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. 2025 Jul 30:12:1535174.
doi: 10.3389/fnut.2025.1535174. eCollection 2025.

Impact of dietary patterns on the survival outcomes of patients with cardiovascular disease

Jinyu Sun #  1   2 , Xingyu Jiang #  2   3 , Zheng Li  2 , Yang Shen  1
Affiliations

Impact of dietary patterns on the survival outcomes of patients with cardiovascular disease

Jinyu Sun et al. Front Nutr. .

Abstract

Background: This study examines the association between dietary patterns and survival outcomes in patients with cardiovascular disease (CVD).

Methods: A total of 9,101 adults with CVD from the 2005-2018 National Health and Nutrition Examination Survey were included. Dietary patterns were evaluated using five indices: the Alternative Healthy Eating Index (AHEI), Dietary Approaches to Stop Hypertension (DASH), Dietary Inflammatory Index (DII), Healthy Eating Index-2020 (HEI-2020), and the Alternative Mediterranean Diet Score (aMED). Associations between dietary indices and all-cause mortality were assessed using Kaplan-Meier survival analysis, weighted Cox regression models, and restricted cubic spline analyses. Predictive performance was evaluated using time-dependent receiver operating characteristic (Time-ROC) curves.

Results: After a median follow-up of 7 years, 1,225 deaths were recorded. Survivors had higher AHEI, DASH scores, and lower DII scores. Kaplan-Meier analysis suggested better survival outcomes associated with higher adherence to healthier dietary patterns (AHEI, DASH, HEI-2020, aMED) and lower adherence to pro-inflammatory diets (DII). Weighted Cox regression revealed significant associations between higher scores on AHEI, DASH, HEI-2020, and aMED and reduced mortality risk (highest vs. lowest tertile HRs: 0.59, 0.73, 0.65, and 0.75, respectively; all P < 0.05). Conversely, higher DII scores were associated with increased mortality risk, with the highest tertile showing significantly elevated risk compared to the lowest tertile (HR = 1.58, 95% CI: 1.21-2.06; P < 0.001). Restricted cubic spline analyses identified a significant non-linear relationship between AHEI scores and mortality (P for non-linearity = 0.036), while other indices exhibited linear associations. Time-ROC analysis indicated that dietary indices maintain relatively consistent predictive effectiveness for mortality risk over time.

Conclusion: Improved healthy dietary patterns could potentially reduce mortality risk in CVD patients, underscoring the need for dietary quality enhancement in managing CVD.

Keywords: cardiovascular disease; dietary patterns; predictive ability; survival outcomes; weighted Cox regression.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Flowchart of data selection for a study. Participants from NHANES (2005-2018) and NDI (1999-2019) are matched, resulting in 39,346 subjects. Exclusions are listed, leading to 9,101 patients with cardiovascular disease.
FIGURE 1
Flow chart of selection of eligible participants.
Kaplan-Meier survival curves for cardiovascular disease patients show cumulative survival over 14 years, stratified by diet quality scores: AHEI, DASH, DII, HEI2020, and aMED. Each chart compares low, moderate, and high scores with significant log-rank P-values below 0.0001.
FIGURE 2
Kaplan-Meier survival curves for patients with cardiovascular disease according to dietary indices categorized into tertiles. Log-rank P-values for all indices are < 0.0001. The red, green, and blue lines represent low, moderate, and high dietary scores, respectively.
Five line graphs (A to E) show hazard ratios with 95% confidence intervals for different dietary indices: AHEI, DASH, DII, HEI2020, and aMED. Results indicate significant overall trends with varying degrees of nonlinear associations, as noted by accompanying p-values. The 95% confidence intervals are shaded, and a dashed line at 1.0 represents the baseline hazard ratio.
FIGURE 3
Restricted cubic spline analyses illustrating the association between dietary indices and mortality risk in patients with cardiovascular disease. (A) Alternative healthy eating index, (B) dietary approaches to stop hypertension, (C) dietary inflammatory index, (D) healthy eating index-2020, and (E) mediterranean diet score. A non-linear relationship was observed for AHEI, while linear associations were found for the other dietary indices.
Five ROC curves compare diet scores: AHEI (A), DASH (B), DII (C), HEI-2020 (D), and aMED (E). Each panel shows true positive rate versus false positive rate with AUC values for 1, 5, and 10 years. AUC at 1 year ranges from 0.596 to 0.622, at 5 years from 0.548 to 0.594, and at 10 years from 0.522 to 0.562.
FIGURE 4
The plots depict the time-dependent area under the receiver operating characteristic curve at 1-year, 5-year, and 10-year follow-up periods for five dietary indices. (A) Alternative healthy eating index, (B) dietary approaches to stop hypertension, (C) dietary inflammatory index, (D) healthy eating index-2020, and (E) mediterranean diet score.
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