Southern Dietary Pattern is Associated With Hazard of Acute Coronary Heart Disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Unhealthy dietary patterns in the American Nations: A crisis with cultural distinctions

INTRODUCTION

Food insecurity and limited healthful food access are critical public health issues in the United States (U.S), with unequal distribution across regions. This report tracked the prevalence of food insecurity, healthful food access, and the food environment, as cultural experiences according to the American Nations Model.

METHODS

Data from the County Health Rankings & Roadmaps program on food insecurity, insufficient healthy food access, and the food environment index were matched at the zip-code level with the American Nations dataset from the Nationhood Lab. Percentages for all three food indicators were estimated based on the population of each American Nation region.

RESULTS

Results show significant disparities across regional cultures. The First Nation, heavily populated by American Indian and Alaska Native communities, reports the highest prevalence of food insecurity (17 %), lowest healthful food access (21 %) and food environment index (4.6 out of 10). New France, Deep South, Great Polynesia, Greater Appalachia, El Norte and Far West, areas with higher minority populations, also show elevated food insecurity rates (range, 11-14 %) and reduced healthful food access (5-9 %). Regions with more favorable metrics across all three indicators include the Spanish Caribbean, Midlands, Yankeedom, Left Coast, Tidewater, and the New Netherlands.

CONCLUSIONS

Disparities in food insecurity, healthful food access, and food environments appear to stem from geographical diversity and cultural history, underscoring the need to recognize and address cultural differences among the American Nations. This insight can inform policy and practices aimed at achieving food security and health equity across the country.

Serum zinc concentration and dietary zinc intake in relation to cognitive function: an analysis of the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort

PURPOSE

There are several pathways by which zinc may be a modifiable factor to slow age-related cognitive decline. We investigated the associations between serum and dietary zinc and cognitive impairment in a longitudinal cohort.

METHODS

We used data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort (n = 30,239) and the REGARDS Trace Element Study (n = 2666). Baseline serum zinc concentrations (2003-2007) were measured using inductively coupled plasma mass spectrometry. Baseline dietary zinc intake was measured via the Block food frequency questionnaire. Serum zinc concentrations and dietary zinc intake were categorized into quartiles. The outcome of interest was impairment on the Six-Item Screener (SIS), a measure of global cognitive functioning administered annually. The Enhanced Cognitive Battery (ECB), a more comprehensive series of tests assessing memory and fluency, was administered every two years and considered a secondary outcome. Associations between zinc and incident impairment were assessed using multivariable logistic regression.

RESULTS

Among 2065 participants with serum zinc data, 184 individuals developed impairment over 10 years of follow-up. In adjusted models, there was no significant association between serum zinc and impairment as assessed by the SIS or the ECB. Among 18,103 participants who had dietary data, 1424 experienced incident impairment on the SIS. Dietary zinc intake was not significantly associated with impairment as assessed by the SIS or the ECB in adjusted models.

CONCLUSION

Findings from this U.S. cohort did not support the hypothesis that serum zinc concentration or dietary zinc intake is associated with the risk of cognitive impairment.

Cancer Incidence Rates in the US in 2016-2020 with Respect to Solar UVB Doses, Diabetes and Obesity Prevalence, Lung Cancer Incidence Rates, and Alcohol Consumption: An Ecological Study

This article reports the results of an ecological study of cancer incidence rates by state in the US for the period 2016-2020. The goals of this study were to determine the extent to which solar UVB doses reduced cancer risk compared to findings reported in 2006 for cancer mortality rates for the periods 1950-1969 and 1970-1794 as well as cancer incidence rates for the period 1998-2002 and to determine which factors were recently associated with cancer risk. The cancer data for non-Hispanic white (European American) men and women were obtained from the Centers for Disease Control and Prevention. Indices were obtained for solar UVB at the surface for July 1992, and alcohol consumption, diabetes, and obesity prevalence near the 2016-2020 period. Lung cancer incidence rates were also used in the analyses as a surrogate for smoking, diet, and air pollution. The cancers for which solar UVB is significantly associated with reduced incidence are bladder, brain (males), breast, corpus uteri, esophageal, gastric, non-Hodgkin's lymphoma, pancreatic, and renal cancer. Lung cancer was significantly associated with colorectal, laryngeal, and renal cancer. Diabetes was also significantly associated with breast, liver, and lung cancer. Obesity prevalence was significantly associated with breast, colorectal, and renal cancer. Alcohol consumption was associated with bladder and esophageal cancer. Thus, diet has become a very important driver of cancer incidence rates. The role of solar UVB in reducing the risk of cancer has been reduced due to people spending less time outdoors, wearing sunscreen that blocks UVB but not UVA radiation, and population increases in terms of overweight and obese individuals, which are associated with lower 25-hydroxyvitamin D concentrations and the generation of systemic inflammation, which is a risk factor for cancer. A dietary approach that would reduce the risk of diabetes, obesity, lung cancer, and, therefore, cancer, would be one based mostly on whole plants and restrictions on red and processed meats and ultraprocessed foods. Solar UVB exposure for a few minutes before applying sunscreen and taking vitamin D supplements would also help reduce the risk of cancer.

Omega-3 Fatty Acids and Risk of Ischemic Stroke in REGARDS

We examined associations between lipidomic profiles and incident ischemic stroke in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Plasma lipids (n = 195) were measured from baseline blood samples, and lipids were consolidated into underlying factors using exploratory factor analysis. Cox proportional hazards models were used to test associations between lipid factors and incident stroke, linear regressions to determine associations between dietary intake and lipid factors, and the inverse odds ratio weighting (IORW) approach to test mediation. The study followed participants over a median (IQR) of 7 (3.4-11) years, and the case-cohort substudy included 1075 incident ischemic stroke and 968 non-stroke participants. One lipid factor, enriched for docosahexaenoic acid (DHA, an omega-3 fatty acid), was inversely associated with stroke risk in a base model (HR = 0.84; 95%CI 0.79-0.90; P = 8.33 × 10-8) and fully adjusted model (HR = 0.88; 95%CI 0.83-0.94; P = 2.79 × 10-4). This factor was associated with a healthy diet pattern (β = 0.21; 95%CI 0.12-0.30; P = 2.06 × 10-6), specifically with fish intake (β = 1.96; 95%CI 0.95-2.96; P = 1.36 × 10-4). DHA was a mediator between fish intake and incident ischemic stroke (30% P = 5.78 × 10-3). Taken together, DHA-containing plasma lipids were inversely associated with incident ischemic stroke and mediated the relationship between fish intake and stroke risk.

Impact of a Medical Fitness Model on Incident Major Adverse Cardiovascular Events: A Prospective Cohort Study of 11 000 Members

BACKGROUND

Cardiovascular disease remains the leading cause of disease burden and death in the world. The medical fitness model may be an alternative public health strategy to address cardiovascular risk factors with medical integrated programming.

METHODS AND RESULTS

We performed a retrospective cohort study between January 1, 2005, and December 31, 2015. Adults (aged ≥18 years) who did not have a prior major adverse cardiovascular event were included. Controls were assigned a pseudo-index date at random on the basis of the frequency distribution of start dates in the medical fitness facility group. Multivariate Cox proportional hazards regression models were adjusted for age, sex, socioeconomic status, comorbidities, and year of index date. We stratified the medical fitness facility group into low-frequency attenders (≤1 weekly visit) and regular-frequency attenders (>1 weekly visit). Our primary outcome was a hospitalization for nonfatal myocardial infarction and stroke, heart failure, or cardiovascular death. We included 11 319 medical fitness facility members and 507 400 controls in our study. Compared with controls, members had a lower hazard risk of a major adverse cardiovascular event-plus (hazard ratio [HR], 0.88 [95% CI, 0.81-0.96]). Higher weekly attendance was associated with a lower hazard risk of a major adverse cardiovascular event-plus compared with controls, but the effect was not significant for lower weekly attendance (low-frequency attenders: HR, 0.94 [95% CI, 0.85-1.04]; regular-frequency attenders: HR, 0.77 [95% CI, 0.67-0.89]).

CONCLUSIONS

Medical fitness facility membership and attendance at least once per week may lower the risk of a major adverse cardiovascular event-plus. The medical fitness model should be considered as a public health intervention, especially for individuals at risk for cardiovascular disease.

Dietary patterns and their associations with sociodemographic and lifestyle factors in adult survivors of childhood cancer: a cross-sectional study

BACKGROUND

Little is known about the specific dietary patterns in adult survivors of childhood cancer.

OBJECTIVES

We aimed to identify dietary patterns specific to childhood cancer survivors and examine their associations with sociodemographic and lifestyle factors.

METHODS

Adult survivors of childhood cancer (mean:31 ± 8 y; n = 3022) and noncancer controls (n = 497) in the St. Jude Lifetime Cohort self-reported diet over the past 12 mo using a validated food frequency questionnaire. Factor analysis with 48 predefined food groups was performed to identify foods consumed together. Subsequently, cluster analysis with energy-adjusted factor scores was used to categorize survivors into a mutually exclusive dietary pattern. Dietary patterns were the primary outcomes. Multivariable multinomial logistic regressions were used to cross-sectionally examine associations between sociodemographic and lifestyle factors and dietary patterns in cancer survivors.

