","article-title":"Socio-Cultural Factors Influencing Food Consumption Patterns in the Black African Population in an Urban Township in South Africa","volume":"14","author":"Puoane","year":"2006","journal-title":"Hum. Ecol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"369","DOI":"10.5830\/CVJA-2013-069","article-title":"Socio-Cultural, Environmental and Behavioural Determinants of Obesity in Black South African Women","volume":"24","author":"Micklesfield","year":"2013","journal-title":"Cardiovasc. J. Afr."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Crowther, N.J., and Norris, S.A. (2012). The Current Waist Circumference Cut Point Used for the Diagnosis of Metabolic Syndrome in Sub-Saharan African Women Is Not Appropriate. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0048883"},{"key":"ref_25","first-page":"1","article-title":"The IDF Consensus Worldwide Definition of the Metabolic Syndrome","volume":"23","author":"Alberti","year":"2006","journal-title":"Diabet. Med."},{"key":"ref_26","unstructured":"World Health Organization (2000). Obesity: Preventing and Managing the Global Epidemic, World Health Organization."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1038\/oby.2011.367","article-title":"Dual-Energy X-Ray Performs as Well as Clinical Computed Tomography for the Measurement of Visceral Fat","volume":"20","author":"Micklesfield","year":"2012","journal-title":"Obesity"},{"key":"ref_28","first-page":"147","article-title":"A Proposed Method to Measure Body Composition in Obese Individuals Using Dual-Energy X-Ray Absorptiometry","volume":"5","author":"Micklesfield","year":"2007","journal-title":"Int. J. Body Compos. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1449S","DOI":"10.1093\/jn\/136.5.1449S","article-title":"Development of a Universally Applicable Household Food Insecurity Measurement Tool: Process, Current Status, and Outstanding Issues","volume":"136","author":"Swindale","year":"2006","journal-title":"J. Nutr."},{"key":"ref_30","first-page":"1","article-title":"An Exercise Intervention to Unravel the Mechanisms Underlying Insulin Resistance in a Cohort of Black South African Women: Protocol for a Randomized Controlled Trial and Baseline Characteristics of Participants","volume":"20","author":"Goedecke","year":"2018","journal-title":"J. Med. Internet Res."},{"key":"ref_31","unstructured":"Nel, J.H., and Steyn, N. (2002). Report on South African Food Consumption Studies Undertaken among Population Groups (1983\u20132000): Average Intakes of Foods Most Commonly Consumed, Department of Health."},{"key":"ref_32","first-page":"35","article-title":"Europe PMC Funders Group Author Manuscript How Well Do Adolescents Determine Portion Sizes of Foods and Beverages?","volume":"15","author":"Steyn","year":"2009","journal-title":"Asia Pac. J. Clin. Nutr."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1487","DOI":"10.2337\/diacare.27.6.1487","article-title":"Use and Abuse of HOMA Modeling","volume":"27","author":"Wallace","year":"2004","journal-title":"Diabetes Care"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1462","DOI":"10.2337\/diacare.22.9.1462","article-title":"Insulin Sensitivity Indices Obtained from Oral Glucose Tolerance Testing: Comparison with the Euglycemic Glucose Clamp","volume":"22","author":"Matsuda","year":"1999","journal-title":"Diabetes Care"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"879","DOI":"10.3758\/BRM.40.3.879","article-title":"Asymptotic and Resampling Strategies for Assessing and Comparing Indirect Effects in Multiple Mediator Models","volume":"40","author":"Preacher","year":"2008","journal-title":"Behav. Res. Methods"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1111\/j.1467-789X.2009.00623.x","article-title":"Subcutaneous and Visceral Adipose Tissue: Structural and Functional Differences","volume":"11","author":"Ibrahim","year":"2010","journal-title":"Obes. Rev."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Snel, M., Jonker, J.T., Schoones, J., Lamb, H., De Roos, A., Pijl, H., Smit, J.W.A., Meinders, A.E., and Jazet, I.M. (2012). Ectopic Fat and Insulin Resistance: Pathophysiology and Effect of Diet and Lifestyle Interventions. Int. J. Endocrinol., 1\u201318.","DOI":"10.1155\/2012\/983814"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1234","DOI":"10.1161\/CIRCULATIONAHA.107.710509","article-title":"Visceral and Subcutaneous Adipose Tissue Volumes Are Cross-Sectionally Related to Markers of Inflammation and Oxidative Stress: The Framingham Heart Study","volume":"116","author":"Pou","year":"2007","journal-title":"Circulation"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1016\/j.cell.2015.01.012","article-title":"Hepatic Acetyl CoA Links Adipose Tissue Inflammation to Hepatic Insulin Resistance and Type 2 Diabetes","volume":"160","author":"Perry","year":"2015","journal-title":"Cell"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"S32","DOI":"10.1038\/sj.ijo.0801274","article-title":"Relationship between Regional Fat Distribution and Insulin Resistance","volume":"24","author":"Bonora","year":"2000","journal-title":"Int. J. Obes."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1146\/annurev-immunol-031210-101322","article-title":"Inflammatory Mechanisms in Obesity","volume":"29","author":"Gregor","year":"2011","journal-title":"Annu. Rev. Immunol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1126\/science.7678183","article-title":"Adipose Expression of Tumor Necrosis Factor-x: Direct Role in Obesity-Linked Insulin Resistance","volume":"259","author":"Hotamisligil","year":"1993","journal-title":"Science"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1111\/j.1365-2265.2010.03883.x","article-title":"Depot- and Ethnic-Specific Differences in the Relationship between Adipose Tissue Inflammation and Insulin Sensitivity","volume":"74","author":"Evans","year":"2011","journal-title":"Clin. Endocrinol. 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