OBJECTIVE The high diabetes incidence among Japanese Americans and Native Hawaiians cannot be explained by BMI. Therefore, we examined the influence of three dietary patterns of "fat and meat," "vegetables," and "fruit and milk" on diabetes risk in the Hawaii component of the Multiethnic Cohort with 29,759 Caucasians, 35,244 Japanese Americans, and 10,509 Native Hawaiians. RESEARCH DESIGN AND METHODS Subjects aged 45-75 years completed a baseline food frequency questionnaire. After 14 years of follow-up, 8,587 subjects with incident diabetes were identified through self-reports or health plan linkages. Risk was assessed using Cox regression stratified by age and adjusted for ethnicity, BMI, physical activity, education, total energy, smoking, alcohol intake, marital status, and hypertension. RESULTS Fat and meat was significantly associated with diabetes risk in men (hazard ratio 1.40 [95% CI 1.23-1.60], P(trend) < 0.0001) and women (1.22 [1.06-1.40], P(trend) = 0.004) when extreme quintiles were compared. Except in Hawaiian women, the magnitude of the risk was similar across ethnic groups although not always significant. After stratification by BMI, fat and meat remained a predictor of disease primarily among overweight men and among overweight Japanese women. Vegetables lowered diabetes risk in men (0.86 [0.77-0.95], P(trend) = 0.004) but not in women, whereas fruit and milk seemed to be more beneficial in women (0.85 [0.76-0.96], P(trend) = 0.005) than in men (0.92 [0.83-1.02], P(trend) = 0.04). CONCLUSIONS Foods high in meat and fat appear to confer a higher diabetes risk in all ethnic groups, whereas the effects of other dietary patterns vary by sex and ethnicity.