RESULTS

Among the 4 dietary patterns identified, the fast-food pattern (36 %) was the most common, followed by the Western contemporary (30 %), the plant-based (20 %), and the animal-based (14 %) patterns in childhood cancer survivors. By contrast, the plant-based (38 %) and fast-food patterns (29 %) were prevalent in controls. In survivors, male sex, younger age, lower educational attainment, and physical inactivity were associated with the fast-food, Western contemporary, or animal-based pattern. Compared with non-Hispanic White survivors consuming the plant-based diet, non-Hispanic Black survivors were 2-5 times more likely to consume the fast-food [odds ratio (OR:= 2.76; 95 % CI: 1.82, 4.18) or the animal-based diet (OR: 5.61; 95 % CI: 3.58, 8.78)]. Moreover, survivors residing in the most deprived area were 2-3 times more likely to consume the fast-food, Western contemporary, or animal-based diet.

CONCLUSIONS

Unhealthy dietary patterns are prevalent in adult survivors of childhood cancer, especially those with lower socioeconomic status and racial minorities. Interventions to improve diet and health in childhood cancer survivors need to concurrently address disparities that contribute to adherence to healthy dietary practices. This trial was registered at clinicaltrials.gov as NCT00760656 (https://classic.

CLINICALTRIALS

gov/ct2/show/NCT00760656).

Ancestry Specific Polygenic Risk Score, Dietary Patterns, Physical Activity, and Cardiovascular Disease

It is unknown whether the impact of high diet quality and physical activity depends on the level of polygenic risk score (PRS) in different ancestries. Our cross-sectional study utilized de-identified data from 1987-2010 for self-reported European Americans (n = 6575) and African Americans (n = 1606). The high-risk PRS increased ASCVD risk by 59% (Risk Ratio (RR) = 1.59; 95% Confidence Interval:1.16-2.17) in the highest tertile for African Americans and by 15% (RR = 1.15; 1.13-1.30) and 18% (RR = 1.18; 1.04-1.35) in the second and highest tertiles compared to the lowest tertile in European Americans. Within the highest PRS tertiles, high physical activity-diet combinations (Dietary Approaches to Stop High Blood Pressure (DASH), Mediterranean, or Southern) reduced ASCVD risks by 9% (RR = 0.91; 0.85-0.96) to 15% (RR = 0.85; 0.80-0.90) in European Americans; and by 13% (RR = 0.87; 0.78-0.97) and 18% (RR = 0.82; 0.72-0.95) for DASH and Mediterranean diets, respectively, in African Americans. Top molecular pathways included fructose metabolism and catabolism linked to obesity, insulin resistance, and type 2 diabetes. Additional molecular pathways for African Americans were Vitamin D linked to depression and aging acceleration and death signaling associated with cancer. Effects of high diet quality and high physical activity can counterbalance the influences of genetically high-risk PRSs on ASCVD risk, especially in African Americans.

Adherence to the healthy eating index-2010 and alternative healthy eating index-2010 in relation to metabolic syndrome among African Americans in the Jackson heart study

OBJECTIVE

The primary objective of this study was to determine whether Healthy Eating Index (HEI) and Alternative Healthy Eating Index (AHEI) scores were associated with incident metabolic syndrome.

DESIGN

This study is a secondary analysis of data from the Jackson Heart Study. HEI and AHEI scores were divided into quintiles and Cox proportional hazards regression models were analysed for 1864 African American adults free from metabolic syndrome at Exam 1 to examine the incidence of metabolic syndrome by quintile of dietary quality score.

SETTING

Hinds, Madison and Rankin counties, Mississippi, USA.

PARTICIPANTS

African American adults, ages 21-94 years, 60·9 % female.

RESULTS

Over a mean follow-up time of 6·7 years, we observed 932 incident cases of metabolic syndrome. After adjusting for multiple covariates, a higher HEI score at Exam 1 was not associated with the risk of incident metabolic syndrome, except when looking at the trend analysis for the subgroup of adults with two metabolic syndrome components at Exam 1 (P-trend = 0·03). A higher AHEI score at Exam 1 was associated with the risk of incident metabolic syndrome (hazard ratio for those in the highest quintile compared to the lowest: 0·80 (95 % CI: 0·65, 0·99), P-trend = 0·03).

CONCLUSION

These findings suggest that a dietary pattern that scores higher on the AHEI may help reduce the risk of metabolic syndrome, even for adults who already have two of the minimum of three components required for a diagnosis of metabolic syndrome.

Empirically derived dietary patterns are associated with major adverse cardiovascular events, all-cause mortality, and congestive cardiac failure in older men: The Concord Health and Ageing in Men Project

BACKGROUND

Diet is associated with major adverse cardiovascular events (MACE).

OBJECTIVE

We evaluated the associations between empirically derived dietary patterns and MACE.

DESIGN

Prospective cohort study.

SETTING

The Concord Health and Ageing in Men Project, Sydney, Australia.

PARTICIPANTS

539 community-dwelling older Australian men aged 75 years and older.

METHODS

Men underwent dietary assessment using a validated dietitian-administered diet history questionnaire. Cox regression analyses were conducted between MACE and the three dietary patterns identified from factor analysis. Five-point MACE comprised of all-cause mortality, myocardial infarction (MI), congestive cardiac failure (CCF), coronary revascularisation, and/or ischaemic stroke. Four-point MACE included the four endpoints of MI, CCF, coronary revascularisation, and/or ischaemic stroke, and excluded all-cause mortality.

RESULTS

At a median of 5.3 (IQR 4.6-6.3) years of follow-up, the incidences were: five-point MACE 31.2% (n = 168); four-point MACE excluding all-cause mortality 17.8% (n = 96); all-cause mortality 20.1% (n = 111); CCF 11.3% (n = 61); MI 3.7% (n = 20); stroke 3.2% (n = 17); and coronary revascularisation 3.1% (n = 15). In fully adjusted analyses, compared to the bottom tertile, the middle tertile of 'vegetables-legumes-seafood' dietary pattern was associated with reduced five-point MACE (HR 0.67 [95% CI: 0.45, 0.99, P = .047]), and CCF (HR 0.31 [95% CI: 0.15, 0.65, P = .002]), whilst the middle tertile of 'wholegrains-milk-other fruits' dietary pattern was associated with increased five-point MACE (HR 1.78 [95% CI: 1.17, 2.70, P = .007]), four-point MACE (HR 1.92 [95% CI: 1.12, 3.30, P = .018]), and CCF (HR 2.33 [95% CI: 1.17, 4.65, P = .016]). For the 'discretionary-starchy vegetables-processed meats' dietary pattern, a higher score was associated with increased five-point MACE (HR 1.33 [95% CI: 1.09, 1.62, P = .004]), and all-cause mortality (HR 1.63 [95% CI: 1.26, 2.12, P < .001]), and compared to the bottom tertile, the top tertile was associated with increased all-cause mortality (HR 2.26 [95% CI: 1.27, 4.00, P = .005]).

CONCLUSION

Older men may benefit from consuming a 'vegetables-legumes-seafood' dietary pattern rather than 'discretionary-starchy vegetables-processed meats' and 'wholegrains-milk-other fruits' dietary patterns for the prevention of MACE.

Ancestry Specific Polygenic Risk Score, Dietary Patterns, Physical Activity, and Cardiovascular Disease

Background

It is unknown whether the impact of high diet-quality and physical activity (PA) depends on the level of polygenic risk score (PRS) in different ancestries.

Objective

Determine the associations and interactions between high-risk PRSs, dietary patterns, and high PA with atherosclerotic cardiovascular disease (ASCVD) in European Americans (EAs) and African Americans (AAs). Another aim determined the molecular pathways of PRS-mapped genes and their relationships with dietary intake.

Methods

Cross-sectional analyses utilized de-identified data from 1987-2010 from 7-National Heart, Lung, and Blood Institute Candidate Gene Association Resource studies from the Database of Genotypes and Phenotypes studies for EAs (n=6,575) and AAs (n=1,606).

Results

The high-risk PRS increased ASCVD risk by 59% (Risk Ratio=1.59;95% Confidence Interval:1.16-2.17) in the highest tertile for AAs and by 15% (RR=1.15;1.13-1.30) and 18% (RR=1.18;1.04-1.35) in the second and highest tertiles compared to the lowest tertile in EAs. Within the highest PRS tertiles, high PA-diet combinations (Dietary Approaches to Stop High Blood Pressure (DASH), or Mediterranean, or Southern) reduced ASCVD risks by 9% (RR=0.91;0.85-0.96) to 15% (RR=0.85;0.80-0.90) in EAs; and by 13% (RR=0.87;0.78-0.97) and 18% (RR=0.82;0.72-0.95) for the DASH and Mediterranean diets, respectively in AAs. Top molecular pathways included fructose metabolism and catabolism linked to obesity, insulin resistance, and type 2 diabetes in both ancestries. Additional molecular pathways for AAs were Vitamin D linked to depression and aging acceleration; and death signaling associated with cancer.

Conclusions

Effects of high diet-quality and high PA can counterbalance the influences of genetically high-risk PRSs on ASCVD risk, especially in AAs.

