White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries

1. Journal club
(prognosis paper)
Presented by
Abdulaziz Bagasi
R4 Family Medicine NGH-Jeddah
Supervised by
Dr.Faisal Algawos
November 2020

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Objectives
• Why this study ?
• PICO
• Study overview
• Critical appraisal
• Conclusion

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Why this study ?
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PICO
P: Population
132,373 individuals aged 35–70 years from 21 countries
I : Intervention
White rice consumption 450 g/day or more
C : Comparison
White rice consumption less than 150 g/day
O : Outcome
Incidence of diabetes after 9.5 years follow up

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Double blind
Methodology

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Study overview
Methodology
• 132.373 individuals from 21 countries
• (Argentina, Bangladesh, Brazil, Canada, Chile, China, Colombia, India, Iran, Malaysia,
occupied Palestine territory, Pakistan, Philippines, Poland, South Africa, Saudi Arabia,
Sweden, Tanzania, Turkey, United Arab Emirates, and Zimbabwe)
• Using standardized questionnaires
• White rice consumption was categorized as
• <150 g/day
• 150 to <300 g/day
• 300 to <450 g/day
• 450 g/day or more

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Result
• The mean follow-up period was 9.5 years
• 6,129 individuals without baseline diabetes developed incident diabetes.
• Higher intake of white rice (<450 g/day compared with <150 g/day) was
associated with increased risk of diabetes
• The highest risk was seen in South Asia followed by other regions of the world
(which included South East Asia, Middle East, South America, North America,
Europe, and Africa)
• In China there was no significant association

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Validity Result Applicability
Critical appraisal

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Validity 1
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• Representative sample

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Validity 2
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• Follow up sufficient (mean 9.5 years)
but no in information about drop out
(Not complete) !

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Validity 3
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• The primary outcome is clear
which is the incidence of DM.
• It is objective ,not blinded

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Validity 4
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Result 1
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• The HR is a comparison between the
probability of events in a treatment
group, compared to the probability of
events in a control group.
• It’s used to see if patients receiving a
treatment progress faster (or slower)
than those not receiving treatment.
• The hazard ratio, which can be defined
as the relative risk of an event
happening at time

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• In the overall cohort, higher intake of white
rice was associated with increased risk of
diabetes
(HR 1.20; 95% CI 1.02–1.40)
• The highest risk was seen in South
Asia
(HR 1.61; 95% CI 1.13–2.30)
• Other regions of the world (which
included South East Asia, Middle
East, South America, North
America, Europe, and Africa)
(HR 1.41; 95% CI 1.08–1.86)
• In China there was no significant
association
(HR 1.04; 95% CI 0.77–1.40)
• In the overall
 Higher intake of rice is relatively
increasing the incidence of DM by 20%
 CI (2%-40%), acceptable
(The narrower the CI the more precise the HR)
• In the South Asia
 Higher intake of rice is relatively
increasing the incidence of DM by 61%
 CI (13%-130%), wide
• Other regions
 Higher intake of rice is relatively
increasing the incidence of DM by 41%
• In China
 Higher intake of rice is relatively
increasing the incidence of DM by 4%

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Applicability
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ADA 2020
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ESC
Guidelines
2019
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Summary of Critical appraisal
Applicability
Result
Validity
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Strengths of the study
1. The largest prospective study on rice and incident diabetes, and it covers 21
countries from five continents.
2. Several potential confounders have been included in the multivariable
analysis.
3. A fairly long period of follow-up.
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Weaknesses/Limitations of the study
1. Measurement of diet was done only at baseline and changes in diet and other lifestyle factors
could have subsequently occurred.
2. Residual confounding due to unmeasured dietary factors, such as alcohol use, or the newly
emerging risk factors like air pollution or use of pesticides cannot be completely ruled out.
3. The majority of the participants in the study (97.3%) were tested for diabetes using fasting
blood glucose due to the costs. Glucose tolerance tests or A1C tests in all participants could
not be done.
4. Information on different types of white rice would have further enhanced the results of this
study.
5. Drop out not mentioned in the study.
6. Study design and methods of the participants not clear and not available.
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Conclusion
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Thank you !