Associations of Diet Quality and All-Cause Mortality Across Levels of Cardiometabolic Health and Disease: A 7.6-Year Prospective Analysis From the Dutch Lifelines Cohort

Associations between dietary macronutrient composition and cardiometabolic health: data from NHANES 1999-2014

PURPOSE

Dietary macronutrients significantly impact cardiometabolic health, yet research often focuses on individual macronutrient relationships. This study aimed to explore the associations between dietary macronutrient composition and cardiometabolic health.

METHODS

This study included 33,681 US adults (49.7 ± 18.3 years; 52.5% female) from the National Health and Nutrition Examination Survey during 1999-2014. Dietary data was derived from 1 to 2 separate 24-hour recalls and cardiometabolic health included lipid profile, glycemic control, blood pressure, and adiposity collected in a mobile examination center. Associations between dietary macronutrient composition and cardiometabolic health were examined using generalized additive models adjusted for age, socio-demographics, lifestyle, and diet quality.

RESULTS

In females, triglycerides (P < 0.01) and HDL cholesterol (P < 0.01) were the least optimal in diets containing lower fat (10%) and higher carbohydrate (75%). In males, HDL cholesterol was positively associated with fat (P < 0.01) and no association with triglycerides was detected. Total-C associations were male specific (P = 0.01) and highest in diets composed of 25% protein, 30% carbohydrate, and 45% fat. In both sexes, systolic blood pressure (P ≤ 0.02) was highest in diets containing lower fat (10%) coupled with moderate protein (25%). Diastolic blood pressure associations were female specific (P < 0.01) with higher values in those consuming the upper range of fat (55%). There were no associations of macronutrient composition with glycemic control or adiposity.

CONCLUSION

This study revealed sex-specific relationships between macronutrient composition and cardiometabolic health. Future research is needed to explore these relationships across age groups.

Adherence to lifelines diet is associated with lower lung cancer risk in 98,459 participants aged 55 years and above: a large prospective cohort study

Background

Lifelines Diet Score (LLDS) was developed based on the 2015 Dutch Dietary Guidelines and current international scientific evidence. As a dietary quality assessment tool, the LLDS aims to evaluate the association between the Lifeline diet and the risk of chronic diseases. However, the evidence linking LLDS to lung cancer risk is currently limited.

Objective

Our objective was to explore whether adherence to the LLDS is associated with reduced incidence and mortality of lung cancer, including its major histological subtypes: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).

Methods

Data for this research were sourced from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Trial. The LLDS for each participant was calculated based on responses to the dietary history questionnaire (DHQ), and subsequently analyzed after being categorized into quintiles. The Cox proportional hazards regression model was utilized to compute the hazard ratios (HRs) and 95% confidence intervals (CIs) for both the incidence and mortality of lung cancer, SCLC and NSCLC. Additionally, stratified analyses were conducted to ascertain possible effect modifiers, and several sensitivity analyses were performed to evaluate the robustness of the findings.

Results

During the mean follow-up periods of 8.8 years for incidence and 15.1 years for mortality, we identified 1,642 new cases and 1,172 related deaths from lung cancer. Participants in the highest quartiles of LLDS compared to those in the lowest exhibited a reduced incidence (HRQ4:Q1 = 0.80, 95% CI = 0.68-0.94, P for trend = 0.003) and mortality (HRQ4:Q1 = 0.81, 95%CI = 0.67-0.98, P for trend = 0.009) of lung cancer. Furthermore, this negative association remained for SCLC incidence (HRQ4:Q1 = 0.55, 95% CI = 0.35-0.87, P for trend = 0.002) and mortality (HRQ4:Q1 = 0.42, 95% CI = 0.25-0.70, P for trend <0.001). The association between LLDS and the incidence and mortality of lung cancer is not influenced by pre-defined potential effect modifiers (all P interaction > 0.05). The sensitivity analyses substantiated the robustness of the results.