A content and quality analysis of free, popular mHealth apps supporting 'plant-based' diets

There has been an increased emphasis on plant-based foods and diets. Although mobile technology has the potential to be a convenient and innovative tool to help consumers adhere to dietary guidelines, little is known about the content and quality of free, popular mobile health (mHealth) plant-based diet apps. The objective of the study was to assess the content and quality of free, popular mHealth apps supporting plant-based diets for Canadians. Free mHealth apps with high user ratings, a high number of user ratings, available on both Apple App and GooglePlay stores, and primarily marketed to help users follow plant-based diet were included. Using pre-defined search terms, Apple App and GooglePlay App stores were searched on December 22, 2020; the top 100 returns for each search term were screened for eligibility. Included apps were downloaded and assessed for quality by three dietitians/nutrition research assistants using the Mobile App Rating Scale (MARS) and the App Quality Evaluation (AQEL) scale. Of the 998 apps screened, 16 apps (mean user ratings±SEM: 4.6±0.1) met the eligibility criteria, comprising 10 recipe managers and meal planners, 2 food scanners, 2 community builders, 1 restaurant identifier, and 1 sustainability assessor. All included apps targeted the general population and focused on changing behaviors using education (15 apps), skills training (9 apps), and/or goal setting (4 apps). Although MARS (scale: 1-5) revealed overall adequate app quality scores (3.8±0.1), domain-specific assessments revealed high functionality (4.0±0.1) and aesthetic (4.0±0.2), but low credibility scores (2.4±0.1). The AQEL (scale: 0-10) revealed overall low score in support of knowledge acquisition (4.5±0.4) and adequate scores in other nutrition-focused domains (6.1-7.6). Despite a variety of free plant-based apps available with different focuses to help Canadians follow plant-based diets, our findings suggest a need for increased credibility and additional resources to complement the low support of knowledge acquisition among currently available plant-based apps. This research received no specific grant from any funding agency.

Associations of dietary patterns with risk of incident atrial fibrillation in the REasons for Geographic And Racial Differences in Stroke (REGARDS)

BACKGROUND

We examined whether the risk of incident atrial fibrillation (AF) in a large, biracial, prospective cohort is lower in participants who adhere to heart-healthy dietary patterns and higher in participants who adhere to less heart-healthy diets.

METHODS

Between 2003 and 2007, the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study enrolled 30,239 Black and White Americans aged 45 years or older. Dietary patterns (convenience, plant-based, sweets, Southern, and alcohol and salads) and the Mediterranean diet score (MDS) were derived based on food frequency questionnaire data. The primary outcome was incident AF at the follow-up visit 2013-2016, defined by either electrocardiogram or self-reported medical history of a physician diagnosis.

RESULTS

This study included 8977 participants (mean age 63 ± 8.3 years; 56% women; 30% Black) free of AF at baseline who completed the follow-up exam an average of 9.4 years later. A total of 782 incident AF cases were detected. In multivariable logistic regression analyses, neither the MDS score (odds ratio (OR) per SD increment = 1.03; 95% confidence interval (CI) 0.95-1.11) or the plant-based dietary pattern (OR per SD increment = 1.03; 95% CI 0.94-1.12) were associated with AF risk. Additionally, an increased AF risk was not associated with any of the less-healthy dietary patterns.

CONCLUSIONS

While specific dietary patterns have been associated with AF risk factors, our findings fail to show an association between diet patterns and AF development.

Plant-Based Nutrition: Exploring Health Benefits for Atherosclerosis, Chronic Diseases, and Metabolic Syndrome-A Comprehensive Review

Atherosclerosis, chronic non-communicable diseases, and metabolic syndrome are highly interconnected and collectively contribute to global health concerns that reduce life expectancy and quality of life. These conditions arise from multiple risk factors, including inflammation, insulin resistance, impaired blood lipid profile, endothelial dysfunction, and increased cardiovascular risk. Adopting a plant-based diet has gained popularity as a viable alternative to promote health and mitigate the incidence of, and risk factors associated with, these three health conditions. Understanding the potential benefits of a plant-based diet for human health is crucial, particularly in the face of the rising prevalence of chronic diseases like diabetes, hypertension, dyslipidemia, atherosclerosis, and cancer. Thus, this review focused on the plausible advantages of consuming a type of food pattern for the prevention and/or treatment of chronic diseases, emphasizing the dietary aspects that contribute to these conditions and the evidence supporting the benefits of a plant-based diet for human health. To facilitate a more in-depth analysis, we present separate evidence for each of these three concepts, acknowledging their intrinsic connection while providing a specific focus on each one. This review underscores the potential of a plant-based diet to target the underlying causes of these chronic diseases and enhance health outcomes for individuals and populations.

Burden of Hypertensive Crisis in Patients With End-Stage Kidney Disease on Maintenance Dialysis: Insights From United States Renal Data System Database

BACKGROUND

There is paucity of information on the incidence, clinical characteristics, admission trends, and outcomes of hypertensive crisis (HTN-C) in patients with end-stage kidney disease (ESKD) who are on maintenance dialysis.

METHODS

We conducted a retrospective observational study of HTN-C admissions in patients with end-stage kidney disease using the United States Renal Data System. We identified patients with end-stage kidney disease aged ≥18 years on dialysis and were hospitalized for HTN-C from January 2006 to August 2015.

RESULTS

A total of 54 483 patients with end-stage kidney disease were hospitalized for HTN-C during the study period. After study exclusions, 37 214 patients were included in the analysis. A majority of patients were Black, there were more women than men and the South region of the country accounted for a great majority of patients. During the study period, hospitalization rates increased from 1060 per 100 000 beneficiary years to 1821 (P_trend<0.0001). Overall, in-hospital mortality, 30-day, and 1-year mortality were 0.6%, 2.3%, and 21.8%, respectively, and 30-day readmission rate was 31.1%. During the study period, most study outcomes showed a significant decreasing trend (in-hospital mortality 0.6%-0.5%, 30-day mortality 2.4%-1.9%, 1-year mortality 23.9%-19.7%, P_trend<0.0001 for all).

CONCLUSIONS

Hospitalizations for HTN-C have increased consistently during the decade studied. Although temporal trends showed improving mortality and readmission rates, the absolute rates were still high with 1 in 3 patients readmitted within 30 days and 1 in 5 patients dying within 1 year of index hospitalization.

The Association of Human Cytomegalovirus Infection and Colorectal Cancer: A Clinical Analysis

Background

Human cytomegalovirus (HCMV) commonly infects humans and establishes lifelong infection. It causes disease and increased mortality rates in patients with immunosuppression. HCMV gene products are found to be present in multiple human malignancies and target cellular functions involved in tumor development; additionally, a tumor-cytoreductive role of CMV has also been observed. The purpose of this study was to evaluate the correlation between CMV infection and the incidence of colorectal cancer (CRC).

Methods

The data were provided by a national database that is compliant with Health Insurance Portability and Accountability Act (HIPAA). Using International Classification of Disease (ICD)-10 and ICD-9 diagnostic codes, the data were filtered to evaluate patients infected with HCMV versus patients never infected with HCMV. Patient data from 2010 to 2019 were assessed. Access to the database was granted by Holy Cross Health, Fort Lauderdale for the purpose of academic research. Standard statistical methods were used.

Results

Between January 2010 and December 2019, the query was analyzed and resulted in 14,235 patients after matching in the infected and control groups. The groups were matched by age range, sex, Charlson Comorbidity Index (CCI) score, and treatment. The incidence of CRC was 1.159% (165 patients) in the HCMV group and 2.845% (405 patients) in the control group. The difference after matching was statistically significant by a P-value < 2.2 × 10^-16 with an odds ratio of 0.37 (95% confidence interval (CI) 0.32 - 0.42).

Conclusions

The study shows a statistically significant correlation between CMV infection and a reduced incidence of CRC. Further evaluation is recommended to assess the potential of CMV in reducing CRC incidence.

Plasma Metabolites Link Dietary Patterns to Stroke Risk

OBJECTIVE

While dietary intake is linked to stroke risk, surrogate markers that could inform personalized dietary interventions are lacking. We identified metabolites associated with diet patterns and incident stroke in a nested cohort from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

METHODS

Levels of 162 metabolites were measured in baseline plasma from stroke cases (n = 1,198) and random controls (n = 904). We examined associations between metabolites and a plant-based diet pattern previously linked to reduced stroke risk in REGARDS. Secondary analyses included 3 additional stroke-associated diet patterns: a Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and Southern diet. Metabolites were tested using Cox proportional hazards models with incident stroke as the outcome. Replication was performed in the Jackson Heart Study (JHS). Inverse odds ratio-weighted mediation was used to determine whether metabolites mediated the association between a plant-based diet and stroke risk.

RESULTS

Metabolites associated with a plant-based diet included the gut metabolite indole-3-propionic acid (β = 0.23, 95% confidence interval [CI] [0.14, 0.33], p = 1.14 × 10-6 ), guanosine (β = -0.13, 95% CI [-0.19, -0.07], p = 6.48 × 10-5 ), gluconic acid (β = -0.11, 95% CI [-0.18, -0.04], p = 2.06 × 10-3 ), and C7 carnitine (β = -0.16, 95% CI [-0.24, -0.09], p = 4.14 × 10-5 ). All of these metabolites were associated with both additional diet patterns and altered stroke risk. Mediation analyses identified guanosine (32.6% mediation, p = 1.51 × 10-3 ), gluconic acid (35.7%, p = 2.28 × 10-3 ), and C7 carnitine (26.2%, p = 1.88 × 10-2 ) as mediators linking a plant-based diet to reduced stroke risk.

