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. 2023 Jul 21;44(28):2560-2579.
doi: 10.1093/eurheartj/ehad269.

Diet, cardiovascular disease, and mortality in 80 countries

Andrew Mente  1   2 , Mahshid Dehghan  1 , Sumathy Rangarajan  1 , Martin O'Donnell  3   4 , Weihong Hu  1 , Gilles Dagenais  5 , Andreas Wielgosz  6 , Scott A Lear  7 , Li Wei  8 , Rafael Diaz  9 , Alvaro Avezum  10 , Patricio Lopez-Jaramillo  11 , Fernando Lanas  12 , Sumathi Swaminathan  13 , Manmeet Kaur  14 , K Vijayakumar  15 , Viswanathan Mohan  16 , Rajeev Gupta  17 , Andrzej Szuba  18 , Romaina Iqbal  19 , Rita Yusuf  20 , Noushin Mohammadifard  21 , Rasha Khatib  22 , Nafiza Mat Nasir  23 , Kubilay Karsidag  24 , Annika Rosengren  25 , Afzalhussein Yusufali  26 , Edelweiss Wentzel-Viljoen  27 , Jephat Chifamba  28 , Antonio Dans  29 , Khalid F Alhabib  30 , Karen Yeates  31 , Koon Teo  1   2   3 , Hertzel C Gerstein  1   2   3 , Salim Yusuf  1   2   3
Affiliations

Diet, cardiovascular disease, and mortality in 80 countries

Andrew Mente et al. Eur Heart J. .

Abstract

Aims: To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries.

Methods and results: A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison).

Conclusion: A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.

Keywords: Cardiovascular events; Diet quality; Dietary patterns; Diverse populations; Global; Mortality.

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Conflict of interest statement

Conflict of interest All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any additional organization for the submitted work. A detailed list of funders is provided in the Supplementary data online, Appendix. The authors have no financial relationships with any organizations, or other relationships or activities that might have influenced the submitted work in the previous 3 years.

Figures

Structured Graphical Abstract
Structured Graphical Abstract
In a combined analysis of data from six international studies involving 245 000 people from 80 countries, a diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and dairy foods is associated with lower risk of cardiovascular disease and mortality in all world regions, especially in lower income countries. PURE, Prospective Urban Rural Epidemiology.
Figure 1
Figure 1
Prospective Urban Rural Epidemiology healthy diet score by country gross national income (n = 147 642).
Figure 2
Figure 2
Median intake of the food categories of the Prospective Urban Rural Epidemiology healthy diet score, overall and by geographic region (n = 147 642).
Figure 3
Figure 3
Association of Prospective Urban Rural Epidemiology healthy diet score vs. events across studies (n = 244 597). Hazard ratios (95%) are per 20 percentile increment in the diet score. Hazard ratios (95% CI) are multivariable adjusted.
Figure 4
Figure 4
Cubic splines for the association of the Prospective Urban Rural Epidemiology healthy diet score with A) total mortality, B) major CVD, and C) composite of death or major CVD in a general population (Prospective Urban Rural Epidemiology, n = 147 642).
Figure 5
Figure 5
Cubic splines for the association of the Prospective Urban Rural Epidemiology healthy diet score with A) total mortality, B) major CVD, and C) composite of death or major CVD in those with previous vascular disease drawn from ONTARGET, TRANSCEND, and ORIGIN (n = 43 834).
Figure 6
Figure 6
Association of Prospective Urban Rural Epidemiology healthy diet score vs. Events in those with and without prior cardiovascular disease in the four independent prospective studies (n = 191 476). Hazard ratios (95%) are per 20 percentile increment in the diet score. Hazard ratios (95% CI) are multivariable adjusted.
Figure 7
Figure 7
Association of diet scores with composite of death or major cardiovascular disease, by country income region and geographic region in the four prospective studies (n = 191 476). Hazard ratios (95% CI) are multivariable adjusted. The top panel (by country income level) shows that an inadequate intake of key foods is of greatest importance in the countries with lower gross national incomes.
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