Conclusion

In conclusion, our research indicates that among 98,459 U.S. adults aged 55 and older, adherence to the LLDS is linked to a diminished incidence and mortality of lung cancer.

The association between Lifelines Diet Score (LLDS) and Polycystic Ovary Syndrome (PCOS) in Iranian women: a case-control study

BACKGROUND

Although adherence to a healthy dietary pattern is one of the primary recommendations for the prevention of polycystic ovary syndrome (PCOS), there is still no conclusive evidence of which specific dietary pattern is best. The Lifelines diet score (LLDS) is a new, evidence-based scoring system to determine diet quality, and its association with PCOS has not been investigated. The present study aimed to assess the association between LLDS and PCOS in Iranian women.

MATERIALS AND METHODS

This frequency-matched case-control study was carried out on 108 women with PCOS and 108 women without PCOS as a control group in Yazd, Iran. Healthy controls were matched to PCOS women based on age and BMI. The validated 178-item food frequency questionnaire was used to assess the usual dietary intake. Logistic regression was used to estimate the association between LLDS and PCOS.

RESULTS

The findings of the present study showed women in the highest tertile of LLDS compared with the participants in the lowest tertile had 90% lower odds of PCOS (Odds Ratio (OR): 0.10; 95% Confidence Interval (CI): 0.04 to 0.21, p for trend: <0.001). This association remained significant after adjustment for energy intake, marital status, pregnancy history, WC, chronic disease history, physical activity, and BMI (Odds Ratio (OR): 0.11; 95% (CI):0.05 to 0.27, p for trend: <0.001).

CONCLUSION

Although the present study found a significant protective association between adherence to LLDS and PCOS, more mechanism-based studies are needed to confirm these findings in the future.

Diet Quality at 3 Years of Age Relates to Lower Body Mass Index but Not Lower Blood Pressure at 10 Years of Age

A healthy diet prevents overweight problems and hypertension. We investigated the associations of a healthy diet with the body mass index (BMI) and blood pressure (BP) in early childhood. In the GECKO birth cohort, height, weight, and BP were measured at 5 and 10 years of age. Diet was evaluated at 3 years using three diet scores: the Dietary Approaches to Stop Hypertension (DASH), the Mediterranean Diet Score (MDS), and the Lifelines Diet Score (LLDS). Linear and logistic regression models assessed the associations of diet scores with the BMI and BP. Of the 1077 children included, 10.8% were overweight or obese at 5 years. That number was 16.5% at 10 years. In addition, 34.5% had elevated BP at 5 years. That number was 23.9% at 10 years. Higher DASH, MDS, and LLDS, which indicate healthier diets, were all associated with lower BMI z-scores at 10 years of age. Higher DASH is related to lower overweight risk at 10 years. None of the diet scores were associated with BP or elevated BP at either 5 or 10 years. Also, in an overweight subset, diet was not related to BP. A healthy diet in early childhood is related to children being less overweight but not having lower BP at 10 years of age.

Optimizing clinical nutrition research: the role of adaptive and pragmatic trials

Evidence-based nutritional recommendations address the health impact of suboptimal nutritional status. Efficacy randomized controlled trials (RCTs) have traditionally been the preferred method for determining the effects of nutritional interventions on health outcomes. Nevertheless, obtaining a holistic understanding of intervention efficacy and effectiveness in real-world settings is stymied by inherent constraints of efficacy RCTs. These limitations are further compounded by the complexity of nutritional interventions and the intricacies of the clinical context. Herein, we explore the advantages and limitations of alternative study designs (e.g., adaptive and pragmatic trials), which can be incorporated into RCTs to optimize the efficacy or effectiveness of interventions in clinical nutrition research. Efficacy RCTs often lack external validity due to their fixed design and restrictive eligibility criteria, leading to efficacy-effectiveness and evidence-practice gaps. Adaptive trials improve the evaluation of nutritional intervention efficacy through planned study modifications, such as recalculating sample sizes or discontinuing a study arm. Pragmatic trials are embedded within clinical practice or conducted in settings that resemble standard of care, enabling a more comprehensive assessment of intervention effectiveness. Pragmatic trials often rely on patient-oriented primary outcomes, acquire outcome data from electronic health records, and employ broader eligibility criteria. Consequently, adaptive and pragmatic trials facilitate the prompt implementation of evidence-based nutritional recommendations into clinical practice. Recognizing the limitations of efficacy RCTs and the potential advantages of alternative trial designs is essential for bridging efficacy-effectiveness and evidence-practice gaps. Ultimately, this awareness will lead to a greater number of patients benefiting from evidence-based nutritional recommendations.

