Reproducibility and validity of diet quality scores derived from food-frequency questionnaires

Causal analysis of undernutrition among adolescents in the context of the agrarian community of North-West Ethiopia: a general structural equation modelling approach

OBJECTIVE

This study was conducted to evaluate the causal analysis of undernutrition among adolescents in the context of the agrarian community of North-West Ethiopia.

DESIGN

A community-based case-control study was conducted among 149 cases and 297 control adolescents.

SETTING

Agrarian communities of North-West Ethiopia.

PARTICIPANTS

Adolescents aged 10-19 years, who reside in a randomly selected study setting.

OUTCOME MEASURES

The stunting and thinness nutritional status of adolescents was determined using the WHO AnthroPlus 2010 software. A general structural equation modelling approach was used to determine a multicausal analysis of undernutrition. The Food Frequency Questionnaire was tested for internal reliability among 30 adolescents. The reliability test for the actual dietary tool was done using Cronbach's alpha coefficient (α), which was 0.79. The model adequacy was tested using the Akaike information criterion and Bayesian information criterion. The significant direct and indirect determinants were identified with a value of p<0.05.

RESULT

Adolescents with lower traditional and mixed dietary pattern consumption habits were determinant factors for stunting with adjusted β=0.65, 95% CL (0.143 to 1.159) with a value of p=0.012, adjusted β=2.697, 95% CL (0.563 to 4.831) with a value of p=0.013, respectively. Breakfast eating frequency had a negative indirect determinant factor on the reduction of stunting via lower traditional habits, with adjusted β=-0.207 (-0.299 to-0.116) with a value of p=0.001, and higher consumption habits of animal sources with traditional alcoholic drinking habits with adjusted β=-0.163, 95% CL (-0.260 to -0.065) with a value of p=0.001. Whereas breakfast eating frequency had a direct influence on thinness with adjusted β=-0.332, 95% CL (-0.588 to -0.076) with a value of p=0.011, and an indirect influence via dietary patterns for both stunting and thinness (p<0.05).

CONCLUSION

Dietary patterns and breakfast-eating frequency were direct and indirect determinant factors for adolescents' stunting and thinness. Public health interventions should be implemented to reduce stunting and thinness by improving the dietary feeding and breakfast consumption habits of adolescents and strengthening the national deworming programmes in study areas and similar settings.

Validation of a food frequency questionnaire for measuring dietary intake of isoflavones and lignans using the method of triads

BACKGROUND

Emerging epidemiologic evidence suggested a protective association between dietary phytoestrogens and multiple chronic diseases, although validation studies on the 2 phytoestrogen subclasses, isoflavones and lignans, estimated from food frequency questionnaires (FFQs) are lacking.

OBJECTIVES

We evaluated the performance of the FFQ for measuring isoflavone and lignan intake among 892 free-living adults in the Anhui Lifestyle Validation Study (ALVS).

METHODS

From July 2021 to July 2022, participants from the ALVS completed a 141-item FFQ and donated fasting morning urine specimens twice, 1-year apart, and completed twelve 24-h dietary recalls (24HDRs) that consisted of 4 quarterly 3 consecutive 24-h dietary recalls (i.e. 2 weekdays and 1 weekend day in each season) between the 2 FFQ assessments. The reproducibility coefficients were assessed by the intraclass correlation coefficient between estimates from the 2 FFQs. The validity coefficients (VCs) were evaluated by the method of triads to calculate correlations between estimates from dietary assessment tools and true dietary intake using biomarkers (the mean of 2 measurements of urinary concentrations of 4 isoflavone metabolites and 4 lignan metabolites), 24HDRs, and FFQs.

RESULTS

The FFQ-derived isoflavones (median: 23.6 mg/d; IQR: 12.1-41.5 mg/d) and lignans (median: 19.7 mg/d; IQR: 11.9-30.7 mg/d) showed good reproducibility with the same intraclass correlation coefficient of 0.55 (95% confidence interval [CI]: 0.46, 0.62). Estimated VCs between the FFQs and theoretical true intake were 0.65 (95% CI: 0.31, 1.00) for isoflavones and 0.48 (95% CI: 0.24, 0.86) for lignans. Compared with FFQ-based assessments, urinary biomarkers showed the same validity in assessing dietary lignans (VC: 0.48; 95% CI: 0.21, 0.88), but dietary isoflavones showed a lower VC of 0.22 (95% CI: 0.03, 0.47).

CONCLUSIONS

FFQ shows reasonable performance in measuring habitual intake of isoflavones and lignans, although urinary isoflavones are unlikely to perform as well as FFQ-based assessment of dietary isoflavones.

Optimal dietary patterns for healthy aging

As the global population ages, it is critical to identify diets that, beyond preventing noncommunicable diseases, optimally promote healthy aging. Here, using longitudinal questionnaire data from the Nurses' Health Study (1986-2016) and the Health Professionals Follow-Up Study (1986-2016), we examined the association of long-term adherence to eight dietary patterns and ultraprocessed food consumption with healthy aging, as assessed according to measures of cognitive, physical and mental health, as well as living to 70 years of age free of chronic diseases. After up to 30 years of follow-up, 9,771 (9.3%) of 105,015 participants (66% women, mean age = 53 years (s.d. = 8)) achieved healthy aging. For each dietary pattern, higher adherence was associated with greater odds of healthy aging and its domains. The odds ratios for the highest quintile versus the lowest ranged from 1.45 (95% confidence interval (CI) = 1.35-1.57; healthful plant-based diet) to 1.86 (95% CI = 1.71-2.01; Alternative Healthy Eating Index). When the age threshold for healthy aging was shifted to 75 years, the Alternative Healthy Eating Index diet showed the strongest association with healthy aging, with an odds ratio of 2.24 (95% CI = 2.01-2.50). Higher intakes of fruits, vegetables, whole grains, unsaturated fats, nuts, legumes and low-fat dairy products were linked to greater odds of healthy aging, whereas higher intakes of trans fats, sodium, sugary beverages and red or processed meats (or both) were inversely associated. Our findings suggest that dietary patterns rich in plant-based foods, with moderate inclusion of healthy animal-based foods, may enhance overall healthy aging, guiding future dietary guidelines.

Gut-Microbiota-Related Metabolite Phenylacetylglutamine and Risk of Incident Coronary Heart Disease Among Women

CONTEXT

Phenylacetylglutamine (PAGln) is a novel metabolite derived from gut microbial metabolism of dietary proteins, specifically phenylalanine, which may be linked to risks of adverse cardiovascular events.

OBJECTIVE

We investigated whether higher plasma levels of PAGln were associated with a greater risk of incident coronary heart disease (CHD) and tested whether adherence to a plant-based diet, which characterizes habitual dietary patterns of animal and plant food intake, modified the associations.

METHODS

We examined associations between plasma PAGln and risk of incident CHD over 11 to 16 years in a nested case-control study of 1520 women (760 incident cases and 760 controls) from the Nurses' Health Study. Separately, we analyzed relations between PAGln and dietary intakes measured through dietary records in the Women's Lifestyle Validation Study (n = 725).

RESULTS

Higher PAGln levels were related to a greater risk of CHD (P < .05 for dose-response relationship). Higher PAGln was associated with greater red/processed meat intake and lower vegetable intake (P < .05 for all). We found a significant interaction between PAGln and adherence to plant-based diet index (PDI) on CHD (Pinteraction = .008); higher PAGln levels were associated with an increased risk of CHD (relative risk per 1 SD: 1.22 [95% CI: 1.05, 1.41]) among women with low PDI but not among those with high PDI.

CONCLUSION

Higher PAGln was associated with higher risk of CHD, particularly in women with dietary patterns of eating more animal foods and fewer plant-based foods. Adherence to plant-based diets might attenuate unfavorable associations between a novel microbial metabolite and CHD risk.

Plasma levels of polyols erythritol, mannitol, and sorbitol and incident coronary heart disease among women

AIMS

Erythritol, a sugar alcohol (polyol), has recently been linked to the risk of major adverse cardiovascular events. We investigated whether plasma erythritol and other polyols (mannitol/sorbitol) were associated with the risk of incident coronary heart disease (CHD).

METHODS AND RESULTS

This prospective nested case-control study included 762 incident cases of CHD and 762 controls from the Nurses' Health Study. Plasma concentrations of polyols were measured at baseline (1989-90 or 2000-02). Associations of erythritol with cardiometabolic risk factors were also analysed in the Women's Lifestyle Validation Study (n = 728; blood collected in 2010-12). Higher erythritol levels were related to more adverse cardiometabolic risk factor status. A relative risk (RR) for CHD per 1-SD increment was 1.15 [95% confidence interval (CI): 1.04, 1.28] for erythritol and 1.16 (95% CI: 1.05, 1.28) for mannitol/sorbitol, after adjusting for diet quality, lifestyles, and adiposity. Compared with women in the lowest quartile, those in the highest quartile (Q4) of erythritol had an RR of 1.55 (95% CI: 1.13, 2.14) for CHD. The RR in the Q4 of erythritol was 1.61 (95% CI: 1.15, 2.24; P = 0.006) when hypertension and dyslipidaemia were further added to the model; the RR was 1.21 (95% CI: 0.86, 1.70) after adjustment for diabetes. For mannitol/sorbitol, the RR in Q4 was 1.42 (95% CI: 1.05, 1.91; P = 0.022) for CHD in the multivariable-adjusted model including diabetes.

CONCLUSION

Higher levels of plasma erythritol and mannitol/sorbitol were related to elevated risks of CHD even after adjustment for diet, lifestyles, adiposity, and other risk factors. The unfavourable association of mannitol/sorbitol, but not of erythritol, with CHD risk remained significant independent of diabetes/hyperglycaemia.