INTERPRETATION

A subset of diet-related metabolites are associated with risk of stroke. These metabolites could serve as surrogate markers that inform dietary interventions. ANN NEUROL 2023;93:500-510.

The Environmental Sustainability of Plant-Based Dietary Patterns: A Scoping Review

BACKGROUND

A large part of the existential threat associated with climate change is the result of current human feeding patterns. Over the last decade, research evaluating the diet-related environmental impacts of plant-based diets has emerged, and a synthesis of the available data is now due.

OBJECTIVES

The objectives of the study were as follows: 1) to compile and summarize the literature on diet-related environmental impacts of plant-based dietary patterns; 2) to assess the nature of the data on impacts of plant-based dietary patterns on both environmental parameters and health (e.g., if land use is reduced for a particular diet, is cancer risk also reduced?); and 3) to determine where sufficient data exist for meta-analyses, in addition to identifying gaps within the literature.

METHODS

Global peer-reviewed studies on the environmental impacts of plant-based diets were searched in Ovid MEDLINE, EMBASE, and Web of Science. After removing duplicates, the screening identified 1553 records. After 2 stages of independent review by 2 reviewers, 65 records met the inclusion criteria and were eligible to be used in synthesis.

RESULTS

Evidence suggests that plant-based diets may offer lower greenhouse gas emissions (GHGEs), land use, and biodiversity loss than offered by standard diets; however, the impact on water and energy use may depend on the types of plant-based foods consumed. Further, the studies were consistent in demonstrating that plant-based dietary patterns that reduce diet-related mortality also promote environmental sustainability.

CONCLUSIONS

Overall, there was agreement across the studies regarding the impact of plant-based dietary patterns on GHGE, land used, and biodiversity loss despite varied plant-based diets assessed.

2023 Guidelines of the Taiwan Society of Cardiology on the Diagnosis and Management of Chronic Coronary Syndrome

Coronary artery disease (CAD) covers a wide spectrum from persons who are asymptomatic to those presenting with acute coronary syndromes (ACS) and sudden cardiac death. Coronary atherosclerotic disease is a chronic, progressive process that leads to atherosclerotic plaque development and progression within the epicardial coronary arteries. Being a dynamic process, CAD generally presents with a prolonged stable phase, which may then suddenly become unstable and lead to an acute coronary event. Thus, the concept of "stable CAD" may be misleading, as the risk for acute events continues to exist, despite the use of pharmacological therapies and revascularization. Many advances in coronary care have been made, and guidelines from other international societies have been updated. The 2023 guidelines of the Taiwan Society of Cardiology for CAD introduce a new concept that categorizes the disease entity according to its clinical presentation into acute or chronic coronary syndromes (ACS and CCS, respectively). Previously defined as stable CAD, CCS include a heterogeneous population with or without chest pain, with or without prior ACS, and with or without previous coronary revascularization procedures. As cardiologists, we now face the complexity of CAD, which involves not only the epicardial but also the microcirculatory domains of the coronary circulation and the myocardium. New findings about the development and progression of coronary atherosclerosis have changed the clinical landscape. After a nearly 50-year ischemia-centric paradigm of coronary stenosis, growing evidence indicates that coronary atherosclerosis and its features are both diagnostic and therapeutic targets beyond obstructive CAD. Taken together, these factors have shifted the clinicians' focus from the functional evaluation of coronary ischemia to the anatomic burden of disease. Research over the past decades has strengthened the case for prevention and optimal medical therapy as central interventions in patients with CCS. Even though functional capacity has clear prognostic implications, it does not include the evaluation of non-obstructive lesions, plaque burden or additional risk-modifying factors beyond epicardial coronary stenosis-driven ischemia. The recommended first-line diagnostic tests for CCS now include coronary computed tomographic angiography, an increasingly used anatomic imaging modality capable of detecting not only obstructive but also non-obstructive coronary plaques that may be missed with stress testing. This non-invasive anatomical modality improves risk assessment and potentially allows for the appropriate allocation of preventive therapies. Initial invasive strategies cannot improve mortality or the risk of myocardial infarction. Emphasis should be placed on optimizing the control of risk factors through preventive measures, and invasive strategies should be reserved for highly selected patients with refractory symptoms, high ischemic burden, high-risk anatomies, and hemodynamically significant lesions. These guidelines provide current evidence-based diagnosis and treatment recommendations. However, the guidelines are not mandatory, and members of the Task Force fully realize that the treatment of CCS should be individualized to address each patient's circumstances. Ultimately, the decision of healthcare professionals is most important in clinical practice.

Oxidative Stress Underpins Clinical, Social, and Genetic Risk Factors for Atherosclerotic Cardiovascular Disease

Background

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death worldwide and is poorly predicted with current risk estimation tools. The biological mechanisms relating ASCVD risk factors to oxidative stress (OS) and how this accumulates ASCVD risk are misunderstood.

Purpose

To develop a comprehensive conceptual model explaining how expanded clinical, social, and genetic ASCVD risk factors accumulate ASCVD risk through OS.

Conclusions

OS (primarily from excess reactive oxygen species) and inflammation are present along the entire ASCVD pathophysiologic continuum. An expanded list of clinical and social ASCVD risk factors (including hypertension, obesity, diabetes, kidney disease, inflammatory diseases, substance use, poor nutrition, psychosocial stress, air pollution, race, and genetic ancestry) influence ASCVD largely through increased OS. Many risk factors exert a positive feedback mechanism to increase OS. One genetic risk factor, haptoglobin (Hp) genotype, is associated with higher ASCVD risk in diabetes and hypothesized to do the same in those with insulin resistance due to the Hp 2-2 genotype increasing OS.

Implications

Understanding the biological mechanisms of OS informs how these ASCVD risk factors relate to each other and compound ASCVD risk. Individualized ASCVD risk estimation should include a comprehensive, holistic perspective of risk factors to better address the clinical, social, and genetic influences of OS. Preventing and reducing OS is key to preventing ASCVD development or progression.

Differences in the Association of Select Dietary Measures With Risk of Incident Type 2 Diabetes

OBJECTIVE

To evaluate associations between a broad range of approaches to classifying diet and incident type 2 diabetes in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

RESEARCH DESIGN AND METHODS

This study included 8,750 Black and White adults without diabetes at baseline. Diabetes was defined according to fasting glucose ≥70 mmol/L, random glucose ≥111 mmol/L, or use of diabetes medications. The exposures were diet scores for Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets and Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND), dietary inflammatory index (DII), dietary inflammation score (DIS), and empirical dietary patterns (plant-based and Southern) determined using data collected with use of the Block98 food-frequency questionnaire. Modified Poisson regression was used to assess association of dietary measures with risk of incident type 2 diabetes, with models adjusted for total energy intake, demographics, lifestyle factors, and waist circumference.

RESULTS

There were 1,026 cases of incident type 2 diabetes during follow-up (11.7%). Adherence to the Southern dietary pattern was most strongly associated with risk of incident type 2 diabetes after adjustment for demographics and lifestyle (quintile [Q]5 vs. lowest Q1: risk ratio [RR] 1.95; 95% CI 1.57, 2.41). Of the diet scores, DIS (Q5 vs. Q1 RR 1.41) and MIND (Q1 vs. Q5 RR 1.33), demonstrated anti-inflammatory diets, had strongest associations with lower diabetes incidence.

CONCLUSIONS

We found associations of several dietary approaches with incident type 2 diabetes. Investigation into mechanisms driving the association with the Southern dietary pattern is warranted. Further research into use of DIS, DII, and MIND diet score should be considered for dietary recommendations for diabetes prevention.

The Conundrum of Obesity and Gastroparesis Hospitalizations: A Retrospective Comparative Analysis of Hospitalization Characteristics and Disparities Amongst Socioeconomic and Racial Backgrounds in the United States

Background/Aims

We aim to assess the influence of obesity on gastroparesis (GP) hospitalizations in the United States (US).

Methods

The National Inpatient Sample was analyzed from 2007-2017 to identify all adult hospitalizations with a primary discharge diagnosis of GP. They were subdivided based on the presence or absence of obesity (body mass index > 30). Hospitalization characteristics, procedural differences, all-cause inpatient mortality, mean length of stay (LOS), and mean total hospital charge (THC) were identified and compared.

Results

From 2007-2017, there were 140 293 obese GP hospitalizations accounting for 13.75% of all GP hospitalizations in the US. Obese GP hospitalizations were predominantly female (76.11% vs 64.36%, P < 0.001) and slightly older (51.9 years vs 50.8 years, P < 0.001) compared to the non-obese cohort. Racial disparities were noted as Blacks (25.49% vs 22%, P < 0.001) had higher proportions of GP hospitalizations with obesity compared to the non-obese cohort. Furthermore, we noted higher rates of inpatient upper endoscopy utilization (6.05% vs 5.42%, P < 0.001), longer mean LOS (5.71 days vs 5.32 days, P < 0.001), and higher mean THC ($53 373 vs $45 040, P < 0.001) for obese GP hospitalizations compared to the non-obese group. However, obese GP hospitalizations had lower rates of inpatient mortality (0.92% vs 1.33%, P < 0.001), and need for nutritional support with endoscopic jejunostomy (0.25 vs 0.56%, P < 0.001) and total parenteral nutrition (1.46% vs 2.33%, P < 0.001) compared to the non-obese cohort.

