The role of dietary patterns' assessment in the predictive ability of cardiovascular disease risk estimation models: a review

Associations of Diet with Health Outcomes in the UK Biobank: A Systematic Review

The UK Biobank is a cohort study that collects data on diet, lifestyle, biomarkers, and health to examine diet-disease associations. Based on the UK Biobank, we reviewed 36 studies on diet and three health conditions: type 2 diabetes (T2DM), cardiovascular disease (CVD), and cancer. Most studies used one-time dietary data instead of repeated 24 h recalls, which may lead to measurement errors and bias in estimating diet-disease associations. We also found that most studies focused on single food groups or macronutrients, while few studies adopted a dietary pattern approach. Several studies consistently showed that eating more red and processed meat led to a higher risk of lung and colorectal cancer. The results suggest that high adherence to "healthy" dietary patterns (consuming various food types, with at least three servings/day of whole grain, fruits, and vegetables, and meat and processed meat less than twice a week) slightly lowers the risk of T2DM, CVD, and colorectal cancer. Future research should use multi-omics data and machine learning models to account for the complexity and interactions of dietary components and their effects on disease risk.

Association Between Dietary Quality Indices and Atherosclerosis Risk: A Case-Control Study

Background:

Several diet quality scores have been developed to evaluate the health benefits of individual diets such as Healthy Eating Index (HEI), Dietary Approach to Stop Hypertension (DASH), and Mediterranean diet score (Med). This study aims to determine the relationship between dominant dietary health scores with the risk of atherosclerosis in Iranian adults.

Methods:

This case-control study was conducted on 323 patients with atherosclerosis and 334 individuals without atherosclerosis as control group. Food Frequency Questionnaire was used for obtaining dietary intakes; then HEI, DASH score, and Med score was calculated. Logistic regression models were used to calculate Odds Ratios (OR) and 95% Confidence intervals (CI) between quartiles of the HEI, DASH and Med and atherosclerosis risk.

Results:

The results showed that total scores for HEI, DASH, and Med in control group was higher than the atherosclerosis group. The results also indicated that higher adherence to HEI (OR: 0.43; CI: [0.24, 0.76], P-trend = .006), DASH (OR: 0.48; CI: [0.3, 0.78], P-trend = .003), and Mediterranean pattern (OR: 0.4; CI: [0.21, 0.76]) decreased odds ratio of atherosclerosis.

Conclusion:

Our findings suggest that adherence to HEI, DASH, and Mediterranean diet might be associated with a lower risk of Atherosclerosis and can have a positive effect on general health and prevention of chronic diseases in people.

Relationship between diet quality and carotid intima-media thickness in people with and without carotid atherosclerosis

BACKGROUND

Dietary assessment and management appear to be essential to limit the impact of cardiovascular risk.

AIM

This study aims to assess the association between diet quality as measured by Alternate Healthy Eating Index (AHEI) and coronary risk as determined by carotid artery intima-media thickness (CIMT) among Saudi adults.

METHODS

A case-control study was conducted in 210 participants who were matched for age and sex and recruited sequentially from King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Demographic and anthropometric variables were measured in all study participants. Dietary intake was measured by food frequency questionnaire.

RESULTS

Obesity was highly prevalent among the study population. The mean AHEI score for the total sample was found to be 58.3 ± 1.67. There were no differences according to the presence and absence of atherosclerotic disease; 45% had a poor diet, and 39% had a diet that needs improvement. Participants with higher CIMT values tended to be of lower AHEI category. Negative correlations were observed between CIMT and AHEI scores and components after adjustment for age and energy intake.

CONCLUSIONS

Adherence to a healthier diet, as reflected by a higher AHEI score, is associated with lower coronary risk, as estimated by CIMT value, independently from obesity and personal behavior factors.