Plant-based diets and urological health

Plant-based diets have grown in popularity owing to multiple health and environmental benefits. Some evidence suggests that plant-based diets are associated with benefits for urological health. In genitourinary oncology, most research has focused on prostate cancer. Clinical trial results suggest a favourable influence of healthy lifestyle modifications including plant-based diets before and after prostate cancer treatment. Epidemiological evidence shows that a diet higher in plant-based and lower in animal-based food is associated with a lower risk of aggressive prostate cancer and better quality-of-life scores than a diet with less plant-based and more animal-based food. Studies on bladder and kidney cancer are scarce, but limited data suggest that vegetarian or plant-forward dietary patterns (increased consumption of fruits and vegetables and minimizing meat) are associated with a lower risk of development of these cancers than dietary patterns with fewer fruits and vegetables and more meat. With respect to benign urological conditions, epidemiological studies suggest that plant-based dietary patterns are associated with a lower risk of benign prostatic hyperplasia and urinary tract infections than non-plant-based dietary patterns. Compared with diets high in animal-based foods and low in plant-based foods, a substantial body of epidemiological evidence also suggests that increased consumption of healthy plant-based food is associated with a lower risk of erectile dysfunction. Plant-based dietary patterns that are high in fruits and vegetables with normal calcium intake, while limiting animal protein and salt, are associated with a lower risk of kidney stone development than dietary patterns that do not follow these parameters. Overall, increasing consumption of plant-based foods and reducing intake of animal-based foods has favourable associations with multiple urological conditions.

Reproducibility and Validity of Plant-Based Dietary Indices in the Cancer Prevention Study-3 Diet Assessment Substudy

BACKGROUND

The Overall Plant-based Diet Index (PDI), the Healthful Plant-based Diet Index (hPDI), and the Unhealthful Plant-based Diet Index (uPDI) are relatively new tools for characterizing the quality of plant-based dietary patterns in epidemiologic studies. Reproducibility and validity of these indices have not been assessed across populations.

OBJECTIVE

The objective of this study was to evaluate the reproducibility and validity of PDI, hPDI, and uPDI in a racially and ethnically diverse population.

METHODS

Participants (n = 433 women, n = 244 men, n = 417 non-Hispanic White, n = 159 non-Hispanic Black, and n = 101 Hispanic) from the 2015-2016 Cancer Prevention Study 3 Dietary Assessment Substudy (CPS-3 DAS) completed the CPS-3 Food Frequency Questionnaire (FFQ) on 2 occasions (FFQ1 and FFQ2) and ≤6 24-h dietary recalls (24HRs) over 1 y. Plant-based diet scores were calculated using energy-adjusted food group intakes from each FFQ and mean 24HRs. Pearson correlations were used to evaluate reproducibility of each score between FFQs. Validity of the scores derived from FFQ2 was assessed relative to the mean of the 24HRs and blood and urine biomarkers.

RESULTS

Pearson correlations for reproducibility between FFQs for men and women were 0.64 and 0.66 for PDI, 0.85 and 0.80 for hPDI, and 0.84 and 0.78 for uPDI. Pearson correlations for validity between FFQ2 and the mean 24HRs for PDI, hPDI, and uPDI for men were 0.54, 0.68, and 0.60, respectively, and for women were 0.49, 0.0.62, and 0.62, respectively. Biomarkers of most carotenoids, total protein, sodium, and potassium showed correlations ≥0.20 with certain plant-based diet scores. Reproducibility and validity were moderate to good in all racial/ethnic subgroups and were highest in non-Hispanic White adults.

CONCLUSIONS

There was good reproducibility and moderate to good validity of PDI within the CPS-3 FFQ. Future work should continue to validate these indices across populations with varied diets and dietary measurement tools.

Modifiable lifestyle factors in the primordial prevention of hypertension in three US cohorts

BACKGROUND

Evidence is lacking on the relative contributions of specific lifestyle factors and their overall contribution to prevention of hypertension, in particular early-onset hypertension.

METHODS

This prospective cohort study included participants of the Nurses' Health Study (NHS, N = 52,780 women, aged 40-67 in 1986), the NHS II (N = 83,871 women, aged 27-46 in 1991), and the Health Professionals Follow-up Study (HPFS, N = 31,269 men, aged 40-75 in 1986), who were free from hypertension, cardiovascular disease and cancer at baseline. Four modifiable lifestyles were evaluated based on hypertension guidelines: BMI, moderate-to-vigorous physical activity, Dietary Approaches to Stop Hypertension (DASH) score, and alcohol intake. Primary outcome was incident self-reported diagnosis of hypertension with 27-31 years of follow-up.

RESULTS

Each lifestyle factor was associated with incident hypertension in dose-dependent manners across the cohorts, with BMI having the strongest associations. On average, adhering to BMI <25 kg/m2 was associated with 20.3 [18.5, 22.0], 25.0 [23.2, 26.8], and 18.6 [16.7, 20.7] months longer periods free from hypertension during 25-year follow-up in each cohort respectively. BMI accounted for approximately 20 % of incident hypertension in NHS and HPFS, and 35 % of early-onset hypertension (age < 55 y). Moderate-to-vigorous physical activity and diet accounted for 10-15 % of incident hypertension in women, and the contributions were greater for early-onset hypertension.

CONCLUSION

Healthy weight during adulthood was most substantially associated with incident hypertension among lifestyle factors, but diet, physical activity, and alcohol intake were also related to the risk across all ages, and hypertension-free periods, with stronger associations in early-onset hypertension.

The association of dietary approaches to stop hypertension measured by the food frequency questionnaire with metabolic syndrome and some inflammatory biomarkers in adolescents with obesity: a case-control study

BACKGROUND

Globally, obesity trends are a serious public health concern. Adolescent obesity is associated with cardiometabolic risk and metabolic disorders in adolescence and may persist into adulthood. The current study was designed to explore the Dietary Approaches to Stop Hypertension (DASH) in adolescents and its relationship with obesity, insulin resistance, metabolic syndrome (MetS), and some inflammatory biomarkers.

METHODS

A total of 90 adolescents with obesity and 90 adolescents with normal weight, participated in the study. Data from a validated 168-item semi-quantitative food frequency questionnaire were used to calculate the DASH score. The association of DASH score with cardiometabolic risk factors was estimated using multivariable logistic regression models. To assess the correlation between the DASH score and dietary factor, the Pearson correlation coefficient (r) was used.

RESULTS

Adolescents with a high DASH score had significantly higher intakes of potassium, magnesium, vitamin C, and vitamin K and lower intakes of sodium compared with those with a low DASH score (P < 0.05 ). There were no significant differences in the DASH score and its components between adolescents with and without metabolic syndrome. Adolescents with metabolic syndrome had significantly higher concentrations of triglycerides, low HDL-C, and high blood pressure compared with those without metabolic syndrome (P < 0.05). There were no significant associations between DASH score and MetS and other cardiometabolic risk factors in crude and multivariate-adjusted models. In addition, the DASH score was positively associated with potassium, magnesium, sodium, vitamins D and C, docosahexaenoic acid, and soluble fiber (P < 0.05).

CONCLUSION

In the current study, there was no significant association between adherence to the DASH diet and odds of metabolic syndrome, and other cardiometabolic risk factors in adolescent. Further prospective studies are needed to confirm these findings.

TRIAL REGISTRATION

Ethics approval was obtained from the research ethics committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1397.179.).

Relative validity of three diet quality scores derived from the Brief-type Self-administered Diet History Questionnaire and Meal-based Diet History Questionnaire in Japanese adults

No study has validated questionnaires for assessing easily calculable diet quality scores in Japan. The Brief-type self-administered Diet History Questionnaire (BDHQ) is widely used to assess dietary intake in Japan, while the Meal-based Diet History Questionnaire (MDHQ) assesses dietary intake for each meal (breakfast, lunch, dinner and snacks) and overall dietary intake. This study examined the relative validity of the BDHQ and MDHQ for assessing three diet quality scores in Japanese adults. A total of 111 women and 111 men aged 30-76 years completed the web MDHQ and BDHQ, followed by 4-non-consective-day weighed dietary records. The diet quality scores examined included the Diet Quality Score for Japanese (DQSJ), Dietary Approaches to Stop Hypertension (DASH) score and Alternate Mediterranean Diet (AMED) score. The means of the three scores for overall diet from the BDHQ were not significantly different from those from the dietary records in both sexes, whereas those from the MDHQ were higher than those from the dietary records, except for the DASH and AMED in women. Pearson's correlation coefficients between both questionnaires and dietary records were 0·57-0·63 for DQSJ, 0·49-0·57 for DASH and 0·31-0·49 for AMED across both sexes and both questionnaires. For each meal, Pearson's correlation coefficients between the MDHQ and dietary records ranged from 0·01 (DASH for snacks in women) to 0·55 (DQSJ for breakfast in men), with a median of 0·35. This study showed that the ability of the BDHQ and MDHQ to rank individuals was good for DQSJ and DASH and acceptable for AMED.

Circulating dimethylguanidino valeric acid, dietary factors, and risk of coronary heart disease

AIMS

Circulating dimethylguanidino valeric acid (DMGV) was identified as a novel metabolite related to cardiorespiratory fitness and cardiometabolic abnormalities. Circulating DMGV levels are subjective to dietary modulation; however, studies on its associations with intakes of coronary heart disease (CHD)-related foods/nutrients are limited. We investigated whether plasma DMGV was related to risk of incident CHD. We tested associations of DMGV with CHD-related dietary intakes measured by 7-day dietary records and estimated corresponding disease risk.