Conclusions

In the US, compared to non-obese, a higher proportion of obese GP hospitalizations were female and Blacks. Obese GP hospitalizations also had higher THC, LOS, and rates of upper endoscopy.

The association between electronic cigarettes, sleep duration, and the adverse cardiovascular outcomes: Findings from behavioral risk factor surveillance system, 2020

The joint effect of electronic cigarette smoking and insufficient sleep duration on cardiovascular disease (CVD) was unclear. This cross-sectional study aimed to evaluate the association between electronic cigarettes, sleep duration, and risk of CVD among American adults. The participants who completed the survey from the behavioral risk factor surveillance system in 2020 were included in this study. The status of electronic cigarette smoking was divided into never, former, and current use. The duration of sleep was categorized into insufficient (<6 h), appropriate (6–9 h), and excessive (>9 h) groups. The CVD group was defined as a patient having any of the following conditions: heart attack, coronary heart disease, or stroke according to self-report. The multivariate logistic regression model was adopted to determine the association between electronic cigarettes, sleep duration, and the risk of CVD. Sensitivity analyses were performed to assess the joint effects on the risk of CVD subtypes, including heart attack, coronary heart disease, and strokes, respectively. Subgroup analyses were performed to estimate the joint effects within the stratum of the age group. The total number of participants included in the present study was 253,561. Of which, 22,908 patients had CVD. In total, 61,293 participants had previously or currently used electronic cigarettes and 37,429 participants had inappropriate sleep duration. Former electronic cigarette users had a 10.8% increased risk of having CVD (OR = 1.108, 95% CI: 1.001–1.227) compared to users who never had electronic cigarettes. Insufficient and excessive sleep durations are associated with increased risks of CVD (OR = 1.592, 95% CI: 1.460–1.735; OR = 1.523, 95% CI: 1.320–1.758). The participants with current vaping status and lack of sleep had a 159.6% increased risk of CVD (OR = 2.596, 95% CI: 1.810–3.723). Sensitivity analyses found similar joint effects of current vaping and insufficient sleep on the risk of heart attack, coronary heart attack, and stroke. The subgroup analyses across each age stratum found that the middle-aged group is most vulnerable to the joint effect of current vaping and insufficient sleep. This study found that both current vaping and inappropriate sleep duration were associated with CVD. Additionally, there was a significant joint effect of current vaping and insufficient sleep on the risk of CVD, especially for middle-aged participants.

Red meat consumption, incident CVD and the influence of dietary quality in the Jackson Heart Study

OBJECTIVES

We investigated the prospective associations between meat consumption and CVD and whether these relationships differ by dietary quality among African American (AA) adults.

DESIGN

Baseline diet was assessed with a regionally specific FFQ. Unprocessed red meat included beef and pork (120 g/serving); processed meat included sausage, luncheon meats and cured meat products (50 g/serving). Incident total CVD, CHD, stroke and heart failure were assessed annually over 9·8 years of follow-up. We characterised dietary quality using a modified Healthy Eating Index-2010 score (m-HEI), excluding meat contributions.

SETTING

Jackson, MS, USA.

PARTICIPANTS

AA adults (n 3242, aged 55 y, 66 % female).

RESULTS

Mean total, unprocessed red and processed meat intakes were 5·7 ± 3·5, 2·3 ± 1·8 and 3·3 ± 2·7 servings/week, respectively. Mostly, null associations were observed between meat categories and CVD or subtypes. However, greater intake of unprocessed red meat (three servings/week) was associated with significantly elevated risk of stroke (hazard ratio = 1·43 (CI: 1·07,1·90)). With the exception of a more positive association between unprocessed meat consumption and stroke among individuals in m-HEI Tertile 2, the strength of associations between meat consumption categories and CVD outcomes did not differ by m-HEI tertile. In formal tests, m-HEI did not significantly modify meat-CVD associations.

CONCLUSIONS

In this cohort of AA adults, total and processed meat were not associated with CVD outcomes, with the exception that unprocessed red meat was related to greater stroke risk. Dietary quality did not modfiy these associations. Research is needed in similar cohorts with longer follow-up and greater meat consumption to replicate these findings.

The Impact of a Plant-Based Diet on Indices of Cardiovascular Health in African Americans: A Cross-Sectional Study

African American (AA) individuals are disproportionately affected by cardiovascular diseases. Plant-based diets (PBD) may be cardioprotective in part through their high antioxidant capacity and low inflammatory load. We tested the hypothesis that AA individuals adhering to a 100% PBD would have better vascular health than AA individuals following a typical American diet (TAD). Eighteen AA individuals participated; 9 (24±4 years; 6 females) were following a PBD for 2.4±0.8 years and 9 (21±2 years; 5 females) were following a TAD. Blood lipids and C-reactive protein (CRP) were assessed. Peripheral and central blood pressure (BP) were measured, and vascular function tests included cerebrovascular reactivity to hypercapnia, brachial artery flow-mediated dilation & reactive hyperemia, and local heating-induced cutaneous hyperemia. Total (TC) and low-density lipoprotein (LDL-C) serum cholesterol were lower (TC: 142±30 vs. 174±36 mg/dl; LDL-C: 76±17 vs. 106±33 mg/dl; p<0.05 and d>0.80 for both) and serum CRP tended to be lower (0.38±0.18 mg/l vs. 0.96±0.89 mg/l; p=0.05, d=0.91) in the PBD cohort. Brachial (b) and central (c) mean arterial BP (MAP) were lower in the PBD cohort (bMAP: 86±5 vs. 91±7 mmHg; cMAP: 81±5 vs. 87±7 mmHg; p<0.05 and d>0.80 for both). All indices of vascular function were similar between groups (p>0.05 for all). A PBD was associated with more optimal blood lipid concentrations and decreased peripheral and central BP in AA individuals, but this association was not present in the various indices of vascular function. Registered at ClinicalTrials.gov: NCT05344287.

Leveraging Observational Cohorts to Study Diet and Nutrition in Older Adults: Opportunities and Obstacles

By 2060, the number of adults aged ≥65 y is expected to double, and the ≥85 y segment of the population is expected to triple in the United States. US federal nutrition guidance is based on the premise that healthy diets contribute to delaying the onset and progression of many age-related diseases and disability. Yet, little is known about the dietary intakes or nutritional needs across the older adulthood age span. This review aims to identify community-based cohorts that collected information on dietary intake of adults ≥65 y in the United States. Thirty-two cohorts met all inclusion criteria. We summarized information on the cohorts' design, demographics, and diet assessment. We also identified key gaps in the existing databases that, if filled, could enhance their utility to address certain research questions. This review serves as a valuable inventory of cohorts that can be leveraged to answer key questions about the diet and nutritional needs of the oldest old, who represent the fastest growing segment of the population in the United States.

AJEDI in Science: Leveraging Instructor Communities to Create Antiracist Curricula

Gateway college science courses continue to exclude students from science, disproportionately discriminating against students of color. As the higher education system strives to reduce discrimination, we need a deliberate, iterative process to modify, supplement, or replace current modalities. By incorporating antiracist, just, equitable, diverse, and inclusive (AJEDI) principles throughout course design, instructors create learning environments that provide an antidote to historically oppressive systems. In this paper, we describe how a community of microbiology instructors who all teach Tiny Earth, a course-based undergraduate research experience, created and rapidly integrated antiracist content and pivoted to an online format in response to the social unrest and pandemic of 2020. The effort strengthened an existing teaching community of practice and produced collective change in classrooms across the nation. We provide a perspective on how instructor communities of practice can be leveraged to design and disseminate AJEDI curriculum.

Relationship between diet and relative risk of pain in a cross-sectional analysis of the REGARDS longitudinal study

Aim: Determine if dietary patterns affect risk of pain. Methods: Data from 16,061 participants (55.4% females, 32.3% Black, age 65 ± 9 years) in the REGARDS study were categorized based on the adherence to previous dietary patterns reflecting the prevalent foods within each (convenience, alcohol/salads, plant-based, sweets/fats and 'Southern'). A modified Poisson regression model was used to determine whether dietary patterns were associated with relative risk (RR) of pain. Results: High adherence to 'Southern' dietary pattern was associated with a 41% (95% CI: 23, 61%) increase in RR of pain. High adherence to a plant-based dietary pattern showed a 22% (95% CI: 11, 31%) decrease in the RR of pain. Conclusion: Poor quality dietary patterns increase the RR of pain, while plant-based patterns lowered the RR. Diet patterns should be incorporated into medical history.

Practical, Evidence-Based Approaches to Nutritional Modifications to Reduce Atherosclerotic Cardiovascular Disease: An American Society for Preventive Cardiology Clinical Practice Statement

Despite numerous advances in all areas of cardiovascular care, cardiovascular disease (CVD) is the leading cause of death in the United States (US). There is compelling evidence that interventions to improve diet are effective in cardiovascular disease prevention. This clinical practice statement emphasizes the importance of evidence-based dietary patterns in the prevention of atherosclerotic cardiovascular disease (ASCVD), and ASCVD risk factors, including hyperlipidemia, hypertension, diabetes, and obesity. A diet consisting predominantly of fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish is optimal for the prevention of ASCVD. Consuming more of these foods, while reducing consumption of foods with saturated fat, dietary cholesterol, salt, refined grain, and ultra-processed food intake are the common components of a healthful dietary pattern. Dietary recommendations for special populations including pediatrics, older persons, and nutrition and social determinants of health for ASCVD prevention are discussed.