Healthy eating index and bone health markers in adults with metabolically healthy and unhealthy obese phenotypes

Background

The Healthy Eating Index (HEI) estimates the diet quality, and low HEI scores are associated with adverse bone outcomes. However, the relationship between HEI scores and bone health in individuals who are obese but otherwise healthy or obese with comorbidities remains unclear.

Objective

We aimed to evaluate the association of HEI scores with bone mineral density (BMD), bone regulating hormones and bone turnover markers in individuals with metabolically healthy obese (MHO) and metabolically unhealthy obese (MUO) phenotypes.

Methods

This was a cross-sectional analysis of 122 adults who were overweight or obese. A questionnaire was completed to obtain demographic data. Body composition and BMD were assessed by a Dual Energy X-Ray Absorptiometry (DXA) exam. The HEI scores and dietary components were calculated using a 24-h dietary recall. Blood samples were collected for the analysis of serum 25-hydroxyvitamin D (s25OHD), total osteocalcin (OC), parathyroid hormone (PTH), and C-terminal telopeptide (CTx) concentrations. The MHO and MUO phenotypes were classified according to the absence or presence of metabolic abnormalities.

Results

The sample mean age was 37.91 ± 12.66 years, 50.8% were men, mean body mass index (BMI) was 30.01 ± 4.63 kg/m2, and 45.9% were classified as the MUO phenotype. The mean HEI scores were 54.42 ± 16.25 and 61.48% had low-diet quality. HEI scores were positively associated with s25OHD in the MUO phenotype group (β = 0.194, 95%CI = 0.038-0.350, p = 0.016). Certain dietary score components, such as fruits, seafood and plant protein, added sugars, whole grains, and fatty acids were also associated with bone health markers. However, HEI scores were not associated with BMD measures, neither with other bone regulating hormones and turnover markers.

Conclusion

There was a positive association between HEI scores and s25OHD in adults who were overweight or obese with MUO phenotype. Additionally, the adequate consumption of specific food groups may benefit bone mass and metabolism. These results emphasize the importance of lifestyle interventions encouraging healthy eating habits to prevent s25OHD deficiency, poor bone health, and cardiometabolic complications.

Dietary Factors and All-Cause Mortality in Individuals With Type 2 Diabetes: A Systematic Review and Meta-analysis of Prospective Observational Studies

BACKGROUND

Type 2 diabetes is a major health concern associated with mortality. Diet may influence the progression of diabetes; however, systematic reviews are lacking.

PURPOSE

This study systematically summarized the evidence on diet and all-cause mortality in individuals with type 2 diabetes.

DATA SOURCES

PubMed and Web of Science were searched until June 2022.

STUDY SELECTION

Prospective observational studies investigating dietary factors in association with all-cause mortality in individuals with type 2 diabetes were selected.