METHODS AND RESULTS

This nested case-control study on the incidence of CHD included 1520 women (760 incident cases of fatal CHD and nonfatal myocardial infarction and 760 controls) from the Nurses' Health Study. Separately, plasma DMGV and CHD-related dietary intakes and cardiometabolic abnormalities were assessed in the Women's Lifestyle Validation Study (WLVS; n = 724). Higher plasma DMGV was related to a greater risk of CHD [relative risk (RR) per 1 SD, 1.26 (95% CI 1.13, 1.40); P-for-linearity = 0.006]. Greater intakes of sodium, energy-dense foods, and processed/red meat were related to higher DMGV levels; every 1 SD intake of sodium was associated with β 0.13 (SE 0.05; P = 0.007) for DMGV Z-scores, which corresponded to a RR of 1.031 (1.016, 1.046) for CHD. High DMGV (the top quartile, Q4) showed a significant RR of 1.60 (1.17, 2.18) after adjusting for diet and lifestyle factors; the RR further adjusting for obesity and hypertension was 1.29 (0.93, 1.79) as compared with the lowest quartile. In both cohorts, greater adiposity and adverse cardiometabolic factor status were significantly related to higher DMGV levels.

CONCLUSION

Higher levels of plasma DMGV, a metabolite reflecting unfavourable CHD-related dietary intakes, were associated with an increased risk of CHD. The unfavourable association was attenuated by cardiometabolic risk factor status. Our study underscores the potential importance of plasma DMGV as an early biomarker associated with diet and the long-term risk of CHD among women.

Global adherence to a healthy and sustainable diet and potential reduction in premature death

The Planetary Health Diet (PHD), also known as the EAT-Lancet reference diet, was developed to optimize global dietary quality while keeping the environmental impacts of food production within sustainable planetary boundaries. We calculated current national and global adherence to the PHD using the Planetary Health Dietary Index (PHDI). In addition, we used data on diet and mortality from three large US cohorts (n = 206,404 men and women, 54,536 deaths) to estimate the total and cause-specific mortality among adults 20 y of age and older that could be prevented by shifting from current diets to the reference PHD. The PHDI varied substantially across countries, although adherence was universally far from optimal (mean PHDI = 85 out of 140). By improving the global PHDI to 120, approximately 15 million deaths (27% of total deaths) could be prevented annually. Estimates of preventable deaths due to this shift ranged from 2.5 million for cardiovascular diseases to 0.7 million for neurodegenerative diseases. Our analysis suggests that adopting healthy and sustainable diets would have major direct health benefits by reducing mortality due to multiple diseases and could contribute substantially to achieving the United Nations Sustainable Development Goals. These numbers of preventable deaths are based on evidence that human biology is similar across racial and ethnic groups, but the exact numerical estimates should be interpreted with caution because some assumptions used for the calculations build on limited data. Refinement of these estimates will be possible when additional regional data on diet and mortality become available.

Cardiovascular Health Score and Atherosclerotic Cardiovascular Disease in the Million Veteran Program

Importance

The American Heart Association proposed Life's Essential 8 (LE8) as an enhanced measurement tool for cardiovascular health.

Objective

To examine the association of LE8 with risk of atherosclerotic cardiovascular disease (ASCVD) incidence and prognosis in veterans.

Design, Setting, and Participants

This was a prospective cohort study of US veterans enrolled in the Department of Veterans Affairs (VA) Million Veteran Program (MVP) between 2011 and 2022. Data were analyzed from 2023 to 2024.

Exposure

LE8 score ranged from 0 to 100, with higher score indicating better cardiovascular health.

Main Outcomes and Measures

The primary outcome was total ASCVD incidence in veterans without baseline ASCVD, and the secondary outcome was incidence of a major adverse cardiovascular event (MACE) among veterans with and without ASCVD at baseline.

Results

A total of 413 052 veterans (mean [SD] age, 65.8 [12.1] years; 378 162 [91.6%] male) were included. Based on 1.7 million person-years of follow-up of 279 868 veterans without any ASCVD at baseline, 45 067 veterans had an ASCVD event during follow-up. Total LE8 score and each component LE8 factor score was associated with incident ASCVD in an inverse, linear, dose-response manner. For veterans without prior ASCVD, those with an LE8 score between 80 and 100 had lower risk of ASCVD compared with those with an LE8 score of 0 to 49 (adjusted hazard ratio [aHR], 0.36 [95% CI, 0.35-0.38]). Similarly, risk of MACE was significantly lower among veterans with an LE8 score of 80 to 100 regardless of baseline ASCVD status (with ASCVD: aHR, 0.52 [95% CI, 0.48-0.56]; without ASCVD: aHR, 0.14 [95% CI, 0.13-0.15]) compared with those with ASCVD and an LE8 score of 0 to 49.

Conclusions and Relevance

In this cohort study of US veterans, higher LE8 scores were associated with significantly lower ASCVD incidence risk and lower likelihood of developing adverse cardiovascular events regardless of ASCVD status at baseline. These results support the utility of LE8 for health promotion and ASCVD prevention.

Socioeconomic Status, Diet, and Behavioral Factors and Cardiometabolic Diseases and Mortality

Importance

It remains unclear how socioeconomic status (SES) is related to the association between diet and health, as well as the role of behavioral factors, in explaining socioeconomic disparities in health outcomes.

Objective

To investigate the associations of neighborhood and individual SES factors, as well as behavioral factors, particularly dietary pattern, with health outcomes.

Design, Setting, and Participants

This prospective cohort study included US health professionals without chronic diseases at baseline who were enrolled in the Health Professionals Follow-Up Study (calendar years 1988-2018), the Nurses' Health Study (calendar years 1992-2018), and the Nurses' Health Study II (calendar years 2001-2019). Data analysis was performed in September 2023.

Exposures

Repeated questionnaires were used to assess neighborhood and individual SES factors and behavioral factors, including dietary pattern (assessed using the Alternative Healthy Eating Index 2010), alcohol intake, body mass index, cigarette smoking, physical activity, sedentary television-viewing time, and sleep duration.

Main Outcomes and Measures

The main outcomes were incident major cardiovascular disease (CVD), type 2 diabetes (T2D), and total mortality. The associations of SES and behavioral factors with outcomes were analyzed using multivariable Cox proportional hazards regression models with hazard ratios (HRs) per 10th- to 90th-percentile increments.

Results

The study analyzed 152 192 participants for major CVD (mean [SD] age, 52.0 [8.7] years; 125 959 female [82.8%]), 151 217 participants for T2D (mean [SD] age, 52.0 [8.6] years; 125 231 female [82.8%]), and 141 145 participants for mortality (mean [SD] age, 51.6 [8.5] years; 117 627 female [83.3%]). A healthy dietary pattern was inversely associated with risk for major CVD (HR, 0.87 [95% CI, 0.82-0.93]), T2D (HR, 0.79 [95% CI, 0.75-0.84]), and total mortality (HR, 0.84 [95% CI, 0.81-0.88]). Without adjusting for neighborhood and individual SES factors, the HRs were 0.85 (95% CI, 0.80-0.91) for risk for major CVD, 0.78 (95% CI, 0.74-0.82) for T2D, and 0.82 (95% CI, 0.79-0.85) for total mortality. Neighborhood SES was inversely associated with risk for major CVD (HR, 0.90 [95% CI, 0.85-0.95]), T2D (HR, 0.92 [95% CI, 0.88-0.97]), and total mortality (HR, 0.91 [95% CI, 0.88-0.94]). Behavioral factors accounted for a large proportion of the associations with risk for major CVD (46.3% [95% CI, 32.5%-60.6%]), T2D (77.4% [95% CI, 64.5%-86.6%]), and total mortality (42.8% [95% CI, 32.9%-53.3%]).

Conclusions and Relevance

In this prospective cohort study of health professionals, associations between diet and health outcomes remained similar without adjusting for SES factors, while health behaviors, including diet, accounted for a large proportion of the associations between neighborhood SES and health. These findings highlight the importance of health behaviors, particularly high-quality diets, in promoting individual health and possibly reducing health disparities associated with SES.

Microbiome-based correction for random errors in nutrient profiles derived from self-reported dietary assessments

Since dietary intake is challenging to directly measure in large-scale cohort studies, we often rely on self-reported instruments (e.g., food frequency questionnaires, 24-hour recalls, and diet records) developed in nutritional epidemiology. Those self-reported instruments are prone to measurement errors, which can lead to inaccuracies in the calculation of nutrient profiles. Currently, few computational methods exist to address this problem. In the present study, we introduce a deep-learning approach-Microbiome-based nutrient profile corrector (METRIC), which leverages gut microbial compositions to correct random errors in self-reported dietary assessments using 24-hour recalls or diet records. We demonstrate the excellent performance of METRIC in minimizing the simulated random errors, particularly for nutrients metabolized by gut bacteria in both synthetic and three real-world datasets. Additionally, we find that METRIC can still correct the random errors well even without including gut microbial compositions. Further research is warranted to examine the utility of METRIC to correct actual measurement errors in self-reported dietary assessment instruments.

Identifying modifiable risk factors to prevent aggressive colorectal cancer

It remains unclear if pre-diagnostic factors influence the developmental pathways of colorectal cancer (CRC) that could enhance tumor aggressiveness. This study used prospective data from 205,489 cancer-free US health professionals to investigate the associations of 31 known or putative risk factors with the risk of aggressive CRC. Tumor aggressiveness was characterized by three endpoints: aggressive CRC (cancer that causes death within 5 years of diagnosis), fatal CRC, and tumor stage at diagnosis. The data augmentation method was used to assess the difference in the associations between risk factors and endpoints. We documented 3201 CRC cases, of which 899 were aggressive. The protective associations of undergoing lower endoscopy (hazard ratios [HR] 0.43, 95% confidence interval (CI) 0.37, 0.49 for aggressive versus HR 0.61, 95% CI 0.56, 0.67 for non-aggressive) and regular use of aspirin (HR 0.70, 95% CI 0.61, 0.81 versus HR 0.84, 95% CI 0.77, 0.92) were stronger for aggressive than non-aggressive CRC (pHeterogeneity <0.05). Lower intake of whole grains or cereal fiber and greater dietary inflammatory potential were associated with a higher risk of aggressive but not non-aggressive CRC. The remaining risk factors showed comparable associations with aggressive CRC and non-aggressive CRC. Aggressive cases were more likely to have KRAS-mutated tumors but less likely to have distal or MSI-high tumors (p < .007). Similar results were observed for fatal CRC and advanced tumor stages at diagnosis. These findings provide initial evidence for the role of pre-diagnostic risk factors in the pathogenesis of aggressive CRC and suggest research priorities for preventive interventions.