Primary and Secondary Prevention of CAD: A Review

Coronary artery disease is the leading cause of death in both men and women, yet adequate control of risk factors can largely reduce the incidence and recurrence of cardiac events. In this review, we discuss various life style and pharmacological measures for both the primary and secondary prevention of coronary artery disease. With a clear understanding of management options, health care providers have an excellent opportunity to educate patients and ameliorate a significant burden of morbidity and mortality.

The importance of healthy lifestyle behaviors in the prevention of cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death globally. Advancements in the treatment of CVD have reduced mortality rates, yet the global burden of CVD remains high. Considering that CVD is still largely a preventable disease, prioritizing preventative measures through healthy lifestyle (HL) behaviors is necessary to lessen the burden of CVD. HL behaviors, such as regular exercise, healthy eating habits, adequate sleep, and smoking cessation, can influence a number of traditional CVD risk factors as well as a less commonly measured risk factor, cardiorespiratory fitness (CRF). It is important to note that cardiac rehabilitation programs, which traditionally have focused on secondary prevention, also emphasize the importance of making comprehensive HL behavior changes. This review discusses preventative measures to reduce the burden of CVD through an increased uptake and assessment of HL behaviors. An overview of the importance of CRF as a risk factor is discussed along with how to improve CRF and other risk factors through HL behavior interventions. The role of the clinician for promoting HL behaviors to prevent CVD is also reviewed.

The Association of Plant-Based Diet With Cardiovascular Disease and Mortality: A Meta-Analysis and Systematic Review of Prospect Cohort Studies

Background: The association between plant-based diets and cardiovascular disease (CVD) remains poorly characterized. Given that diet represents an important and a modifiable risk factor, this study aimed to assess (1) the relationships between the impact of adherence to plant-based diets on cardiovascular mortality, incident CVD, and stroke; (2) if associations differed by adherence to healthful and less healthful plant-based diets.

Methods and Findings: MEDLINE and EMBASE databases were searched up to May 2021. Studies assessing CVD outcomes with relation to plant-based dietary patterns or according to plant-based dietary indices (PDI) were included. A meta-analysis of hazard ratios (HR) was conducted using DerSimonian and Laird random effects model. Thirteen studies involving 410,085 participants were included. Greater adherence to an overall plant-based dietary pattern was significantly associated with a lower risk of cardiovascular mortality (pooled HR: 0.92, 95% CI: 0.86–0.99 p = 0.0193, I² = 88.5%, N = 124,501) and a lower risk of CVD incidence (pooled HR: 0.90, 95% CI: 0.82–0.98, p = 0.0173, I² = 87.2%, N = 323,854). Among the studies that used PDI, unhealthful plant-based diets were associated with increased risk of cardiovascular mortality (pooled HR: 1.05, 95% CI: 1.01–1.09, p = 0.0123, I² = 0.00%, N = 18,966), but not CVD incidence. Conversely, healthful plant-based diets were associated with decreased CVD incidence (pooled HR: 0.87, 95% CI: 0.80–0.95, p = 0.0011, I² = 57.5%, N = 71,301), but not mortality. Vegetarians also had significantly lower CVD incidence (HR: 0.81, 95% CI: 0.72–0.91, p = 0.0004, I² = 22.2%, N = 16,254), but similar CVD mortality or stroke risk when compared to the meat-eaters.

Conclusion: To date, this comprehensive study examines the effects of a plant-based diet on major clinical endpoints using more holistic PDIs. These findings highlight the favorable role of healthful plant-based foods in reducing cardiovascular mortality and CVD.

A non-traditional dietary pattern increases risk of coronary artery disease in the Nepalese population

OBJECTIVES

Several dietary patterns are associated with cardiovascular diseases. Traditional, Western, Mediterranean, and vegetarian are common dietary patterns, derived from principal component analysis (PCA) of dietary food intakes associated with cardiovascular diseases; however, these patterns were derived mostly from the diet habits of people in Western and European countries. Therefore, the present study aimed to determine dietary patterns linked with coronary artery disease (CAD) in the Nepalese population.

METHODS

Food frequency questionnaires were used to estimate dietary intakes in 306 people with CAD and 306 people in a control group matched for age and sex. PCA was performed to deduce the dietary patterns, and conditional logistic regression was executed to determine the association of the dietary patterns with CAD.

RESULTS

The component of PCA with higher loadings of refined grain, sugar, and meat and lower loadings of milk, whole grain, and fruit was named the non-traditional dietary pattern in the present study. We found a 34% increased risk of CAD (odds ratio, 1.34; 95% confidence interval, 1.14-1.58; P < 0.001) associated with this dietary pattern after adjusting for smoking, physical activity, and cardiometabolic risk factors. Dietary-pattern scores were further categorized into tertiles, and the third tertile was observed with significanly higher odds of CAD than the first tertile (odds ratio, 2.32; 95% confidence interval, 1.3-4.14; P for trend = 0.004).

CONCLUSIONS

PCA-derived non-traditional dietary patterns can be a risk for developing CAD in Nepalese people. However, further cohort studies or randomized community trials are suggested to confirm our findings.

Association between Plant-Based Dietary Patterns and Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Plant-based diets, characterized by a higher consumption of plant foods and a lower consumption of animal foods, are associated with a favorable cardiovascular disease (CVD) risk, but evidence regarding the association between plant-based diets and CVD (including coronary heart disease (CHD) and stroke) incidence remain inconclusive. A literature search was conducted using the PubMed, EMBASE and Web of Science databases through December 2020 to identify prospective observational studies that examined the associations between plant-based diets and CVD incidence among adults. A systematic review and a meta-analysis using random effects models and dose–response analyses were performed. Ten studies describing nine unique cohorts were identified with a total of 698,707 participants (including 137,968 CVD, 41,162 CHD and 13,370 stroke events). Compared with the lowest adherence, the highest adherence to plant-based diets was associated with a lower risk of CVD (RR 0.84; 95% CI 0.79–0.89) and CHD (RR 0.88; 95% CI 0.81–0.94), but not of stroke (RR 0.87; 95% CI 0.73–1.03). Higher overall plant-based diet index (PDI) and healthful PDI scores were associated with a reduced CVD risk. These results support the claim that diets lower in animal foods and unhealthy plant foods, and higher in healthy plant foods are beneficial for CVD prevention. Protocol was published in PROSPERO (No. CRD42021223188).

What makes a plant-based diet? a review of current concepts and proposal for a standardized plant-based dietary intervention checklist

Within the last decades, plant-based diets have received increasing interest for their potential benefits to human and environmental health. The concept of plant-based diet, however, varies widely in its definition. Current definitions range from the exclusion of all animal products to diets that include meat, fish, and dairy in varying quantities. Therefore, the main objectives of this review were twofold: (a) to investigate how researchers use the term plant-based diet in nutrition intervention studies and (b) what types of food a plant-based diet may include. Searching two databases, we found that the term “plant-based diet” evokes varying ideas to researchers and clinicians. Fifty percent of the retrieved studies that included a plant-based dietary intervention completely proscribed animal products and used the term plant-based diet interchangeably with a vegan diet. In contrast, an ~33% of trials included dairy products and 20% of dietary interventions emphasized a semi-vegetarian dietary pattern. Based on specific examples, we point out how the usage of the umbrella term “plant-based diet” may cause significant ambiguity. We often encountered incomplete descriptions of plant-based dietary interventions, which makes comparison and reproducibility of studies difficult. As a consequence, we urge others to use the term “plant-based diet” only in conjunction with a detailed dietary description. To facilitate this process, we provide a template of a standardized plant-based intervention reporting checklist. Finally, the present review also highlights the urgent need for a consensus definition of the term plant-based diet and its content.

Epidemiology of Geographic Disparities of Myocardial Infarction Among Older Adults in the United States: Analysis of 2000-2017 Medicare Data

Background: There are substantial geographic disparities in the life expectancy (LE) across the U.S. with myocardial infarction (MI) contributing significantly to the differences between the states with highest (leading) and lowest (lagging) LE. This study aimed to systematically investigate the epidemiology of geographic disparities in MI among older adults.

Methods: Data on MI outcomes among adults aged 65+ were derived from the Center for Disease Control and Prevention-sponsored Wide-Ranging Online Data for Epidemiologic Research database and a 5% sample of Medicare Beneficiaries for 2000–2017. Death certificate-based mortality from MI as underlying/multiple cause of death (CBM-UCD/CBM-MCD), incidence-based mortality (IBM), incidence, prevalence, prevalence at age 65, and 1-, 3-, and 5-year survival, and remaining LE at age 65 were estimated and compared between the leading and lagging states. Cox model was used to investigate the effect of residence in the lagging states on MI incidence and survival.

