Non-linear associations between healthy Nordic foods and all-cause mortality in the NOWAC study: a prospective study

Abstract

Background: The shape of the associations between intake of foods basic in a healthy Nordic diet and long-term health is not well known. Therefore, we have examined all-cause mortality in a large, prospective cohort of women in Norway in relation to intake of: Nordic fruits and vegetables, fatty fish, lean fish, wholegrain products, and low-fat dairy products.

Methods: A total of 83 669 women who completed a food frequency questionnaire between 1996 and 2004 were followed up for mortality until the end of 2018. Cox proportional hazards regression models were used to examine the associations between consumption of the Nordic food groups and all-cause mortality. The Nordic food groups were examined as categorical exposures, and all but wholegrain products also as continuous exposures in restricted cubic spline models.

Results: A total of 8 507 women died during the 20-year follow-up period. Nordic fruits and vegetables, fatty fish and low-fat dairy products were observed to be non-linearly associated with all-cause mortality, while higher intake of lean fish and wholegrain products reduced all-cause mortality. Intake levels and hazard ratios (HR) and 95% confidence intervals (CI) associated with lowest mortality were approximately 200 g/day of Nordic fruits and vegetables (HR 0.83 (95% CI: 0.77-0.91)), 10-20 g/day of fatty fish (10 g/day: HR 0.98 (95% CI: 0.94-1.02)) and 200 g/day of low-fat dairy products (HR 0.96 (95% CI: 0.81-1.01)) compared to no consumption. Consumption of fatty fish ≥ 60 g/day compared to no intake statistically significantly increased the mortality (60 g/day: HR 1.08 (95% CI: 1.01-1.16)), as did consumption of low-fat dairy products ≥ 800 g/day compared to no intake (800 g/day: HR 1.10 (95% CI: 1.02-1.20)). After stratification by smoking status, the observed association between Nordic fruits and vegetables and all-cause mortality was stronger in ever smokers.

Conclusion: The associations between intake of foods basic in healthy Nordic diets and all-cause mortality may be non-linear. Therefore, assumptions of linear associations between traditional Nordic food groups and health outcomes could lead to wrong conclusions in analyses of healthy Nordic diets.

Keywords: All-cause mortality; Cohort study; Fatty fish; Fruits and vegetables; Healthy Nordic diet; Lean fish; Low-fat dairy; Non-linear; Sustainable diet; Wholegrains.

Fig. 1

Intake of Nordic food groups and all-cause mortality by restricted cubic spline regression. From: Non-linear associations between healthy Nordic foods and all-cause mortality in the NOWAC study: a prospective study. Nordic food groups modeled by restricted cubic splines with 3 knots at percentiles 10%, 50% and 90% (Nordic fruits and vegetables 57; 164; 336. Low-fat dairy products 0; 138; 550. Fatty fish 0; 13; 35. Lean fish 0; 24; 66 g/day). Black line hazard ratio, grey area 95% confidence interval. Mutually adjusted for the healthy Nordic food groups, age (underlying timescale), BMI < 20, 20–24.9, 25–29.9, ≥ 30 (kg/m2), physical activity (low, medium, high), smoking status (never, current heavy smoker early starter, current moderate smoker early starter, current smoker late starter, former smoker early starter, former smoker late starter), education (< 10, 10–12, > 12 years of schooling), intake of energy (kJ/day continuous), alcohol (non-consumer, 0–5, > 5 g/day), and processed red meat (< 15, 15–29, 30–44, ≥ 45 g/day), stratified by subcohorts (n = 5)

Fig. 2

Intake of Nordic fruits and vegetables and all-cause mortality by restricted cubic splines stratified by never and ever smokers. From: Non-linear associations between healthy Nordic foods and all-cause mortality in the NOWAC study: a prospective study. Nordic fruits and vegetables modeled by restricted cubic splines with 3 knots at percentiles 10%, 50% and 90% (Never smokers: 65; 173; 343. Ever smokers: 53; 160; 332). Black line hazard ratio, grey area 95% confidence interval. Age-adjusted and mutually adjusted for the healthy Nordic food groups, BMI < 20, 20–24.9, 25–29.9, ≥ 30 (kg/m2), physical activity (low, medium, high), education (< 10, 10–12, > 12 years of schooling), intake of energy (kJ/day continuous), alcohol (non-consumer, 0–5, > 5 g/day), and processed red meat (< 15, 15–29, 30–44, ≥ 45 g/day). *Additionally, adjusted for pack-years