Racial and Ethnic Disparities in Dietary Intake and Quality Among United States Veterans

Background

Dietary quality plays an important role in disease development and prognosis, and diet is also a key contributor to disparities in many chronic diseases and health conditions.

Objectives

This study aimed to assess racial and ethnic disparities experienced by veterans; we examined food intake and dietary quality across different racial and ethnic groups of United States veterans.

Methods

The study included 420,730 males and females aged 19-107 y (91.2% males) enrolled in the Veterans Affairs Million Veteran Program with plausible dietary intake measured by food frequency questionnaire. Dietary quality was evaluated with dietary approaches to stop hypertension (DASH) score. Dietary intakes of various race and ethnicity groups were standardized to the age distribution of non-Hispanic White participants, separately for males and females. Differences across race and ethnicity groups were compared using general linear regression models after adjustment for socioeconomic and lifestyle factors as well as military service.

Results

Compared to non-Hispanic White males, non-Hispanic Black males had a relatively lower DASH score, higher red and processed meats, higher sugar-sweetened beverages (SSBs), and lower low-fat dairy intakes. Non-Hispanic Asian males had a relatively higher DASH score as compared to non-Hispanic White males with relatively higher intakes of fruits and vegetables and relatively lower intakes of sodium, red meat and SSBs. Age-standardized DASH scores of Hispanic males and "Other" race/ethnicity groups were not statistically different from non-Hispanic White males. Similar race and ethnicity dietary patterns were found in females, although not all reached a statistically significant level.

Conclusions

A modest difference in overall dietary quality (i.e., DASH score) was observed, but unique differences in food preferences across the different racial/ethnic groups were identified. Findings from our study may provide insight for the potential development of specific interventions to help address nutritional disparities experienced among veterans.

Microbiome-based correction for random errors in nutrient profiles derived from self-reported dietary assessments

Since dietary intake is challenging to directly measure in large-scale cohort studies, we often rely on self-reported instruments (e.g., food frequency questionnaires, 24-hour recalls, and diet records) developed in nutritional epidemiology. Those self-reported instruments are prone to measurement errors, which can lead to inaccuracies in the calculation of nutrient profiles. Currently, few computational methods exist to address this problem. In the present study, we introduce a deep-learning approach --- Microbiome-based nutrient profile corrector (METRIC), which leverages gut microbial compositions to correct random errors in self-reported dietary assessments using 24-hour recalls or diet records. We demonstrate the excellent performance of METRIC in minimizing the simulated random errors, particularly for nutrients metabolized by gut bacteria in both synthetic and three real-world datasets. Further research is warranted to examine the utility of METRIC to correct actual measurement errors in self-reported dietary assessment instruments.

What to Eat for Cancer Prevention: The Total Dietary Pattern as a Combination Treatment for Prevention

ABSTRACT

Over the past 2 decades, the search for dietary factors for developing cancer prevention guidelines has led to a significant expansion in the study of dietary patterns and their relation to cancer. Dietary patterns, which consider the types, amounts, variety, and combination of consumed foods, may encompass additive, synergistic, or interactive effects on human health, compared with individual nutrients or foods. In this review, we discuss the history and methodologies of dietary pattern research, describe common dietary indices used in cancer research, and summarize the existing evidence on dietary patterns and cancer risk. Current evidence supports the beneficial role of dietary patterns that are rich in vegetables, legumes, whole fruit, and whole grains and limited in added sugars, refined grains, processed foods, and red and processed meat in preventing various cancers, including breast, colorectal, and prostate cancers. Additionally, emerging evidence suggests that dietary patterns based on biological mechanisms, such as hyperinsulinemic diet and inflammatory diet, hold promise and may be priority areas for future research.

Association of healthy and unhealthy plant-based diets with telomere length

BACKGROUND & AIMS

Previous studies have shown that plant-rich dietary patterns, such as the Mediterranean diet, are associated with longer telomeres. However, no association has been found between vegetarian diet and telomere length. We hypothesized that the quality of plant-based diets plays an important role in telomere length.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey 1999-2002. Diet was assessed using a 24-h recall method. Plant-based diet quality was assessed using the overall plant-based diet index (PDI), healthy PDI (hPDI), and unhealthy PDI (uPDI). Telomere length was measured using quantitative PCR. Linear and ordinal logistic regression models were used to assess the association of PDIs with log-transformed telomere length and ordinal quintiles of telomere length in descending order, respectively.

RESULTS

In both regression models, the overall PDI was not associated with telomere length. The hPDI was associated with longer telomere length [percentage change = 2.34%, 95% confidence interval (CI): 0.42%, 4.31%, Ptrend = 0.016; odds ratio (OR) = 0.81, 95% CI: 0.69, 0.95, Ptrend = 0.013]. However, uPDI was associated with shorter telomere length (percentage change = -3.17%, 95% CI: -5.65%, -0.62%, Ptrend = 0.017; OR = 1.25, 95% CI:1.03, 1.53, Ptrend = 0.014) and this inverse association was stronger in the non-Hispanic white population (Pinteraction = 0.001 in both regression models).

CONCLUSIONS

A plant-based dietary pattern rich in healthy plant foods is associated with longer telomeres. However, plant-based dietary patterns rich in unhealthy plant-based foods are associated with shorter telomere lengths, especially in non-Hispanic white populations.

Healthy dietary patterns and risk of prostate cancer in men at high genetic risk

Prostate cancer has high heritability. Healthy lifestyle has been associated with lower lethal prostate cancer risk among men at increased genetic susceptibility, but the role of healthy dietary patterns remains unknown. We prospectively followed 10,269 genotyped men in the Health Professionals Follow-up Study (1993-2019). Genetic risk was quantified using an established polygenic risk score (PRS). Five dietary patterns were investigated: healthy eating index, Mediterranean, diabetes risk-reducing, hyperinsulinemic and inflammatory diet. Overall and lethal prostate cancer rates (metastatic disease/prostate cancer-specific death) were analyzed using multivariable Cox proportional hazards models. During 26 years of follow-up, 2133 overall and 253 lethal prostate cancer events were documented. In the highest PRS quartile, higher adherence to a diabetes risk-reducing diet was associated with lower rates of overall (top vs. bottom quintile HR [95% CI], 0.74 [0.58-0.94]) and lethal prostate cancer (0.43 [0.21-0.88]). A low insulinemic diet was associated with similar lower rates (overall, 0.76 [0.60-0.95]; lethal, 0.46 [0.23-0.94]). Other dietary patterns showed weaker, but similar associations. In the highest PRS quartile, men with healthy lifestyles based on body weight, physical activity, and low insulinemic diet had a substantially lower rate (0.26 [0.13-0.49]) of lethal prostate cancer compared with men with unhealthy lifestyles, translating to a lifetime risk of 3.4% (95% CI, 2.3%-5.0%) among those with healthy lifestyles and 9.5% (5.3%-16.7%) among those with unhealthy lifestyles. Our findings indicate that lifestyle modifications lowering insulin resistance and chronic hyperinsulinemia could be relevant in preventing aggressive prostate cancer among men genetically predisposed to prostate cancer.

24-h urinary sodium and potassium excretions, plasma metabolomic profiles, and cardiometabolic biomarkers in the United States adults: a cross-sectional study

BACKGROUND

High-sodium and low-potassium intakes are associated with a higher risk of hypertension and cardiovascular disease, but there are limited data on the circulating metabolomics profiles of 24-h urinary sodium and potassium excretions in free-living individuals.

OBJECTIVES

We aimed to characterize the metabolomics signatures of a high-sodium and low-potassium diet in a cross-sectional study.

METHODS

In 1028 healthy older adults from the Women's and Men's Lifestyle Validation Studies, we investigated the association of habitual sodium and potassium intakes measured by 2 to 4 24-h urine samples with plasma metabolites (quantified using liquid chromatography-tandem mass spectrometry) and metabolomic pathways. Our primary exposures were energy-adjusted 24-h urinary sodium excretion, potassium excretion, and sodium-to-potassium ratio, calculated based on energy expenditure derived from the doubly labeled water method. We then assessed the partial correlations of their metabolomics scores, derived from elastic net regressions, with cardiometabolic biomarkers.

RESULTS

Higher sodium excretion was associated with 38 metabolites including higher piperine, phosphatidylethanolamine, and C5:1 carnitine. In pathway analysis, higher sodium excretion was associated with enhanced biotin and propanoate metabolism and enhanced degradation of lysine and branched-chain amino acids (BCAAs). Metabolites associated with higher potassium and lower sodium-to-potassium ratio included quinic acid and proline-betaine. After adjusting for confounding factors, the metabolomics score for sodium-to-potassium ratio positively correlated with fasting insulin (Spearman's rank correlation coefficient ρ = 0.27), C-peptide (ρ = 0.30), and triglyceride (ρ = 0.46), and negatively with adiponectin (ρ = -0.40), and high-density lipoprotein cholesterol (ρ = -0.42).

CONCLUSIONS

We discovered metabolites and metabolomics pathways associated with a high-sodium diet, including metabolites related to biotin, propanoate, lysine, and BCAA pathways. The metabolomics signature for a higher sodium low-potassium diet is associated with multiple components of elevated cardiometabolic risk.

