[Skip to Content]
[Skip to Content Landing]
Views 24,622
Citations 0
Original Investigation
June 15, 2020

Association Between Healthy Eating Patterns and Risk of Cardiovascular Disease

Author Affiliations
  • 1Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 3Division of Preventive Medicine, Department of Medicine Research, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 4Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 5Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 6Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
  • 7Now with Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 8Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
  • 9Now with Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2020;180(8):1090-1100. doi:10.1001/jamainternmed.2020.2176
Key Points

Question  Are there associations of different healthy eating patterns with long-term risk of cardiovascular disease?

Findings  In this cohort study of individuals from the Nurses’ Health Study, Nurses’ Health Study II, and Health Professionals Follow-up Study (165 794 women and 43 339 men) with up to 32 years of follow-up, greater adherence to various healthy eating patterns was associated with lower risk of cardiovascular disease. The associations between dietary scores and risk of cardiovascular disease were consistent across different subgroups.

Meaning  These findings support the recommendations of the 2015-2020 Dietary Guidelines for Americans that multiple healthy eating patterns can be adapted to individual food traditions and preferences.

Abstract

Importance  The 2015-2020 Dietary Guidelines for Americans recommend multiple healthy eating patterns. However, few studies have examined the associations of adherence to different dietary patterns with long-term risk of cardiovascular disease (CVD).

Objective  To examine the associations of dietary scores for 4 healthy eating patterns with risk of incident CVD.

Design, Setting, and Participants  Prospective cohort study of initially healthy women from the Nurses’ Health Study (NHS) (1984-2016) and the NHS II (1991-2017) and men from the Health Professionals Follow-up Study (HPFS) (1986-2012). The dates of analysis were July 25 to December 4, 2019.

Exposures  Healthy Eating Index–2015 (HEI-2015), Alternate Mediterranean Diet Score (AMED), Healthful Plant-Based Diet Index (HPDI), and Alternate Healthy Eating Index (AHEI).

Main Outcomes and Measures  Cardiovascular disease events, including fatal and nonfatal coronary heart disease (CHD) and stroke.

Results  The final study sample included 74 930 women in the NHS (mean [SD] baseline age, 50.2 [7.2] years), 90 864 women in the NHS II (mean [SD] baseline age, 36.1 [4.7] years), and 43 339 men in the HPFS (mean [SD] baseline age, 53.2 [9.6] years). During a total of 5 257 190 person-years of follow-up, 23 366 incident CVD cases were documented (18 092 CHD and 5687 stroke) (some individuals were diagnosed as having both CHD and stroke). Comparing the highest with the lowest quintiles, the pooled multivariable-adjusted hazard ratios (HRs) of CVD were 0.83 (95% CI, 0.79-0.86) for the HEI-2015, 0.83 (95% CI, 0.79-0.86) for the AMED, 0.86 (95% CI, 0.82-0.89) for the HPDI, and 0.79 (95% CI, 0.75-0.82) for the AHEI (P for trend <.001 for all). In addition, a 25-percentile higher dietary score was associated with 10% to 20% lower risk of CVD (pooled HR, 0.80 [95% CI, 0.77-0.83] for the HEI-2015; 0.90 [95% CI, 0.87-0.92] for the AMED; 0.86 [95% CI, 0.82-0.89] for the HPDI; and 0.81 [95% CI, 0.78-0.84] for the AHEI). These dietary scores were statistically significantly associated with lower risk of both CHD and stroke. In analyses stratified by race/ethnicity and other potential risk factors for CVD, the inverse associations between these scores and risk of CVD were consistent in most subgroups.

Conclusions and Relevance  In 3 large prospective cohorts with up to 32 years of follow-up, greater adherence to various healthy eating patterns was consistently associated with lower risk of CVD. These findings support the recommendations of the 2015-2020 Dietary Guidelines for Americans that multiple healthy eating patterns can be adapted to individual food traditions and preferences.

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    EXPAND ALL
    Food for thought - dietary patterns and cardiovascular disease
    Sashi Ganes, BSc (Hons) | Cardiff University School of Medicine
    To the editor,
    In the June issue of JAMA Internal Medicine, Shan et al report that greater adherence to healthy eating patterns were consistently associated with lower cardiovascular disease risk (1). This commendable study with large sample size and 32-year follow up adds to the current evidence on the association between dietary patterns and cardiovascular disease. Despite these notable strengths, caution must be exercised before generalising these results.

    Firstly, assessing whether cardiovascular disease is associated with adherence to these diets is challenging. Not only is there great variability in dietary patterns within two years, but cardiovascular disease
    can remain dormant for prolonged periods of time before symptoms manifest (2). Hence, lack of adjustment of other factors that may alter baseline cardiometabolic profiling, may contribute to residual confounding. These include statin use, neuropsychiatric symptoms, education levels, patterns of shift work, income status and air-pollution. Centre clustering may account for the latter covariates. Lifestyle interventions and treatments for primary prevention of cardiovascular disease have also significantly improved over the study period and this should also be accounted for (indirectly by adjusting to study year).

    Next, the use of food frequency questionnaires employed in this study is questionable. The close-ended nature of these dietary assessment coupled with low accuracy due to recall bias may misclassify the diets consumed. In this group of study participants, who were medical professionals in the United States (which also limits generalisability of these results), other dietary assessments such as dietary records would have provided more accurate results (3). The 24-hour dietary recall assessments have also been found to be more reliable than frequency questionnaires and future studies should utilise interactive web-based versions of these dietary assessment (4). This will allow identification of the type of diet consumed with greater precision consumed (i.e type of milk, preparation of fish). There are also notable differences within single dietary patterns such as Mediterranean diets in different geographic locale hence precise identification of specific nutrients, along with dietary patterns, may allow causative agents for disease and health to be further parsed (5).

    Finally, there is a lack of all-cause mortality analysis in this study. Dietary patterns and nutrient consumptions also affect other non-communicable diseases such as cancer. It would be interesting to present these data to the readers for this specific study population.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    ×