Western Dietary Pattern Is Associated With Severe Coronary Artery Disease

The independent predictive value of an unhealthy diet on the severity of coronary artery disease (CAD) requires further investigation. We assessed the impact of dietary pattern on CAD severity. In this cohort study, we included 188 symptomatic stable patients with CAD. Patients were categorized as having severe CAD or nonsevere CAD by coronary angiography. Among several demographics and clinical characteristics, all patients were tested using a semiquantitative food frequency questionnaire. Concerning baseline demographic characteristics, there was no difference between patients with severe CAD and nonsevere CAD. Principal component analysis revealed 8 distinct dietary patterns. The first component Western dietary pattern (increased intake of fat, red meat, and carbohydrates and minimal consumption of fruits and green leafy vegetables) was predictive of severe CAD (area under the curve: 0.73, 95% confidence intervals: 0.64-0.83, P < .001). In conclusion, an unhealthy Western type of diet is associated with the severity of coronary artery lesions in patients with stable CAD. These findings highlight the role of dietary patterns when estimating cardiovascular risk for the management of patients with CAD.

Diet quality is associated with reduced incidence of cancer and self-reported chronic disease: Observations from Alberta's Tomorrow Project

The objective of this study was to assess diet quality using the Healthy Eating Index-2005 Canada (HEI-2005-Canada) and its association with risk of cancer and chronic disease in a sample of Alberta's Tomorrow Project (ATP) participants. Food frequency questionnaires completed by 25,169 participants (38% men; mean age 50.3 (9.2)) enrolled between 2000 and 2008 were used to calculate HEI-2005-Canada scores. Data from a subset of participants (n=10,735) who reported no chronic disease at enrollment were used to investigate the association between HEI-2005-Canada score and development of self-reported chronic disease at follow-up (2008). Participants were divided into HEI-2005-Canada score quartiles. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for cancer and chronic disease incidence. In this cohort, mean HEI-2005-Canada scores for men and women were 50.9 and 55.5 (maximum range 0-100), respectively. In men, higher HEI-2005-Canada score (Q4 vs. Q1) was associated with lower cancer risk (HR (95% CI) 0.63 (0.49-0.83)) over the course of follow-up (mean (SD)=10.4 (2.3) years); the same was not observed in women. In contrast, higher overall HEI-2005-Canada score (Q4 vs. Q1) was associated with lower risk of self-reported chronic disease (0.85 (0.75-0.97)) in both men and women over follow-up (4.2 (2.3) years). In conclusion, in this cohort better diet quality was associated with a lower risk of cancer in men and lower risk of chronic disease in both sexes. Future studies with longer follow-up and repeated measures of diet may be helpful to elucidate sex-specific associations between dietary quality and disease outcomes.

Optimizing diet and nutrition for cancer survivors: A review

The number of cancer survivors is increasing and they are often highly motivated to search for information about nutrition and about physical activity in order to try to improve their treatment outcomes, quality of life and overall survival. In the light of these concerns, the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) as well as the American Cancer Society recommend a largely plant-based diet with limited consumption of red and processed meat, and limited consumption of alcohol, as well as the maintenance of a healthy weight throughout life and regular engagement in physical activity. There is a need for well-designed large observational and intervention studies to shed more light on the association between diet and cancer survivorship, and to suggest additional means for the secondary prevention of cancer.

Mediterranean diet for type 2 diabetes: cardiometabolic benefits

Dietary patterns influence various cardiometabolic risk factors, including body weight, lipoprotein concentrations, and function, blood pressure, glucose-insulin homeostasis, oxidative stress, inflammation, and endothelial health. The Mediterranean diet can be described as a dietary pattern characterized by the high consumption of plant-based foods, olive oil as the main source of fat, low-to-moderate consumption of fish, dairy products and poultry, low consumption of red and processed meat, and low-to-moderate consumption of wine with meals. The American Diabetes Association and the American Heart Association recommend Mediterranean diet for improving glycemic control and cardiovascular risk factors in type 2 diabetes. Prospective studies show that higher adherence to the Mediterranean diet is associated with a 20-23 % reduced risk of developing type 2 diabetes, while the results of randomized controlled trials show that Mediterranean diet reduces glycosylated hemoglobin levels by 0.30-0.47 %, and is also associated with a 28-30 % reduced risk for cardiovascular events. The mechanisms by which Mediterranean diet produces its cardiometabolic benefits in type 2 diabetes are, for the most, anti-inflammatory and antioxidative: increased consumption of high-quality foods may cool down the activation of the innate immune system, by reducing the production of proinflammatory cytokines while increasing that of anti-inflammatory cytokines. This may favor the generation of an anti-inflammatory milieu, which in turn may improve insulin sensitivity in the peripheral tissues and endothelial function at the vascular level and ultimately act as a barrier to the metabolic syndrome, type 2 diabetes and development of atherosclerosis.