DATA SYNTHESIS

We identified 107 studies. Moderate certainty of evidence was found for inverse associations of higher intakes of fish (summary risk ratios per serving/week: 0.95; 95% CI 0.92, 0.99; n = 6 studies), whole grain (per 20 g/day: 0.84; 95% CI 0.71, 0.99; n = 2), fiber (per 5 g/day: 0.86; 95% CI 0.81, 0.91; n = 3), and n-3 polyunsaturated fatty acids (per 0.1 g/day: 0.87; 95% CI 0.82, 0.92; n = 2) and mortality. There was low certainty of evidence for inverse associations of vegetable consumption (per 100 g/day: 0.88; 95% CI 0.82, 0.94; n = 2), plant protein (per 10 g/day: 0.91; 95% CI 0.87, 0.96; n = 3), and for positive associations of egg consumption (per 10 g/day: 1.05; 95% CI 1.03, 1.08; n = 7) and cholesterol intake (per 300 mg/day: 1.19; 95% CI 1.13, 1.26; n = 2). For other dietary factors, evidence was uncertain or no association was observed.

CONCLUSIONS

Higher intake of fish, whole grain, fiber, and n-3 polyunsaturated fatty acids were inversely associated with all-cause mortality in individuals with type 2 diabetes. There is limited evidence for other dietary factors, and, thus, more research is needed.

Adherence to lifelines diet score and risk factors of metabolic syndrome among overweight and obese adults: A cross-sectional study

Background

Metabolic syndrome (MetS) is one of the most significant public health issues worldwide, and diet quality is an important controllable environmental factor influencing the incidence of MetS. Numerous dietary scores have been established to assess compliance with dietary recommendations or eating patterns, many of which are not entirely food-based. Hence, Lifelines Diet Score (LLDS) was developed in response to the shortcomings of existing tools. This study aimed to assess any possible links between total food quality and cardiometabolic risk factors among overweight and obese adults.

Methods

This cross-sectional study included 338 overweight and obese individuals [body mass index (BMI) > 25 kg/m2] aged 20-50 years in Tabriz, Iran. To collect dietary data, we used a validated semi-quantitative Food Frequency Questionnaire (FFQ) for Iranian population. Enzymatic-colorimetric methods were used to assess serum glucose and lipids, and enzyme-linked immunosorbent assay (ELISA) kits were used to measure insulin levels. In addition, the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and Quantitative Insulin Sensitivity Check Index (QUICKI) were calculated.

Results

BMI and hip circumference (HC) were significantly different (P < 0.05) amongst LLDS tertiles. Adherence to the highest tertile of LLDS was associated with lower SBP, and the subjects in higher LLDS tertiles significantly had lower systolic blood pressure (SBP) (P = 0.04). Triglyceride (TG) levels were also lower in the third tertile of LLDS with a near-significant P-value (P = 0.05).

Conclusion

According to our results, a higher diet quality score, determined by LLDS, can be associated with a lower risk of MetS. Further experimental and longitudinal studies are needed to better understand this relationship.

Associations of Dietary Fats with All-Cause Mortality and Cardiovascular Disease Mortality among Patients with Cardiometabolic Disease

Previous studies have shown distinct associations between specific dietary fats and mortality. However, evidence on specific dietary fats and mortality among patients with cardiometabolic disease (CMD) remains unclear. The aim of this study was to estimate the association between consumption of specific fatty acids and survival of patients with CMD and examine whether cardiometabolic biomarkers can mediate the above effects. The study included 8537 participants with CMD, from the Third National Health and Nutrition Examination Survey (NHANES III) and NHANES 1999–2014. Cox proportional hazards regression, restricted cubic spline regression, and isocaloric substitution models were used to estimate the associations of dietary fats with all-cause mortality and cardiovascular disease (CVD) mortality among participants with CMD. Mediation analysis was performed to assess the potential mediating roles of cardiometabolic biomarkers. During a median follow-up of 10.3 years (0–27.1 years), 3506 all-cause deaths and 882 CVD deaths occurred. The hazard ratios (HRs) of all-cause mortality among patients with CMD were 0.85 (95% confidence interval (CI), 95% CI, 0.73–0.99; p trend = 0.03) for ω-6 polyunsaturated fatty acids (ω-6 PUFA), 0.86 (95% CI, 0.75–1.00; p trend = 0.05) for linoleic acid (LA), and 0.86 (95% CI, 0.75–0.98; p trend = 0.03) for docosapentaenoic acid (DPA). Isocalorically replacing energy from SFA with PUFA and LA were associated with 8% and 4% lower all-cause mortality respectively. The HRs of CVD mortality among CMD patients comparing extreme tertiles of specific dietary fats were 0.60 (95% CI, 0.48–0.75; p trend = 0.002) for eicosapentaenoic acid (EPA), and 0.64 (95% CI, 0.48–0.85; p trend = 0.002) for DPA and above effects were mediated by levels of total cholesterol (TC), triglycerides (TG), low density lipoprotein cholesterol (LDL), and high density lipoprotein cholesterol (HDL). Restricted cubic splines showed significant negative nonlinear associations between above specific dietary fats and mortality. These results suggest that intakes of ω-6 PUFA, LA, and DPA or replacing SFA with PUFA or LA might be associated with lower all-cause mortality for patients with CMD. Consumption of EPA and DPA could potentially reduce cardiovascular death for patients with CMD, and their effects might be regulated by cardiometabolic biomarkers indirectly. More precise and representative studies are further needed to validate our findings.

