Association of dietary choline intake with all-cause and disease-specific mortality among individuals with diabetes: A population-based prospective cohort study

Evidence regarding the association between dietary choline intake and mortality in individuals with diabetes remains limited. This study aimed to evaluate the relationship between dietary choline intake and all-cause, cardiovascular disease (CVD), and cancer-related mortality among adults with diabetes. A total of 4,712 participants with diabetes were included from the NHANES 2007-2018 cycles. Dietary choline intake was estimated using two 24-hour dietary recalls, and mortality outcomes were ascertained via linkage to National Death Index records through December 31, 2019. Cox proportional hazards models and Kaplan-Meier analyses were employed to assess the associations between choline intake and mortality. Restricted cubic spline models were used to examine potential non-linear relationships, and threshold analyses were conducted to identify inflection points. Over a median follow-up of 6.42 years, 805 deaths were documented, including 267 from CVD and 126 from cancer. A U-shaped association was observed between dietary choline intake and all-cause mortality (p for non-linearity < 0.0001). Compared with the lowest quartile, multivariable-adjusted hazard ratios (HRs) for all-cause mortality were 0.64 (95% CI: 0.47-0.88) for the second quartile, 0.59 (0.43-0.82) for the third, and 0.69 (0.43-1.09) for the highest quartile. No significant associations were found between choline intake and either CVD or cancer mortality. These findings indicate a U-shaped relationship between dietary choline intake and all-cause mortality in individuals with diabetes, with intakes between 286.77 and 538.86 mg/day associated with the lowest risk—providing potential implications for dietary guidance in diabetes management.