Physical Activity Level Improves the Predictive Accuracy of Cardiovascular Disease Risk Score: The ATTICA Study (2002-2012)

BACKGROUND

Although physical activity (PA) has long been associated with cardiovascular disease (CVD), assessment of PA status has never been used as a part of CVD risk prediction tools. The aim of the present work was to examine whether the inclusion of PA status in a CVD risk model improves its predictive accuracy.

METHODS

Data from the 10-year follow-up (2002-2012) of the n = 2020 participants (aged 18-89 years) of the ATTICA prospective study were used to test the research hypothesis. The HellenicSCORE (that incorporates age, sex, smoking, total cholesterol, and systolic blood pressure levels) was calculated to estimate the baseline 10-year CVD risk; assessment of PA status was based on the International Physical Activity Questionnaire. The estimated CVD risk was tested against the observed 10-year incidence (i.e., development of acute coronary syndromes, stroke, or other CVD according to the World Health Organization [WHO]-International Classification of Diseases [ICD]-10 criteria). Changes in the predictive ability of the nested CVD risk model that contained the HellenicSCORE plus PA assessment were evaluated using Harrell's C and net reclassification index.

RESULTS

Both HellenicSCORE and PA status were predictors of future CVD events (P < 0.05). However, the estimating classification bias of the model that included only the HellenicSCORE was significantly reduced when PA assessment was included (Harrel's C = 0.012, P = 0.032); this reduction remained significant even when adjusted for diabetes mellitus and dietary habits (P < 0.05).

CONCLUSIONS

CVD risk scores seem to be more accurate by incorporating individuals' PA status; thus, may be more effective tools in primary prevention by efficiently allocating CVD candidates.

Alternative health eating index and the Dietary Guidelines from American Diabetes Association both may reduce the risk of cardiovascular disease in type 2 diabetes patients

BACKGROUND

In the general population, a higher Alternate Healthy Eating Index (AHEI)-2010 score is related to decreased cardiovascular disease (CVD) risk. Few studies have described the dietary patterns that reduce the risk of CVD or coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM) patients. In the present study, the association between the American Diabetes Association (ADA)-recommended dietary pattern, AHEI-2010 , and CVD risk factors and the CVD incidence over 52 months in T2DM patients was evaluated.

METHODS

The ADA score was developed from the ADA dietary recommendations. In this prospective study, the 24-h dietary recall of 124 adult T2DM patients without nephropathy or chronic kidney disease was collected. The CVD risk factors were collected at baseline and at 6-month follow-up.

RESULTS

Compared with lower ADA and AHEI-2010 score participants, the higher score participants exhibited a significantly lower waist circumference, serum low-density lipoprotein cholesterol level and 10-year risk of CHD. Participants with higher ADA dietary scores had a significantly reduced risk of central obesity and systolic blood pressure >140 mmHg. Higher AHEI-2010 scores were significantly related to a reduced risk of serum low-density lipoprotein cholesterol > 100 mg dL(-1) . Seven participants had their first-ever CVD during the follow-up period, although neither ADA score, nor AHEI-2010 score could predict CVD incidence.

CONCLUSIONS

The ADA-recommended dietary pattern and a higher AHEI-2010 score might both exhibit reduced risk factors of CVD in T2DM patients.

Exploring the path of Mediterranean diet on 10-year incidence of cardiovascular disease: the ATTICA study (2002-2012)

BACKGROUND AND AIMS

A Mediterranean diet has been associated with lower all-cause and cardiovascular disease (CVD) morbidity and mortality, but the clinical and behavioral pathway has not been well understood and appreciated. The aim of this work was to explore the path between adherence to a Mediterranean-type diet, lifestyle behaviors, clinical status, and a 10-year incidence of CVD.

