Association Between Healthy Eating Patterns and Risk of Cardiovascular Disease

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.

Figure 1.. Hazard Ratios of Cardiovascular Disease (CVD), Coronary Heart Disease (CHD), and Stroke per 25-Percentile Increment in the 4 Dietary Scores^a

The multivariable analysis was adjusted for age (continuous), race/ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic [NHS and NHS II only]), body mass index (calculated as weight in kilograms divided by height in meters squared [<21, 21-24.9, 25-29.9, 30-34.9, or ≥35]), physical activity (quintile), smoking status (never, former, or current [1-14, 15-24, or ≥25 cigarettes per day]), alcohol intake (0, 0.1-4.9, 5.0-14.9, 15.0-19.9, 20.0-29.9, or ≥30 g/d), menopausal status (premenopausal or postmenopausal [never, past, or current postmenopausal hormone use]), oral contraceptive use (never, past, or current [NHS II only]), marital status (married, divorced/separated/single, or widowed), living alone or with others (alone or not), family history of myocardial infarction (yes or no), total energy intake (quintile), multivitamin use (yes or no), and aspirin use (yes or no). Results were pooled using the fixed-effect model with inverse-variance weighting. AHEI indicates Alternate Healthy Eating Index; AMED, Alternate Mediterranean Diet Score; HEI-2015, Healthy Eating Index–2015; HPDI, Healthful Plant-Based Diet Index; HPFS, Health Professionals Follow-up Study; HR, hazard ratio; and NHS, Nurses’ Health Study. ^aCalculated per 25-percentile increment in the 4 dietary scores (25 points for the HEI-2015, 9 points for the AMED, 18 points for the HPDI, and 25 points for the AHEI).

Figure 2.. Pooled Hazard Ratios of Cardiovascular Disease According to the 4 Dietary Scores Across Subgroups

The multivariable analysis was adjusted for age (continuous), race/ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic [Nurses’ Health Study and Nurses’ Health Study II only]), body mass index (calculated as weight in kilograms divided by height in meters squared [<21, 21-24.9, 25-29.9, 30-34.9, or ≥35]), physical activity (quintile), smoking status (never, former, or current [1-14, 15-24, or ≥25 cigarettes per day]), alcohol intake (0, 0.1-4.9, 5.0-14.9, 15.0-19.9, 20.0-29.9, or ≥30 g/d), menopausal status (premenopausal or postmenopausal [never, past, or current postmenopausal hormone use]), oral contraceptive use (never, past, or current [Nurses’ Health Study II only]), marital status (married, divorced/separated/single, or widowed), living alone or with others (alone or not), family history of myocardial infarction (yes or no), total energy intake (quintile), multivitamin use (yes or no), and aspirin use (yes or no). Results were pooled using the fixed-effect model with inverse-variance weighting. AHEI indicates Alternate Healthy Eating Index; AMED, Alternate Mediterranean Diet Score; HEI-2015, Healthy Eating Index–2015; HPDI, Healthful Plant-Based Diet Index; and HR, hazard ratio. ^aCalculated per 25-percentile increment in the 4 dietary scores (25 points for the HEI-2015, 9 points for the AMED, 18 points for the HPDI, and 25 points for the AHEI). These results are from the Nurses’ Health Study and Nurses’ Health Study II.