Prediction of 24-Hour Urinary Sodium Excretion Using Machine-Learning Algorithms

BACKGROUND

Accurate quantification of sodium intake based on self-reported dietary assessments has been a persistent challenge. We aimed to apply machine-learning (ML) algorithms to predict 24-hour urinary sodium excretion from self-reported questionnaire information.

METHODS AND RESULTS

We analyzed 3454 participants from the NHS (Nurses' Health Study), NHS-II (Nurses' Health Study II), and HPFS (Health Professionals Follow-Up Study), with repeated measures of 24-hour urinary sodium excretion over 1 year. We used an ensemble approach to predict averaged 24-hour urinary sodium excretion using 36 characteristics. The TOHP-I (Trial of Hypertension Prevention I) was used for the external validation. The final ML algorithms were applied to 167 920 nonhypertensive adults with 30-year follow-up to estimate confounder-adjusted hazard ratio (HR) of incident hypertension for predicted sodium. Averaged 24-hour urinary sodium excretion was better predicted and calibrated with ML compared with the food frequency questionnaire (Spearman correlation coefficient, 0.51 [95% CI, 0.49-0.54] with ML; 0.19 [95% CI, 0.16-0.23] with the food frequency questionnaire; 0.46 [95% CI, 0.42-0.50] in the TOHP-I). However, the prediction heavily depended on body size, and the prediction of energy-adjusted 24-hour sodium excretion was modestly better using ML. ML-predicted sodium was modestly more strongly associated than food frequency questionnaire-based sodium in the NHS-II (HR comparing Q5 versus Q1, 1.48 [95% CI, 1.40-1.56] with ML; 1.04 [95% CI, 0.99-1.08] with the food frequency questionnaire), but no material differences were observed in the NHS or HPFS.

CONCLUSIONS

The present ML algorithm improved prediction of participants' absolute 24-hour urinary sodium excretion. The present algorithms may be a generalizable approach for predicting absolute sodium intake but do not substantially reduce the bias stemming from measurement error in disease associations.

External validation of the colorectal cancer risk score LiFeCRC using food frequency questions in the HUNT study

PURPOSE

To mitigate the increasing colorectal cancer (CRC) incidence globally and prevent CRC at the individual level, individual lifestyle information needs to be easily translated into CRC risk assessment. Several CRC risk prediction models exist and their clinical usefulness depends on their ease of use. Our objectives were to assess and externally validate the LiFeCRC score in our independent, unselected population and to investigate the use of simpler food frequency measurements in the score.

METHODS

Incidental colon and rectal cancer cases were compared to the general population among 78,580 individuals participating in a longitudinal health study in Norway (HUNT). Vegetable, dairy product, processed meat and sugar/confectionary consumption was scored based on food frequency. The LiFeCRC risk score was calculated for each individual.

RESULTS

Over a median of 10 years following participation in HUNT, colon cancer was diagnosed in 1355 patients and rectal cancer was diagnosed in 473 patients. The LiFeCRC score using food frequencies demonstrated good discrimination in CRC overall (AUC 0.77) and in sex-specific models (AUC men 0.76 and women 0.77) in this population also including individuals ≥ 70 years and patients with diabetes. It performed somewhat better in colon (AUC 0.80) than in rectal cancer (AUC 0.72) and worked best for female colon cancer (AUC 0.81).

CONCLUSION

Readily available clinical variables and food frequency questions in a modified LiFeCRC score can identify patients at risk of CRC and may improve primary prevention by motivating to lifestyle change or participation in the CRC screening programme.

Prepregnancy plant-based diets and risk of hypertensive disorders of pregnancy

BACKGROUND

Plant-based diets have been associated with a lower risk of cardiovascular disease in nonpregnant adults, but specific evidence for their effects on risk of hypertensive disorders of pregnancy is scarce.

OBJECTIVE

This study aimed to evaluate the prospective association between adherence to plant-based diets before pregnancy and the risk for hypertensive disorders of pregnancy. We hypothesized that women with higher adherence to plant-based diets would have a lower risk for hypertensive disorders of pregnancy.

STUDY DESIGN

We followed 11,459 parous women (16,780 singleton pregnancies) without chronic diseases, a history of preeclampsia, and cancers who participated in the Nurses' Health Study II (1991-2009), which was a prospective cohort study. Diet was assessed every 4 years using a validated food frequency questionnaire from which we calculated the plant-based diet index (higher score indicates higher adherence) to evaluate the health associations of plant-based diets among participants while accounting for the quality of plant-based foods. Participants self-reported hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension. We estimated the relative risk of hypertensive disorders of pregnancy in relation to plant-based diet index adherence in quintiles using generalized estimating equations log-binomial regression while adjusting for potential confounders and accounting for repeated pregnancies for the same woman.

RESULTS

The mean (standard deviation) age at first in-study pregnancy was 35 (4) years. A total of 1033 cases of hypertensive disorders of pregnancy, including 482 cases of preeclampsia (2.9%) and 551 cases of gestational hypertension (3.3%) were reported. Women in the highest quintile of plant-based diet index were significantly associated with a lower risk for hypertensive disorders of pregnancy than women in the lowest quintile (relative risk, 0.76; 95% confidence interval, 0.62-0.93). There was an inverse dose-response relationship between plant-based diet index and risk for hypertensive disorders of pregnancy. The multivariable-adjusted relative risk (95% confidence interval) of hypertensive disorders of pregnancy for women in increasing quintiles of plant-based diet index were 1 (ref), 0.93 (0.78-1.12), 0.86 (0.72-1.03), 0.84 (0.69-1.03), and 0.76 (0.62-0.93) with a significant linear trend across quintiles (P trend=.005). This association was slightly stronger for gestational hypertension (relative risk, 0.77; 95% confidence interval, 0.60-0.99) than for preeclampsia (relative risk, 0.80; 95% confidence interval, 0.61-1.04). Mediation analysis suggested that body mass index evaluation for dietary assessment and pregnancy explained 39% (95% confidence interval, 15%-70%]) of the relation between plant-based diet index and hypertensive disorders of pregnancy and 48% (95% confidence interval, 12%-86%]) of the relation between plant-based diet index and gestational hypertension.

CONCLUSION

Higher adherence to plant-based diets was associated with a lower risk of developing hypertensive disorders of pregnancy. Much of the benefit seems to be related to improved weight control.

Cancer Diagnoses After Recent Weight Loss

Importance

Weight loss is common in primary care. Among individuals with recent weight loss, the rates of cancer during the subsequent 12 months are unclear compared with those without recent weight loss.

Objective

To determine the rates of subsequent cancer diagnoses over 12 months among health professionals with weight loss during the prior 2 years compared with those without recent weight loss.

Design, Setting, and Participants

Prospective cohort analysis of females aged 40 years or older from the Nurses' Health Study who were followed up from June 1978 until June 30, 2016, and males aged 40 years or older from the Health Professionals Follow-Up Study who were followed up from January 1988 until January 31, 2016.

Exposure

Recent weight change was calculated from the participant weights that were reported biennially. The intentionality of weight loss was categorized as high if both physical activity and diet quality increased, medium if only 1 increased, and low if neither increased.

Main Outcome and Measures

Rates of cancer diagnosis during the 12 months after weight loss.

Results

Among 157 474 participants (median age, 62 years [IQR, 54-70 years]; 111 912 were female [71.1%]; there were 2631 participants [1.7%] who self-identified as Asian, Native American, or Native Hawaiian; 2678 Black participants [1.7%]; and 149 903 White participants [95.2%]) and during 1.64 million person-years of follow-up, 15 809 incident cancer cases were identified (incident rate, 964 cases/100 000 person-years). During the 12 months after reported weight change, there were 1362 cancer cases/100 000 person-years among all participants with recent weight loss of greater than 10.0% of body weight compared with 869 cancer cases/100 000 person-years among those without recent weight loss (between-group difference, 493 cases/100 000 person-years [95% CI, 391-594 cases/100 000 person-years]; P < .001). Among participants categorized with low intentionality for weight loss, there were 2687 cancer cases/100 000 person-years for those with weight loss of greater than 10.0% of body weight compared with 1220 cancer cases/100 000 person-years for those without recent weight loss (between-group difference, 1467 cases/100 000 person-years [95% CI, 799-2135 cases/100 000 person-years]; P < .001). Cancer of the upper gastrointestinal tract (cancer of the esophagus, stomach, liver, biliary tract, or pancreas) was particularly common among participants with recent weight loss; there were 173 cancer cases/100 000 person-years for those with weight loss of greater than 10.0% of body weight compared with 36 cancer cases/100 000 person-years for those without recent weight loss (between-group difference, 137 cases/100 000 person-years [95% CI, 101-172 cases/100 000 person-years]; P < .001).

Conclusions and Relevance

Health professionals with weight loss within the prior 2 years had a significantly higher risk of cancer during the subsequent 12 months compared with those without recent weight loss. Cancer of the upper gastrointestinal tract was particularly common among participants with recent weight loss compared with those without recent weight loss.

Advancing nutrition science to meet evolving global health needs

Populations in crisis!A global overview of health challenges and policy efforts within the scope of current nutrition issues, from persistent forms of undernutrition, including micronutrient deficiency, to diet-related chronic diseases. Nutrition science has evolved from a therapeutic and prevention emphasis to include a focus on diets and food systems. Working and consensus definitions are needed, as well as guidance related to healthy diets and the emerging issues that require further research and consensus building. Between nutrient deficiency and chronic disease, nutrition has evolved from focusing exclusively on the extremes of overt nutrient deficiency and chronic disease prevention, to equipping bodies with the ability to cope with physiologic, metabolic, and psychological stress. Just what is 'optimal nutrition', is that a valid public health goal, and what terminology is being provided by the nutrition science community? Nutrition research on 'healthspan', resilience, and intrinsic capacity may provide evidence to support optimal nutrition. Finally, experts provide views on ongoing challenges of achieving consensus or acceptance of the various definitions and interventions for health promotion, and how these can inform government health policies.Nutrition topics that receive particular focus in these proceedings include choline, NAD-replenishment in neurodegenerative diseases, and xanthophyll carotenoids. Choline is a crucial nutrient essential for cellular metabolism, requiring consumption from foods or supplements due to inadequate endogenous synthesis. Maternal choline intake is vital for fetal and infant development to prevent neural tube defects. Neurodegenerative diseases pose a growing health challenge, lacking effective therapies. Nutrition, including NAD-replenishing nutrients, might aid prevention. Emerging research indicates xanthophyll carotenoids enhance vision and cognition, potentially impacting age-related diseases.