METHODS AND RESULTS

The ATTICA study was carried out in the Athens area during 2001-2002 and included 3042 participants free of CVD at baseline (49.8% men, aged 18-89). Adherence to a Mediterranean diet was assessed using the MedDietScore (range 0-55). During 2011-2012, 2583 out of the 3042 participants were found during the 10-year follow-up (15% lost to follow-up). Adherence to a Mediterranean diet decreased CVD risk (relative Risk (RR) per 1/55 unit = 0.96, 95% confidence interval (CI): 0.93, 1.00), independently of various sociodemographic, lifestyle, and clinical factors. Subgroup analyses revealed that participants with an unhealthy lifestyle (i.e., smokers, and obese and sedentary persons) remained protected from CVD through a greater adherence to a Mediterranean diet (RR for smokers = 0.92, 95%CI: 0.88, 0.97; RR for obese participants = 0.90, 95%CI: 0.82, 0.979; and RR for sedentary participants = 0.95, 95%CI: 0.90, 0.99). Path analysis revealed that adherence to a Mediterranean diet not only decreases the levels of C-reactive protein and interleukin-6 but also has an independent protective role against CVD risk per se (total effect of the MedDietScore on CVD = -0.003, 95%CI: -0.005 to 0.000).

CONCLUSION

Adherence to a Mediterranean diet confers a considerable reduction on CVD risk, independent of various factors. Therefore, even subjects with unhealthy lifestyle behaviors may benefit from adherence to this diet, suggesting another dimension to prevention strategies.

Ten-year (2002-2012) cardiovascular disease incidence and all-cause mortality, in urban Greek population: the ATTICA Study

AIM

The 10-year incidence of cardiovascular disease (CVD) and all-cause mortality, as well as its determinants, in a sample of men and women from Greece, was evaluated.

METHODS

From May 2001 to December 2002, 1514 men and 1528 women (>18y) without any clinical evidence of CVD or any other chronic disease, at baseline, living in greater Athens area, in Greece, were enrolled. In 2011-12, the 10-year follow-up was performed in 2583 participants (15% of the participants were lost to follow-up). Incidence of fatal or non-fatal CVD (coronary heart disease, acute coronary syndromes, stroke, or other CVD) was defined according to World Health Organization (WHO)-International Coding Diseases (ICD)-10 criteria.

RESULTS

The 10-year CVD incidence was 19.7% in men and 11.7% in women (p<0.001). Multi-adjusted analysis revealed that the determinants of CVD events were increased age (Hazard ratio (HR) per year=1.06, 95%Confidence Interval (CI): 1.04, 1.08), male sex (HR=1.40, 95%CI: 0.90, 2.19), smoking (HR=1.53, 95%CI: 1.03, 2.27), C-reactive protein levels (HR per 1mg/L=1.06, 95%CI: 1.02, 1.15), as well as adherence to Mediterranean diet (protective) (HR per 1/55 units=0.98, 95%CI: 0.95, 1.01).

CONCLUSION

The burden of CVD and its related risk factors is at emerging rates, in Greece, making the need for effective public health actions, more necessary than ever before.

Assessment of diet quality improves the classification ability of cardiovascular risk score in predicting future events: The 10-year follow-up of the ATTICA study (2002-2012)

BACKGROUND

In past years the prediction of cardiovascular disease (CVD) risk has received special attention; however, the presented risk models have so far not been very successful or appreciated.

DESIGN

The aim of the present work was to examine whether the inclusion of a diet quality evaluation in a CVD risk prediction model is associated with the accuracy of estimating future events.

METHODS

The working sample consisted of the 2009 ATTICA study participants (aged 18-89 years). The HellenicSCORE (a calibration of the European Society of Cardiology SCORE, based on age, gender, smoking habits, systolic blood pressure and total cholesterol) was calculated as a proxy of heart disease risk, while assessment of diet quality was based on the MedDietScore, which evaluates adherence to a Mediterranean diet. Fatal or non-fatal incidence of CVD (i.e., development of acute coronary syndromes, stroke or other CVD according to WHO-ICD-10 criteria) was calculated using the 10-year follow-up (2002-2012) data of the ATTICA study participants.

RESULTS

The MedDietScore and the HellenicSCORE were significant predictors of CVD events (p < 0.05). The estimating bias (i.e., misclassification rate of cases) of the model that included only the HellenicSCORE was significantly reduced by the inclusion of MedDietScore in the risk model (Harrell's C = 0.027, p = 0.012), improving the classification ability of the risk model by 56%.

CONCLUSION

The inclusion of dietary evaluation increased the accuracy of HellenicSCORE risk estimation and, thus, its incorporation into CVD risk prediction scores might help clinicians and public health professionals to better allocate future CVD candidates.