Objective  To explore the association between dietary behavior and the incidence of type 2 diabetes mellitus (T2DM) among rural adults in Deqing county, Zhejiang province and to provide evidences for implementing relevant interventions.

  Methods  We conducted a dynamic prospective cohort study among a total of 28 233 diabetes-free permanent residents aged 18 – 64 years randomly selected from 2, 6, and 7 rural communities between 2006 – 2008, 2011 – 2012, and 2013 – 2014, respectively. Questionnaire survey, physical examination and laboratory test were carried out among the participants. Univariate and multivariate Cox regression were applied to explore the associations between diet preference and T2DM.

  Results  By the end of study, a total of 2 773 participants, including 874 deaths, were lost to follow-up, with a rate of loss to follow-up of 9.82%. Totally 369 new T2DM incidents were identified till November 2015 and the incident density was 3.13 per 1 000 person years (PYs). Among the participants reporting main dietary pattern of balanced diet, vegetarian diet, and meat or fish diet, the number of T2DM incidents newly identified were 227, 46, and 96 and the T2DM incident density were 2.59/1 000 PYs, 2.88/1 000 PYs, and 6.67/1 000 PYs, respectively. The results of univariate Cox regression revealed that the T2DM risk was 2.58 times higher (hazard ratio HR = 2.58, 95% confidence interval 95% CI: 2.03 – 3.27) among the participants with a main dietary pattern of meat or fish diet than among those with a main dietary pattern of balanced diet. The results of multivariate Cox regression demonstrated that compared to the participants with a main dietary pattern of balanced diet, those with a main dietary pattern of meat or fish diet had a significantly increased risk of T2DM incidence (HR = 2.46, 95% CI: 1.94 – 3.13) after adjusting 11 confounding factors including gender, age, education, occupation, smoking, alcohol drinking, tea drinking, body mass index, hypertension, impaired fasting glucose, and familial history of diabetes.

  Conclusion  Meat or fish dietary pattern could increase the incidence risk of T2DM among rural adult residents and the results should be concerned in future prevention and control of T2DM among the population.