Plant-based diets and the incidence of cardiovascular disease: the Million Veteran Program

Background

A healthful plant-based diet was associated with lower risks of coronary heart disease and type 2 diabetes, and a favourable profile of adiposity-associated biomarkers, while an unhealthful plant-based diet was associated with elevated risk of cardiometabolic disease in health professional populations. However, little is known about the associations between plant-based dietary patterns and risk of cardiovascular disease (CVD) in US veterans.

Methods

The study population consisted of 148 506 participants who were free of diabetes, CVD and cancer at baseline in the Veterans Affairs (VA) Million Veteran Program. Diet was assessed using a Food Frequency Questionnaire at baseline. We calculated an overall Plant-Based Diet Index (PDI), a healthful PDI (hPDI) and an unhealthful PDI (uPDI). The CVD endpoints included non-fatal myocardial infarction (MI) and acute ischaemic stroke (AIS) identified through high-throughput phenotyping algorithms approach and fatal CVD events identified by searching the National Death Index.

Results

With up to 8 years of follow-up, we documented 5025 CVD cases. After adjustment for confounding factors, a higher PDI was significantly associated with a lower risk of CVD (HR comparing extreme quintiles=0.75, 95% CI 0.68 to 0.82, P trend<0.0001). We observed an inverse association between hPDI and the risk of CVD (HR comparing extreme quintiles=0.71, 95% CI 0.64 to 0.78, P trend<0.001), whereas uPDI was positively associated with the risk of CVD (HR comparing extreme quintiles=1.12, 95% CI 1.02 to 1.24, P trend<0.001). We found similar associations of hPDI with subtypes of CVD; a 10-unit increment in hPDI was associated with HRs (95% CI) of 0.81 (0.75 to 0.87) for fatal CVD, 0.86 (0.79 to 0.94) for non-fatal MI and 0.86 (0.78 to 0.95) for non-fatal AIS.

Conclusions

Plant-based dietary pattern enriched with healthier plant foods was associated with a substantially lower CVD risk in US veterans.

Association of Gestational Diabetes With Subsequent Long-Term Risk of Mortality

Importance

Gestational diabetes has been associated with numerous chronic diseases. However, few studies have examined the association of gestational diabetes with long-term mortality risk.

Objective

To investigate the associations between gestational diabetes and long-term risks of total and cause-specific mortality.

Design, Setting, and Participants

This cohort study analyzed participants of the Nurses' Health Study II who were followed for 30 years (1989-2019). Participants included US female nurses aged 25 to 42 years who reported at least 1 pregnancy (≥6 months) at 18 years or older across their reproductive life span. Data were analyzed from May 1, 2022, to May 25, 2023.

Exposure

Gestational diabetes across the reproductive life span.

Main Outcomes and Measures

Hazard ratios (HRs with 95% CIs) for total and cause-specific mortality were estimated by Cox proportional hazards regression models.

Results

A total of 91 426 parous participants were included, with a mean (SD) age of 34.9 (4.7) years and a body mass index of 24.1 (4.7) at baseline. During a follow-up period of 2 609 753 person-years, 3937 deaths were documented, including 255 deaths from cardiovascular disease and 1397 from cancer. Participants with a history of gestational diabetes had a higher crude mortality rate than those without a history of gestational diabetes (1.74 vs 1.49 per 1000 person-years; absolute difference = 0.25 per 1000 person-years). The corresponding HR for total mortality was 1.28 (95% CI, 1.13-1.44), which did not materially change after additional adjustment for potential confounders and lifestyle factors during the reproductive life span (HR, 1.25; 95% CI, 1.11-1.41). The association persisted regardless of the subsequent development of type 2 diabetes and was more robust among participants who adopted less healthy lifestyles; experienced gestational diabetes in 2 or more pregnancies (HR, 1.48; 95% CI, 0.99-2.19); had gestational diabetes both in the initial and subsequent pregnancies (HR, 1.71; 95% CI, 1.11-2.63); and concurrently reported hypertensive disorders in pregnancy (HR, 1.80; 95% CI, 1.21-2.67), preterm birth (HR, 2.46; 95% CI, 1.66-3.64), or low birth weight (HR, 2.11; 95% CI, 1.21-3.68). Cause-specific mortality analyses revealed that gestational diabetes was directly associated with the risk of mortality due to cardiovascular disease (HR, 1.59; 95% CI, 1.03-2.47). Additionally, gestational diabetes was inversely associated with cancer mortality (HR, 0.76; 95% CI, 0.59-0.98); however, it was only evident among participants who later developed type 2 diabetes.

Conclusions and Relevance

Results of this cohort study suggest that participants who reported a history of gestational diabetes exhibited a small but elevated risk of subsequent mortality over 30 years. The findings emphasize the importance of considering gestational diabetes as a critical factor in later-life mortality risk.

Association of the Mediterranean Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) Diet With the Risk of Dementia

Importance

Dementia threatens the well-being of older adults, making efforts toward prevention of great importance.

Objective

To evaluate the association of the Mediterranean-Dietary Approaches to Stop Hypertension (DASH) Intervention for Neurodegenerative Delay (MIND) diet with the risk of dementia in 3 prospective studies and a meta-analysis.

Design, Setting, and Participants

Cohort analyses included the Whitehall II study (WII), the Health and Retirement Study (HRS), and the Framingham Heart Study Offspring cohort (FOS), and the meta-analysis included 11 cohort studies. Participants were middle-aged and older women and men from WII in 2002 to 2004, HRS in 2013, and FOS in 1998 to 2001 without dementia at the study baseline. Data were analyzed from May 25 to September 1, 2022.

Exposures

MIND diet score was measured using food frequency questionnaires, and scores ranged from 0 to 15, with a higher score indicating higher adherence to the MIND diet.

Main Outcome and Measures

Incident all-cause dementia, with cohort-specific definitions.

Results

Included in this study were 8358 participants (mean [SD] age, 62.2 [6.0] years; 5777 male [69.1%]) from WII, 6758 participants (mean [SD] age, 66.5 [10.4] years; 3965 female [58.7%]) from HRS, and 3020 participants (mean [SD] age, 64.2 [9.1] years; 1648 female [54.6%]) from FOS. The mean (SD) baseline MIND diet score was 8.3 (1.4) in WII, 7.1 (1.9) in HRS, and 8.1 (1.6) in FOS. Over 166 516 person-years, a total of 775 participants (220 in WII, 338 in HRS, and 217 in FOS) developed incident dementia. In the multivariable-adjusted Cox proportional hazard model, higher MIND diet score was associated with lower risk of dementia (pooled hazard ratio [HR] for every 3-point increment, 0.83; 95% CI, 0.72-0.95; P for trend = .01; I2 = 0%). The associations were consistently observed in subgroups defined by sex, age, smoking status, and body mass index. In the meta-analysis of 11 cohort studies with 224 049 participants (5279 incident dementia cases), the highest tertile of MIND diet score was associated with lower risk of dementia compared with the lowest tertile (pooled HR, 0.83; 95% CI, 0.76-0.90; I2 = 35%).

Conclusions and Relevance

Results suggest that adherence to the MIND diet was associated with lower risk of incident dementia in middle-aged and older adults. Further studies are warranted to develop and refine the specific MIND diet for different populations.

Plant-based dietary patterns and the risk of digestive system cancers in 3 large prospective cohort studies

Little is known about the relation between plant-based dietary patterns and digestive system cancers. This study investigated the prospective association between 3 pre-defined indices of plant-based dietary pattern and risk of digestive system cancers, as a whole or individually. We utilized data from 3 prospective cohorts, the Nurses' Health Study (1984-2018, 74,496 women aged 65 ± 10.9 years), Nurses' Health Study II (1991-2017, 91,705 women aged 49.3 ± 8.3 years), and Health Professionals Follow up Study (1986-2016, 45,472 men aged 65.4 ± 11.0 years). We used Cox proportional hazards regression models to estimate multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) of digestive system cancers across 3 plant-based diet index scores: overall plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI). During a follow-up of 4,914,985 person-years, we identified 6,518 cases of digestive system cancers. In the pooled analysis of 3 cohorts, the HRs (95% CIs) per 10-point increase in hPDI score were 0.93 (0.89, 0.97) for total digestive system cancer, 0.94 (0.89, 0.99) for gastrointestinal tract cancer, 0.89 (0.81, 0.98) for accessory organ cancer, and 0.68 (0.52, 0.91) for liver cancer. In contrast, the HRs (95% CIs) per 10-point increase in uPDI score was 1.06 (1.01, 1.11) for gastrointestinal tract cancer and 1.07 (1.01, 1.13) for colorectal cancer. A healthy plant-based dietary pattern was associated with reduced risks of total digestive system cancers as well as individual cancers in the gastrointestinal tract and the accessory organs. Emphasizing the healthiness and quality of plant-based diets may be important for the prevention of developing cancers in the digestive system.