Results: Between 2000 and 2017, MI mortality was higher in the lagging than in the leading states (per 100,000, CBM-UCD: 236.7–583.7 vs. 128.2–357.6, CBM-MCD: 322.7–707.7 vs. 182.4–437.7, IBM: 1330.5–1518.9 vs. 1003.3–1197.0). Compared to the leading states, lagging states had higher MI incidence (1.1–2.0% vs. 0.9–1.8%), prevalence (10.2–13.1% vs. 8.3–11.9%), pre-existing prevalence (2.5–5.1% vs. 1.4–3.6%), and lower survival (70.4 vs. 77.2% for 1-year, 63.2 vs. 67.2% for 3-year, and 52.1 vs. 58.7% for 5-year), and lower remaining LE at age 65 among MI patients (years, 8.8–10.9 vs. 9.9–12.8). Cox model results showed that the lagging states had greater risk of MI incidence [Adjusted hazards ratio, AHR (95% Confidence Interval, CI): 1.18 (1.16, 1.19)] and death after MI diagnosis [1.22 (1.21, 1.24)]. Study results also showed alarming declines in survival and remaining LE at age 65 among MI patients.

Conclusion: There are substantial geographic disparities in MI outcomes, with lagging states having higher MI mortality, incidence, and prevalence, lower survival and remaining LE at age 65. Disparities in MI mortality in a great extent could be due to between-the-state differences in MI incidence, prevalence at age 65 and survival. Observed declines in survival and remaining LE require an urgent analysis of contributing factors that must be addressed.

Nutrition Intervention for Reduction of Cardiovascular Risk in African Americans Using the 2019 American College of Cardiology/American Heart Association Primary Prevention Guidelines

INTRODUCTION

The 2019 American College of Cardiology/American Heart Association (ACC/AHA) Prevention Guidelines emphasize reduction in dietary sodium, cholesterol, refined carbohydrates, saturated fat and sweetened beverages. We hypothesized that implementing this dietary pattern could reduce cardiovascular risk in a cohort of volunteers in an urban African American (AA) community church, during a 5-week ACC/AHA-styled nutrition intervention, assessed by measuring risk markers and adherence, called HEART-LENS (Helping Everyone Assess Risk Today Lenten Nutrition Study).

METHODS

The study population consisted of 53 volunteers who committed to eat only home-delivered non-dairy vegetarian meals (average daily calories 1155, sodium 1285 mg, cholesterol 0 mg; 58% carbohydrate, 17% protein, 25% fat). Body mass index (BMI) and fasting serum markers of cardiometabolic and risk factors were measured, with collection of any dietary deviation.

RESULTS

Of 53 volunteers, 44 (mean age 60.2 years, 37 women) completed the trial (88%); 1 was intolerant of the meals, 1 completed both blood draws but did not eat delivered food, and 7 did not return for the tests. Adherence to the diet was reported at 93% in the remaining 44. Cardiometabolic risk factors improved significantly, highlighted by a marked reduction in serum insulin (-43%, p = 0.000), hemoglobin A1c (6.2% to 6.0%, p = 0.000), weight and BMI (-10.2 lbs, 33 to 31 kg/m², p = 0.000), but with small reductions of fasting glucose (-6%, p = 0.405) and triglyceride levels (-4%, p = 0.408). Additionally, improved were trimethylamine-N-oxide (5.1 to 2.9 µmol/L, -43%, p = 0.001), small dense low-density lipoprotein cholesterol (LDL) (24.2 to 19.1 mg/dL, -21%, p = 0.000), LDL (121 to 104 mg/dL, -14%, p = 0.000), total cholesterol (TC) (190 to 168 mg/dL, -12%, p = 0.000), and lipoprotein (a) (LP(a)) (56 to 51 mg/dL, -11%, p = 0.000); high sensitivity C-reactive protein (hs-CRP) was widely variable but reduced by 16% (2.5 to 2.1 ng/mL, p = NS) in 40 subjects without inflammatory conditions. Soluble urokinase plasminogen activator (suPAR) levels were not significantly changed. The ACC/AHA pooled cohort atherosclerotic cardiovascular disease (ASCVD) risk scores were calculated for 41 and 36 volunteers, respectively, as the ASCVD risk could not be calculated for 3 subjects with low lipid fractions at baseline and 8 subjects after intervention (p = 0.184). In the remaining subjects, the mean 10-year risk was reduced from 10.8 to 8.7%, a 19.4% decrease (p = 0.006), primarily due to a 14% decrease in low-density lipoprotein cholesterol and a 10 mm Hg (6%) reduction in systolic blood pressure.

CONCLUSIONS

In this prospective 5-week non-dairy vegetarian nutrition intervention with good adherence consistent with the 2019 ACC/AHA Guidelines in an at-risk AA population, markers of cardiovascular risk, cardiometabolism, and body weight were significantly reduced, including obesity, low-density lipoprotein cholesterol (LDLc) density, LP(a), inflammation, and ingestion of substrates mediating production of trimethylamine-N-oxide (TMAO). Albeit reduced, hs-CRP and suPAR, were not lowered consistently. This induced a significant decrease in the 10-year ASCVD risk in this AA cohort. If widely adopted, this could dramatically reduce and possibly eradicate, the racial disparity in ASCVD events and mortality, if 19% of the 21% increase is eliminated by this lifestyle change.

Dietary patterns related to total mortality and cancer mortality in the United States

Purpose

This study investigated the association between dietary patterns, total mortality, and cancer mortality in the United States.

Methods

We identified the four major dietary patterns at baseline from 13,466 participants of the NHANES III cohort using principal component analysis (PCA). Dietary patterns were categorized into ‘prudent’ (fruits and vegetables), ‘western’ (red meat, sweets, pastries, oils), ‘traditional’ (red meat, legumes, potatoes, bread), and ‘fish and alcohol’. We estimated hazard ratios for total mortality, and cancer mortality using Cox regression models.

Results

A total of 4,963 deaths were documented after a mean follow-up of 19.59 years. Higher adherence to the ‘prudent’ pattern was associated with the lowest risk of total mortality (5th vs. 1st quintile HR 0.90, 95% CI 0.82–0.98), with evidence that all-cause mortality decreased as consumption of the pattern increased. No evidence was found that the ‘prudent’ pattern reduced cancer mortality. The ‘western’ and the ‘traditional’ patterns were associated with up to 22% and 16% increased risk for total mortality (5th vs. 1st quintile HR 1.22, 95% CI 1.11–1.34; and 5th vs. 1st quintile HR 1.16, 95% CI 1.06–1.27, respectively), and up to 33% and 15% increased risk for cancer mortality (5th vs. 1st quintile HR 1.33, 95% CI 1.10–1.62; and 5th vs. 1st quintile HR 1.15, 95% CI 1.06–1.24, respectively). The associations between adherence to the ‘fish and alcohol’ pattern and total mortality, and cancer mortality were not statistically significant.

Conclusion

Higher adherence to the ‘prudent’ diet decreased the risk of all-cause mortality but did not affect cancer mortality. Greater adherence to the ‘western’ and ‘traditional’ diet increased the risk of total mortality and mortality due to cancer.

Effect of age, BMI, and gender on urinary risk factors in pediatric idiopathic stone formers

INTRODUCTION

The incidence of pediatric urolithiasis has been increasing over the years; however, the etiology of this increase is not well understood. Age, body mass index, and gender have been examined as possible risk factors for stone disease, but with inconsistent and variable associations.

OBJECTIVE

We aim to investigate the urine chemistry factors, as assessed by 24-h urinary parameters, in pediatric stone formers at a large volume tertiary referral center in the highest areas in the United States, the Southeast, based on age, body mass index, and gender.

STUDY DESIGN

We retrospectively reviewed all pediatric stone formers who completed a 24-h study between 2005 and 2016. Patients were stratified by age (3-10 versus 11-18 years of age), overweight status (above versus below the 85th percentile for body mass index), and gender (male versus female) (Summary Figure). Statistical analysis included analysis of variance and logistic regression.

RESULTS

243 patients were included in our analysis. Patients in the first decade of life were found to have greater numbers of urinary risk factors than those in the second decade. Non-overweight patients were more likely to have hyperoxaluria and hyperuricosuria, while overweight patients were more likely to have hypocitraturia. Female patients were more likely to have higher hyperoxaluria, while male patients were more likely to have hypercalciuria.

DISCUSSION

In contrast to prior publications, obesity is not linked to increased risk of urolithiasis with non-overweight individuals having a greater number of risk factors than the overweight cohort. Despite stone disease being more prevalent in adolescents, the greatest number of risk factors were present in the first decade of life. Lastly, female children had more urinary risk factors than males. Further understanding of the underlying causes of stone disease in various pediatric populations is warranted.

CONCLUSION

While more urinary risk factors were identified in younger, non-overweight, and female patients, there remains no consensus on the urinary risk factors for pediatric urolithiasis. Further study is needed to elucidate the risk factors and pathophysiology of pediatric stone disease.

Mediterranean Diet Score, Dietary Patterns, and Risk of Sudden Cardiac Death in the REGARDS Study

Background

Sudden cardiac death (SCD) is a common cause of death in the United States. Few previous studies have investigated the associations of diet scores and dietary patterns with risk of SCD. We investigated the associations of the Mediterranean diet score and various dietary patterns with risk of SCD in participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study cohort.

