Adherence to the EAT-Lancet Healthy Reference Diet in Relation to Risk of Cardiovascular Events and Environmental Impact: Results From the EPIC-NL Cohort

Abstract

Background The Healthy Reference Diet (HRD) was created to formulate dietary guidelines that would be healthy and sustainable. We aimed to construct a diet score measuring adherence to the HRD and to explore its association with cardiovascular events and environmental impact. Methods and Results We included 35 496 participants from the population-based EPIC-NL (European Prospective Investigation into Cancer and Nutrition-Netherlands) study. HRD scores were calculated using data from food frequency questionnaires (0-140). Data on morbidity and mortality were retrieved through linkage with national and death registries. Data on environmental impact indicators were obtained from life cycle assessments. Associations between adherence to the HRD and cardiovascular events were estimated with Cox proportional hazard models. Linear regression analysis was conducted for the adherence to the HRD and each environmental indicator. High adherence to the HRD was associated with 14%, 12%, and 11% lower risks of cardiovascular disease (hazard ratio [HR]_Q4vsQ1, 0.86 [95% CI, 0.78-0.94]), coronary heart disease (HR_Q4vsQ1, 0.88 [95% CI, 0.78-1.00]), and total stroke (HR_Q4vsQ1, 0.89 [95% CI, 0.72-1.10]), respectively. High HRD adherence was associated with 2.4% (95% CI, -5.0 to 0.2) lower greenhouse gas emissions, 3.9% (95% CI, -5.2 to -2.6) less land use, 0.5% (95% CI, -2.6 to 1.6), less freshwater eutrophication, 3.3% (95% CI, -5.8 to -0.8), less marine eutrophication, 7.7% (95% CI, -10.8 to -4.6), less terrestrial acidification, and 32.1 % (95% CI, 28.5-35.7) higher blue water use. Conclusions High adherence to the HRD was associated with lower risk of cardiovascular disease, coronary heart disease, and modestly lower levels of most environmental indicators but a higher level of blue water use.

Keywords: EAT‐Lancet; healthy reference diet; planetary health; sustainability.

Figure. Regression coefficients and 95% CIs for the association between quartiles of the HRDea score and environmental indicators, adjusted for age, sex, and energy intake (n=35 496).

GHG indicates global greenhouse gas; HRDea score, energy‐adjusted healthy reference diet score; Kg CO₂‐eq = kilograms of carbon dioxide equivalent; Kg N‐eq, kilograms of nitrogen equivalent; Kg P‐eq, kilograms of phosphorus equivalent; Kg SO₂‐eq, kilograms of sulfur dioxide equivalent; m² per year, square meters per year; m³ per day, cubic meters per day; Q1, first quartile; Q2, second quartile; Q3, third quartile; and Q4, fourth quartile.