Optimal dietary patterns for prevention of chronic disease

Multiple dietary patterns have been associated with different diseases; however, their comparability to improve overall health has yet to be determined. Here, in 205,852 healthcare professionals from three US cohorts followed for up to 32 years, we prospectively assessed two mechanism-based diets and six diets based on dietary recommendations in relation to major chronic disease, defined as a composite outcome of incident major cardiovascular disease (CVD), type 2 diabetes and cancer. We demonstrated that adherence to a healthy diet was generally associated with a lower risk of major chronic disease (hazard ratio (HR) comparing the 90th with the 10th percentile of dietary pattern scores = 0.58-0.80). Participants with low insulinemic (HR = 0.58, 95% confidence interval (CI) = 0.57, 0.60), low inflammatory (HR = 0.61, 95% CI = 0.60, 0.63) or diabetes risk-reducing (HR = 0.70, 95% CI = 0.69, 0.72) diet had the largest risk reduction for incident major CVD, type 2 diabetes and cancer as a composite and individually. Similar findings were observed across gender and diverse ethnic groups. Our results suggest that dietary patterns associated with markers of hyperinsulinemia and inflammation and diabetes development may inform on future dietary guidelines for chronic disease prevention.

Dietary patterns and risk of colorectal cancer: a comparative analysis

BACKGROUND

Although several dietary patterns have been associated with incident colorectal cancer (CRC), it is unclear which diet is optimal.

METHODS

Participants included 48 409 men and 169 772 women from three USA-based prospective cohort studies. We compared the associations of 18 dietary patterns with CRC risk, including two reference scores. The reference scores were derived based on the dietary recommendations for cancer prevention and CRC-specific dietary risk factors mentioned in the 2018 World Cancer Research Fund/American Institute of Cancer Research (WCRF/AICR) Third Expert Report. Multivariable Cox proportional hazards models were fitted to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

Most dietary patterns showed moderate correlations with the WCRF dietary score (absolute values of Spearman correlation coefficients: 0.45-0.63), except the Plant-based diet index, low-carbohydrate diets, the Empirical dietary index for hyperinsulinemia (EDIH) and Empirical dietary inflammation pattern (EDIP). HR for the 10th-90th percentile difference in the score was 0.86 (95% CI: 0.78-0.94) for the Dietary Approaches to Stop Hypertension score (DASH), 1.15 (1.06-1.26) for Western dietary pattern, 1.20 (1.10-1.31) for EDIH and 1.23 (1.13-1.34) for EDIP. These associations between patterns and CRC risk persisted after adjusting for the two reference scores.

CONCLUSIONS

Although further research is needed to improve the WCRF/AICR dietary recommendations, our comprehensive assessment of dietary patterns revealed that the DASH, Western dietary pattern, EDIH and EDIP may be the most relevant diets for preventing CRC.

An updated validation of the Dietary Quality Score: associations with risk factors for cardiometabolic diseases in a Danish population

PURPOSE

This study assessed the validity of the Dietary Quality Score (DQS) and investigated the association between the DQS and risk factors for cardiometabolic diseases.

METHODS

The DQS was calculated based on an updated 23-item FFQ and validated against a 376-item FFQ. A sub-sample of 450 men and women aged 18-73 years, from the Danish Diet, Cancer and Health-Next generations (DCH-NG) cohort, completed the updated 23-item FFQ. We investigated the associations between the DQS and risk factors for cardiometabolic diseases (lipids, haemoglobin A1c (HbA1c), high-sensitive C-reactive protein (hs-CRP), blood pressure (BP), waist circumference (WC), visceral and total fat mass) using linear regression models.

RESULTS

A high DQS, i.e. healthy dietary habits, was significantly associated with a higher intake of fruits, vegetables, fish, fibre, several vitamins and minerals and a lower intake of saturated fat. Moreover, a high DQS was significantly associated with lower levels of LDL cholesterol (P = 0.0133), Hs-CRP (P = 0.0449), WC (P = 0.0161), visceral fat (P = 0.0003), total fat mass (P = 0.0106) and total fat percentage (P = 0.0030) and significantly associated with a higher HDL cholesterol (P = 0.0379) level, when adjusting for education, smoking habits and physical activity. There was no association with total cholesterol, triglycerides, HbA1c, BP and BMI.

CONCLUSION

The DQS, based on the updated 23-item FFQ, is a valid tool to classify individuals into groups with low, average and high dietary quality in the Danish population. Furthermore, a high DQS is significantly associated with lower levels of several risk factors for cardiometabolic diseases.

Healthy Eating Patterns and Risk of Total and Cause-Specific Mortality

Importance

The current Dietary Guidelines for Americans recommend multiple healthy eating patterns. However, few studies have examined the associations of adherence to different dietary patterns with long-term risk of total and cause-specific mortality.

Objective

To examine the associations of dietary scores for 4 healthy eating patterns with risk of total and cause-specific mortality.

Design, Setting, and Participants

This prospective cohort study included initially healthy women from the Nurses' Health Study (NHS; 1984-2020) and men from the Health Professionals Follow-up Study (HPFS; 1986-2020).

Exposures

Healthy Eating Index 2015 (HEI-2015), Alternate Mediterranean Diet (AMED) score, Healthful Plant-based Diet Index (HPDI), and Alternate Healthy Eating Index (AHEI).

Main Outcomes and Measures

The main outcomes were total and cause-specific mortality overall and stratified by race and ethnicity and other potential risk factors.

Results

The final study sample included 75 230 women from the NHS (mean [SD] baseline age, 50.2 [7.2] years) and 44 085 men from the HPFS (mean [SD] baseline age, 53.3 [9.6] years). During a total of 3 559 056 person-years of follow-up, 31 263 women and 22 900 men died. When comparing the highest with the lowest quintiles, the pooled multivariable-adjusted HRs of total mortality were 0.81 (95% CI, 0.79-0.84) for HEI-2015, 0.82 (95% CI, 0.79-0.84) for AMED score, 0.86 (95% CI, 0.83-0.89) for HPDI, and 0.80 (95% CI, 0.77-0.82) for AHEI (P < .001 for trend for all). All dietary scores were significantly inversely associated with death from cardiovascular disease, cancer, and respiratory disease. The AMED score and AHEI were inversely associated with mortality from neurodegenerative disease. The inverse associations between these scores and risk of mortality were consistent in different racial and ethnic groups, including Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

Conclusions and Relevance

In this cohort study of 2 large prospective cohorts with up to 36 years of follow-up, greater adherence to various healthy eating patterns was consistently associated with lower risk of total and cause-specific mortality. These findings support the recommendations of Dietary Guidelines for Americans that multiple healthy eating patterns can be adapted to individual food traditions and preferences.

Degree of adherence to plant-based diet and total and cause-specific mortality: prospective cohort study in the Million Veteran Program

OBJECTIVE

To examine the association between adherence to plant-based diets and mortality.

DESIGN

Prospective study. We calculated a plant-based diet index (PDI) by assigning positive scores to plant foods and reverse scores to animal foods. We also created a healthful PDI (hPDI) and an unhealthful PDI (uPDI) by further separating the healthy plant foods from less-healthy plant foods.

SETTING

The VA Million Veteran Program.

PARTICIPANTS

315 919 men and women aged 19-104 years who completed a FFQ at the baseline.

RESULTS

We documented 31 136 deaths during the follow-up. A higher PDI was significantly associated with lower total mortality (hazard ratio (HR) comparing extreme deciles = 0·75, 95 % CI: 0·71, 0·79, Ptrend < 0·001]. We observed an inverse association between hPDI and total mortality (HR comparing extreme deciles = 0·64, 95 % CI: 0·61, 0·68, Ptrend < 0·001), whereas uPDI was positively associated with total mortality (HR comparing extreme deciles = 1·41, 95 % CI: 1·33, 1·49, Ptrend < 0·001). Similar significant associations of PDI, hPDI and uPDI were also observed for CVD and cancer mortality. The associations between the PDI and total mortality were consistent among African and European American participants, and participants free from CVD and cancer and those who were diagnosed with major chronic disease at baseline.

CONCLUSIONS

A greater adherence to a plant-based diet was associated with substantially lower total mortality in this large population of veterans. These findings support recommending plant-rich dietary patterns for the prevention of major chronic diseases.

Metabolic profile predicts incident cancer: A large-scale population study in the UK Biobank

BACKGROUND AND AIMS

Analyses to predict the risk of cancer typically focus on single biomarkers, which do not capture their complex interrelations. We hypothesized that the use of metabolic profiles may provide new insights into cancer prediction.

METHODS

We used information from 290,888 UK Biobank participants aged 37 to 73 years at baseline. Metabolic subgroups were defined based on clustering of biochemical data using an artificial neural network approach and examined for their association with incident cancers identified through linkage to cancer registry. In addition, we evaluated associations between 38 individual biomarkers and cancer risk.

RESULTS

In total, 21,973 individuals developed cancer during the follow-up (median 3.87 years, interquartile range [IQR] = 2.03-5.58). Compared to the metabolically favorable subgroup (IV), subgroup III (defined as "high BMI, C-reactive protein & cystatin C") was associated with a higher risk of obesity-related cancers (hazard ratio [HR] = 1.26, 95 % CI = 1.21 to 1.32) and hematologic-malignancies (e.g., lymphoid leukemia: HR = 1.83, 95%CI = 1.44 to 2.33). Subgroup II ("high triglycerides & liver enzymes") was strongly associated with liver cancer risk (HR = 5.70, 95%CI = 3.57 to 9.11). Analysis of individual biomarkers showed a positive association between testosterone and greater risks of hormone-sensitive cancers (HR per SD higher = 1.32, 95%CI = 1.23 to 1.44), and liver cancer (HR = 2.49, 95%CI =1.47 to 4.24). Many liver tests were individually associated with a greater risk of liver cancer with the strongest association observed for gamma-glutamyl transferase (HR = 2.40, 95%CI = 2.19 to 2.65).

CONCLUSIONS

Metabolic profile in middle-to-older age can predict cancer incidence, in particular risk of obesity-related cancer, hematologic malignancies, and liver cancer. Elevated values from liver tests are strong predictors for later risk of liver cancer.