Methods and Results

Diet was assessed with a food frequency questionnaire administered at baseline in REGARDS. The Mediterranean diet score was derived based on the consumption of specific food groups considered beneficial or detrimental components of that diet. Dietary patterns were derived previously using factor analysis, and adherence to each pattern was scored. SCD events were ascertained through regular contacts. Cox proportional hazards regression was used to examine the risk of SCD events associated with the Mediterranean diet score and adherence to each of the 5 dietary patterns overall and stratifying on history of coronary heart disease at baseline. The analytic sample included 21 069 participants with a mean 9.8±3.8 years of follow‐up. The Mediterranean diet score showed a trend toward an inverse association with risk of SCD after multivariable adjustment (hazard ratio [HR] comparing highest with lowest group, 0.74; 95% CI, 0.55–1.01; P_trend=0.07). There was a trend toward a positive association of the Southern dietary pattern with risk of SCD (HR comparing highest with lowest quartile of adherence, 1.46; 95% CI, 1.02–2.10; P_trend=0.06).

Conclusions

In REGARDS participants, we identified trends toward an inverse association of the Mediterranean diet score and a positive association of adherence to the Southern dietary pattern with risk of SCD.

Chinese Guideline on the Primary Prevention of Cardiovascular Diseases

Abstract

Cardiovascular disease is the leading cause of mortality in China. Primary prevention of cardiovascular disease with a focus on lifestyle intervention and risk factor control has been shown to effectively delay or prevent the occurrence of cardiovascular events. To promote a healthy lifestyle and enhance the detection, diagnosis, and treatment of cardiovascular risk factors such as hypertension, dyslipidemia, and diabetes, and to improve the overall capacity of primary prevention of cardiovascular disease, the Chinese Society of Cardiology of Chinese Medical Association has collaborated with multiple societies to summarize and evaluate the latest evidence with reference to relevant guidelines and subsequently to develop recommendations for primary cardiovascular disease prevention in Chinese adults. The guideline consists of 10 sections: introduction, methodology for developing the guideline, epidemiology of cardiovascular disease in China and challenges in primary prevention, general recommendations for primary prevention, assessment of cardiovascular risk, lifestyle intervention, blood pressure control, lipid management, management of type 2 diabetes, and use of aspirin. The promulgation and implementation of this guideline will play a key role in promoting the practice of primary prevention for cardiovascular disease in China.

National trends in cholecystectomies in the US: a 15-year comparison of two surgical approaches

BACKGROUND

The two approaches for performing cholecystectomy are open and laparoscopic ones. This study aims to characterize national trends of cholecystectomies in the United States (US) and determine differences by approach, age group, primary payer, teaching status and location of healthcare center.

METHODS

Retrospective analysis of patients undergoing cholecystectomy was done using the US National Inpatient Sample from 1997 to 2011. Trends in open and laparoscopic cholecystectomy were analyzed, as well as comparison between age groups, primary payer, location and teaching status of hospitals operations were performed at.

RESULTS

Around 6 million cholecystectomies performed from 1997 to 2011. The laparoscopic approach was significantly more common than the open (p-value <0.001). A significant decrease in open cholecystectomies is seen since 1997. Age group of 65-84 had significantly the most cases in the open approach (p-value <0.001), while in laparoscopic the 18-44 age group had the significantly highest amount (p-value <0.001). Medicare covered the most cases for open, while private insurance covered the most in the laparoscopic approach. Most cases were performed in urban, private non-profit, non-teaching hospitals in both groups. In the laparoscopic group the South had a significantly higher (p-value <0.001) number of cases compared to all other U.S. regions.

CONCLUSIONS

Cholecystectomies remained constant from 1997 to 2011. The number of open cholecystectomies decreased over time in favor of laparoscopic ones. More funding should be given to private non-teaching hospitals as they perform the majority of cholecystectomies nationwide. Better management of cholecystectomy risk factors is needed in the South.

Associations of dietary patterns and nutrients with coronary artery calcification and pericardial adiposity in a longitudinal study of adults with and without type 1 diabetes

PURPOSE

To examine the associations of dietary patterns and nutrients with coronary artery calcification (CAC) and pericardial adiposity (PAT) in adults with and without type 1 diabetes.

METHODS

We conducted a six-year longitudinal analysis of data from Coronary Artery Calcification in Type 1 Diabetes study [n = 1255; T1D: n = 563; non-DM: n = 692] collected at baseline, year 3 and year 6. Participants completed a validated food frequency questionnaire, a physical examination, and fasting (12 h overnight fast) biochemical analyses. CAC and PAT were measured using electron beam computed tomography. Dietary patterns were identified using factor analysis. Generalized estimating equations were used to examine associations of dietary patterns and nutrients with CAC and PAT in models adjusted for traditional cardiovascular risks.

RESULTS

The 'starchy veggies, meats and alcohol pattern' was associated with significantly increased risk of CAC presence in all adjusted models; an increasing trend was observed with CAC progression. Increasing intake of dietary proteins and total fats were also associated with higher risk of the presence and/or progression of CAC in adjusted models (all p < 0.05). PAT was positively associated with dietary total fats, and inversely associated with dietary intakes of saturated fats, omega-3 fats and fiber in models adjusted for age, sex, total calories, time, diabetes status, systolic blood pressure, serum lipids and physical activity.

CONCLUSION

Diets high in total fats and proteins, and in meats (processed and red) and alcohol may increase risks of CAC, while saturated fats, omega-3-fats and fiber may be protective against pericardial adiposity as a risk factor for coronary artery disease. ClinicalTrials.gov Identifier: NCT00005754.

The Impact of a Plant-Based Diet on Gestational Diabetes: A Review

Gestational diabetes mellitus (GDM) represents a challenging pregnancy complication in which women present a state of glucose intolerance. GDM has been associated with various obstetric complications, such as polyhydramnios, preterm delivery, and increased cesarean delivery rate. Moreover, the fetus could suffer from congenital malformation, macrosomia, neonatal respiratory distress syndrome, and intrauterine death. It has been speculated that inflammatory markers such as tumor necrosis factor-alpha (TNF-α), interleukin (IL) 6, and C-reactive protein (CRP) impact on endothelium dysfunction and insulin resistance and contribute to the pathogenesis of GDM. Nutritional patterns enriched with plant-derived foods, such as a low glycemic or Mediterranean diet, might favorably impact on the incidence of GDM. A high intake of vegetables, fibers, and fruits seems to decrease inflammation by enhancing antioxidant compounds. This aspect contributes to improving insulin efficacy and metabolic control and could provide maternal and neonatal health benefits. Our review aims to deepen the understanding of the impact of a plant-based diet on oxidative stress in GDM.

Metabolomic Markers of Southern Dietary Patterns in the Jackson Heart Study

SCOPE

New biomarkers are needed that are representative of dietary intake.

METHODS AND RESULTS

We assess metabolites associated with Southern dietary patterns in 1401 Jackson Heart Study participants. Three dietary patterns are empirically derived using principal component analysis: meat and fast food, fish and vegetables, and starchy foods. We randomly select two subsets of the study population: two-third sample for discovery (n = 934) and one-third sample for replication (n = 467). Among the 327 metabolites analyzed, 14 are significantly associated with the meat and fast food dietary pattern, four are significantly associated with the fish and vegetables dietary pattern, and none are associated with the starchy foods dietary pattern in the discovery sample. In the replication sample, nine remain associated with the meat and fast food dietary pattern [indole-3-propanoic acid, C24:0 lysophosphatidylcholine (LPC), N-methyl proline, proline betaine, C34:2 phosphatidylethanolamine (PE) plasmalogen, C36:5 PE plasmalogen, C38:5 PE plasmalogen, cotinine, hydroxyproline] and three remain associated with the fish and vegetables dietary pattern [1,7-dimethyluric acid, C22:6 lysophosphatidylethanolamine, docosahexaenoic acid (DHA)].

CONCLUSION

Twelve metabolites are discovered and replicated in association with dietary patterns detected in a Southern U.S. African-American population, which could be useful as biomarkers of Southern dietary patterns.

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.

Correlates of a southern diet pattern in a national cohort study of blacks and whites: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

The Southern dietary pattern, derived within the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort, is characterised by high consumption of added fats, fried food, organ meats, processed meats and sugar-sweetened beverages and is associated with increased risk of several chronic diseases. The aim of the present study was to identify characteristics of individuals with high adherence to this dietary pattern. We analysed data from REGARDS, a national cohort of 30 239 black and white adults ≥45 years of age living in the USA. Dietary data were collected using the Block 98 FFQ. Multivariable linear regression was used to calculate standardised beta coefficients across all covariates for the entire sample and stratified by race and region. We included 16 781 participants with complete dietary data. Among these, 34·6 % were black, 45·6 % male, 55·2 % resided in stroke belt region and the average age was 65 years. Black race was the factor with the largest magnitude of association with the Southern dietary pattern (Δ = 0·76 sd, P < 0·0001). Large differences in Southern dietary pattern adherence were observed between black participants and white participants in the stroke belt and non-belt (stroke belt Δ = 0·75 sd, non-belt Δ = 0·77 sd). There was a high consumption of the Southern dietary pattern in the US black population, regardless of other factors, underlying our previous findings showing the substantial contribution of this dietary pattern to racial disparities in incident hypertension and stroke.