Diet quality indices are associated with sleep and mental health status among diabetic women: a cross-sectional study

OBJECTIVE

Diabetes is a common chronic disease with many complications. Controlling these complexities may enhance the quality of life. This study was conducted to investigate the association between diet quality indices and sleep, stress, anxiety, and depression among diabetic women.

DESIGN

Cross-sectional study.

SETTING

A validated and reliable food frequency questionnaire was filled to assess the dietary intake and adherence to the diet quality indices. Pittsburgh Sleep Quality Index and 21 items Depression, Anxiety, and Stress Scale were used to assess the sleep and mental disorders, respectively.

PARTICIPANTS

This study was conducted on 230 Tehrani women with type 2 diabetes.

RESULTS

Patients who were in the top tertile of diet quality index consumed less fat, saturated mono-and poly-unsaturated fatty acids, and sodium (P < 0.05). Participants who were in top tertile of diet quality indices consumed more fruits, and vegetables. Patients in the highest tertile of diet quality index-international had less risk of depression (OR: 0.17; 95% CI: 0.07; 0.41), anxiety (OR: 0.36; 95% CI: 0.16; 0.80), stress (OR: 0.09; 95% CI: 0.04; 0.21), and poor sleep (OR: 0.12; 95% CI: 0.04; 0.36). Patients in the highest tertile of healthy eating index-international had less risk of depression (OR: 0.06; 95% CI: 0.02; 0.21), anxiety (OR: 0.10; 95% CI: 0.04; 0.26), stress (OR: 0.11; 95% CI: 0.05; 0.26), and poor sleep (OR: 0.08; 95% CI: 0.03; 0.20).

CONCLUSION

Patients with higher adherence to diet quality indices were likely less to have mental disorders or poor sleep.

LEVEL OF EVIDENCE

Level V: based on descriptive studies (a Cross-sectional study).

Distinct Diet-Microbiota-Metabolism Interactions in Overweight and Obese Pregnant Women: a Metagenomics Approach

Diet and gut microbiota are known to modulate metabolic health. Our aim was to apply a metagenomics approach to investigate whether the diet-gut microbiota-metabolism and inflammation relationships differ in pregnant overweight and obese women. This cross-sectional study was conducted in overweight (n = 234) and obese (n = 152) women during early pregnancy. Dietary quality was measured by a validated index of diet quality (IDQ). Gut microbiota taxonomic composition and species diversity were assessed by metagenomic profiling (Illumina HiSeq platform). Markers for glucose metabolism (glucose, insulin) and low-grade inflammation (high sensitivity C-reactive protein [hsCRP], glycoprotein acetylation [GlycA]) were analyzed from blood samples. Higher IDQ scores were positively associated with a higher gut microbiota species diversity (r = 0.273, P = 0.007) in obese women, but not in overweight women. Community composition (beta diversity) was associated with the GlycA level in the overweight women (P = 0.04) but not in the obese. Further analysis at the species level revealed a positive association between the abundance of species Alistipes finegoldii and the GlycA level in overweight women (logfold change = 4.74, P = 0.04). This study has been registered at ClinicalTrials.gov under registration no. NCT01922791 (https://clinicaltrials.gov/ct2/show/NCT01922791).