Long-term diet and risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and Coronavirus Disease 2019 (COVID-19) severity

BACKGROUND

The role of diet on Coronavirus Disease 2019 (COVID-19) is emerging. We investigated the association between usual diet before the onset of the pandemic and risk and severity of subsequent SARS-CoV-2 infection.

METHODS

We included 42,935 participants aged 55-99 y in 2 ongoing cohort studies, the Nurses' Health Study II and Health Professionals Follow-up Study, who completed a series of COVID-19 surveys in 2020 and 2021. Using data from FFQs before COVID-19, we assessed diet quality using the Alternative Healthy Eating Index (AHEI)-2010, the alternative Mediterranean Diet (AMED) score, an Empirical Dietary Index for Hyperinsulinemia (EDIH), and an Empirical Dietary Inflammatory Pattern (EDIP). We calculated multivariable-adjusted ORs and 95% CIs for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and severity of COVID-19 after controlling for demographic, medical, and lifestyle factors.

RESULTS

Among 19,754 participants tested for SARS-CoV-2, 1941 participants reported a positive result. Of these, 1327 reported symptoms needing assistance and another 109 were hospitalized. Healthier diets, represented by higher AHEI-2010 and AMED scores and lower EDIH and EDIP scores, were associated with lower likelihood of SARS-CoV-2 infection (quartile 4 compared with quartile 1: OR: 0.80; 95% CI: 0.69, 0.92 for AHEI-2010; OR: 0.78; 95% CI: 0.67, 0.92 for AMED; OR: 1.36; 95% CI: 1.16, 1.57 for EDIH; and OR: 1.13; 95% CI: 0.99, 1.30 for EDIP; all P-trend ≤ 0.01). In the analysis of COVID-19 severity, participants with healthier diet had lower likelihood of severe infection and were less likely to be hospitalized owing to COVID-19. However, associations were no longer significant after controlling for BMI and pre-existing medical conditions.

CONCLUSIONS

Diet may be an important modifiable risk factor for SARS-CoV-2 infection, as well as for severity of COVID-19. This association is partially mediated by BMI and pre-existing medical conditions.

Lung Cancer Risk in Men and Compliance with the 2018 WCRF/AICR Cancer Prevention Recommendations

Lung cancer is the most common and deadly form of cancer worldwide, especially in men. The 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) updated cancer prevention recommendations, and a standard scoring system (2018 WCRF/AICR Score) was published. The purpose of this study was to develop the adapted version of the 2018 WCRF/AICR Score with respect to lung cancer prevention recommendation (Ad-LC WCRF/AICR Score) and to examine the association between lung cancer risk in men and the Ad-LC WCRF/AICR Score as well as its single components. A case-control study was conducted among 439 men aged 45-80 years (187 controls, 252 primary lung cancer cases). Lifestyle and dietary data were collected with a questionnaire including the 62-item food frequency questionnaire (FFQ-6^®). The Ad-LC WCRF/AICR Score was used as a categorized and continuous variable. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for lung cancer risk were calculated with the partly and fully adjusted model. One component of the score was independently associated with a lower risk of lung cancer in men, regardless of the set of confounders used. In the fully adjusted model following the recommendation "Limit smoking" was associated with a lower risk of lung cancer-in the never smokers by 87% (OR: 0.13; 95% CI: 0.04-0.37; p = 0.0002) and in the moderate smokers by 45% (OR: 0.55; 95% CI: 0.33-0.91; p = 0.0189) compared with the heavy smokers as a reference. By adding the single components making up the Ad-LC WCRF/AICR Score, the combination of three components or more, reducing the risk of lung cancer compared to lower compliance as a reference by 45% to 78% and by 39% to 66% for intermediate compliance (except two models out of seven) and higher compliance, respectively. In the fully adjusted model, the risk of lung cancer for the total Ad-LC WCRF/AICR Score was lower by 47% (OR: 0.53; 95% CI: 0.32-0.88; p = 0.0129) in higher compliance with the score compared to those with the lower compliance. Each one-point increase in the Ad-LC WCRF/AICR Score reduced lung cancer risk by 34% (OR: 0.66; 95% CI: 0.45-0.95; p = 0.0267). The results support previous evidence that limiting smoking reduces the risk of lung cancer in men. It also provides an insight into cancer research by showing that following the combined 2018 cancer prevention recommendations related to diet, lifestyle and body fatness was associated with a lower risk of lung cancer in men.

A Healthful Plant-Based Diet Is Associated with Lower Odds of Nonalcoholic Fatty Liver Disease

There is little evidence for the associations of the overall plant-based diet index (PDI), the healthful PDI (hPDI), and the unhealthful PDI (uPDI) with the odds of nonalcoholic fatty liver disease (NAFLD). We present a nationwide cross-sectional study among US adults aged 18 years or older. Diet was assessed by 24-h recalls. Overall PDI, hPDI, and uPDI were constructed based on 18 food groups. NAFLD was defined based on controlled attenuation parameter derived via transient elastography (TE) in the absence of other causes of chronic liver disease. Among 3900 participants with eligible TE examination, 1686 were diagnosed with NAFLD. The overall PDI was not associated with NAFLD prevalence (comparing extreme tertiles of PDI score OR = 1.03, 95% CI 0.76, 1.38, ptrend = 0.609). However, hPDI was inversely (OR = 0.50, 95% CI 0.35, 0.72, ptrend < 0.001), while uPDI was positively associated with odds of NAFLD (OR = 1.37, 95% CI 0.93, 2.02, ptrend = 0.009) in the multivariable-adjusted models without body mass index (BMI). After further adjustment for BMI, only the association of hPDI with NAFLD remained statistically significant (OR = 0.64, 95% CI 0.46, 0.87, ptrend = 0.006). Such inverse association appeared stronger in non-Hispanic whites, but not in other racial/ethnic groups (pinteraction = 0.009). Our findings suggest that a plant-based diet rich in healthy plant foods might be associated with lower odds of NAFLD, particularly among US non-Hispanic whites. Clinical trials and cohort studies to validate our findings are needed.

Dietary quality and risk of heart failure in men

BACKGROUND

Due to the increasing disease burden, strategies to predict and prevent heart failure (HF) are urgently needed.

OBJECTIVE

We aimed to investigate whether the Alternative Healthy Eating Index (AHEI) and the clinically abbreviated Prime Diet Quality Score (PDQS) are associated with the risk of overall HF, HF with preserved ejection fraction (HFpEF), and HF with reduced ejection fraction (HFrEF).

METHODS

Our study included 44,525 men from the Health Professionals Follow-up Study (HPFS) who were free from cardiovascular disease and cancer at baseline. The AHEI and PDQS were computed based on dietary data repeatedly measured using semiquantitative FFQs. HF, HFpEF, and HFrEF were adjudicated based on review of medical records through 2008. Associations of diet quality with incident HF were estimated with multivariate-adjusted Cox proportional hazards models.

RESULTS

During 929,911 person-years of follow-up, 803 HF cases were documented, including 184 with HFpEF and 181 with HFrEF among those with ejection fraction (EF) data. Adjusting for potential confounders, we did not observe a significant association between the AHEI and overall HF (HR per SD: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.57) or between the PDQS and overall HF (HR per SD: 0.98; 95% CI: 0.91, 1.06; P-trend = 0.82). Both dietary indices were not significantly associated with HFpEF. However, a higher AHEI was associated with lower risk of HFrEF upon comparison of the extreme quintiles (HR per SD: 0.81; 95% CI: 0.69, 0.96; P-trend = 0.02). Every SD increment in the PDQS was associated with 20% lower risk of HFrEF (HR per SD: 0.80; 95% CI: 0.68, 0.95; P-quadratic = 0.03).

CONCLUSIONS

A healthy overall diet was associated with lower risk of HFrEF, and associations were similar with the AHEI and PDQS. We did not observe a significant association between dietary indices and either overall HF or HFpEF.

Association Between Dietary Total Antioxidant Capacity and Diet Quality in Adults

Background

Diet quality is a major contributor to human health. In addition, antioxidants have a great contribution to several chronic conditions. The purpose of this study was to evaluate if dietary total antioxidant capacity (TAC) can be considered as a measure of diet quality in a Middle Eastern country.

Methods

In this cross-sectional study on 6,724 Iranian adults, we used a validated food frequency questionnaire (FFQ) to assess dietary intakes. Data derived from the FFQ was used to calculate dietary TAC and well-known diet quality scores including alternate healthy eating index (AHEI) and dietary diversity score (DDS). Dietary TAC was calculated based on the ferric reducing-antioxidant power (FRAP) values reported in earlier publications. AHEI and DDS have also been constructed based on previous publications. Cross-classification was used to examine the agreement between these measures.

Results

Mean age and BMI of study participants were 36.89 ± 8.08 y and 24.97 ± 3.87 kg/m², respectively. We found that individuals in the highest tertile of dietary TAC had higher scores of AHEI (57.53 ± 0.20 vs. 52.03 ± 0.20, P < 0.001) and DDS (5.56 ± 0.03 vs. 4.15 ± 0.03, P < 0.001) compared with those in the lowest tertile. Participants' distribution on the basis of the cross-classification analysis indicated that the classifications were in exact agreement for 42.6%, within an adjacent tertile for 33.05%, and in gross misclassification for 20% of individuals. When this was examined between dietary TAC and DDS, we found that exact agreement in the classifications was for 59.2% of participants. Notably, a very low proportion of gross misclassification was seen in this regard such that only 6% of participants were classified in the opposing tertiles, indicating additional support for a good agreement.

Conclusion

We found that dietary TAC might be considered as a proper measure for the assessment of diet quality because it was well correlated with well-known measures of diet quality including DDS and AHEI scores.