IMPORTANCE We observed partially distinct diet-gut microbiota-metabolism and inflammation responses in overweight and obese pregnant women. In overweight women, gut microbiota community composition and the relative abundance of A. finegoldii were associated with an inflammatory status. In obese women, a higher dietary quality was related to a higher gut microbiota diversity and a healthy inflammatory status.

Ultraprocessed food consumption and kidney function decline in a population-based cohort in the Netherlands

BACKGROUND

Ultraprocessing makes food products more convenient, appealing, and profitable. Recent studies show that high ultraprocessed food (UPF) intake is associated with cardiometabolic diseases.

OBJECTIVES

The aim of this study is to investigate the association between UPF consumption and risks of kidney function decline in the general population.

METHODS

In a prospective, general population-based Lifelines cohort from Northern Netherlands, 78,346 participants free of chronic kidney disease (CKD) at baseline responded to a 110-item FFQ. We used a multivariable regression analysis to study the associations of the proportion (in grams/day) of UPFs in the total diet with a composite kidney outcome [incident CKD or a ≥30% estimated glomerular filtration rate (eGFR) decline relative to baseline] and annual change in eGFR.

RESULTS

On average, 37.7% of total food intake came from UPFs. After 3.6 ± 0.9 years of follow-up, 2470 participants (3.2%) reached the composite kidney outcome. Participants in the highest quartile of UPF consumption were associated with a higher risk of the composite kidney outcome (OR, 1.27; 95% CI, 1.09-1.47; P = 0.003) compared with those in the lowest quartile, regardless of their macro- or micronutrient intake or diet quality. Participants in the highest quartile had a more rapid eGFR decline (β, -0.17; 95% CI, -0.23 to -0.11; P < 0.001) compared with those in the lowest quartile. Associations were generally consistent across different subgroups.

CONCLUSIONS

Higher UPF consumption was associated with a higher risk of a composite kidney outcome (incident CKD or ≥30% eGFR decline) and a more rapid eGFR decline in the general population, independent of confounders and other dietary indices.

Diet quality and incident chronic kidney disease in the general population: The Lifelines Cohort Study

RATIONALE & AIMS

Healthy dietary patterns have been associated with a lower risk of chronic kidney disease (CKD). We aimed to investigate the association of a fully food-based diet quality score assessed by the Lifelines Diet Score (LLDS) with either incident CKD or eGFR decline in the general population.

METHODS

For this study, data from a prospective general population-based Lifelines cohort in the Northern Netherlands was used. Diet was assessed with a 110-item food frequency questionnaire at baseline. The LLDS, based on international evidence for diet-disease relations at the food group level, was calculated to assess diet quality. For the analysis, the score was divided into tertiles. Logistic regression was performed to evaluate the association of the LLDS at baseline with either incident CKD (eGFR <60 mL/min/1.73 m²) or a ≥20% eGFR decline at the second study visit, adjusted for relevant confounders.

RESULTS

A total of 78 346 participants free of CKD at baseline were included. During a mean (SD) follow-up of 3.6 ± 0.9 years, 2071 (2.6%) participants developed CKD and 7611 (9.7%) had a ≥20% eGFR decline. Participants in the highest tertile of LLDS had a lower risk of incident CKD (fully adjusted OR 0.83, [95% CI: 0.72-0.96]) and ≥20% eGFR decline (fully adjusted OR 0.80, [95% CI: 0.75-0.86]), compared with those in the lowest tertile. Similar dose-response associations were observed in continuous LLDS.

CONCLUSIONS

Higher adherence to a high-quality diet was associated with a lower risk of incident CKD or ≥20% eGFR decline in the general population.