Healthy Eating Patterns and Risk of Total and Cause-Specific Mortality

“[Introduction] According to the Global Burden of Disease Study 2017, unhealthy diet is estimated as one of the leading causes of death globally.

[..] using 2 large prospective cohorts with data on repeated measures of dietary habits, we derived dietary scores for 4 healthy dietary patterns, including the Healthy Eating Index 2015 (HEI-2015), Alternate Mediterranean Diet (AMED) score, Healthful Plant-based Diet Index (HPDI), and Alternate Healthy Eating Index (AHEI). We then examined their associations with total and cause-specific mortality. We also specifically examined these associations stratified by race and ethnicity and other potential risk factors.

[Methods] This cohort study used data from the Nurses’ Health Study (NHS) and the Health Professionals Follow-up Study (HPFS). The NHS is a prospective cohort study of 121 700 female registered nurses aged 30 to 55 years from 11 US states that began in 1976. The HPFS is a prospective cohort study of 51 529 male health professionals aged 40 to 75 years at baseline that began in 1986. [..]

Dietary information was collected with the use of a validated semiquantitative food frequency questionnaire (FFQ) with over 130 items administered every 2 to 4 years. [..] Using the food and nutrient components, we calculated the HEI-2015, AMED score, HPDI, and AHEI to measure adherence to the Healthy US-Style Eating Pattern, Alternate Mediterranean Eating Pattern, Healthy Plant-based Eating Pattern, and Alternate Healthy Eating Pattern. [..] Briefly, the HEI-2015 includes 13 components and ranges from 0 to 100, with higher scores indicating higher adherence to DGAs [Dietary Guidelines for Americans]. The AMED score includes 9 components and ranges from 9 to 45, with higher scores indicating a healthier Mediterranean diet. The HPDI includes 18 components and ranges from 18 to 90, with higher scores indicating a healthier plant-based diet. The AHEI, based on DGAs with modification to include factors related to chronic disease risk, includes 10 components and ranges from 0 to 100, with higher scores indicating a healthier diet.

Every 2 years, participants returned a mailed validated questionnaire that obtained updated information on their lifestyle and other risk factors, including age, body weight, smoking status, physical activity, aspirin use, multivitamin use, menopausal status and postmenopausal hormone use in women, and physician diagnosis of chronic diseases. [..]

[Results] The final study sample included 75 230 women from the NHS (mean [SD] baseline age, 50.2 [7.2] years) and 44 085 men from the HPFS (mean [SD] baseline age, 53.3 [9.6] years). [..]

After adjustment for potential confounders, when comparing the highest with the lowest quintiles, the pooled HRs of all-cause mortality were 0.81 (95% CI, 0.79-0.84) for HEI-2015, 0.82 (95% CI, 0.79-0.84) for AMED score, 0.86 (95% CI, 0.83-0.89) for HPDI, and 0.80 (95% CI, 0.77-0.82) for AHEI (P < .001 for trend for all). [..]

The associations between dietary patterns and total mortality did not differ significantly by race and ethnicity; the HRs of total mortality per 25-percentile difference in HEI-2015 were 0.55 (95% CI, 0.33-0.89; P = .21 for interaction) in Hispanic women, 0.59 (95% CI, 0.41-0.84; P = .19 for interaction) in non-Hispanic Black women, 0.75 (95% CI, 0.72-0.78) in non-Hispanic White women, and 0.72 (95% CI, 0.62-0.85; P = .65 for interaction) in other racial and ethnic minority groups. [..]

Significant interactions were detected between 4 dietary scores and total mortality by sex and smoking status; HRs were higher among women than among men and among current and ever smokers than among never smokers. The significant inverse associations between dietary scores and total mortality remained largely unchanged when pack-years of smoking were further adjusted, the baseline and simple updated dietary data were used, the diet was continuously updated until the end of follow-up, and the random-effects model was used. When applying a competing risk regression model for cause-specific mortality, the results remained consistent with those from the primary analysis. [..]

[Discussion] Our results are generally consistent with previous studies that reported inverse associations between individual dietary scores and all-cause mortality. The Atherosclerosis Risk in Communities (ARIC) study, the Dietary Patterns Methods Project, and the Women’s Health Initiative Observational Study found similar inverse associations in direction and magnitude for HEI-2015, AHEI, and AMED. [..] Our findings support the recommendations of the current DGAs to achieve long-term health benefits by adherence to various healthy eating patterns that can be adopted based on individuals’ health needs, food preferences, and cultural traditions, although all these diet patterns encourage high consumption of healthy plant-based foods. [..]

Our results of lower HRs for the AHEI and HEI-2015 than for the AMED score were expected given that the AHEI and HEI-2015 are mostly based on current knowledge of dietary factors contributing to cardiovascular disease. The current evidence on healthy eating patterns and cancer mortality remains controversial. Our data support that healthy eating patterns may be associated with reduced mortality from all cancers, but the presence of associations varied for mortality due to specific cancer, which were consistent with some previous findings for incidence of these specific cancers.”

The Alternate Healthy Eating Index components and criteria for scoring (from the article’s appendix):

Component – criteria for maximum score of 10

  • Whole fruit – > 4 servings/day
  • Vegetable (excluding potatoes) – > 5 servings/day
  • Whole grains – women > 75 grams/day, men > 90 grams/day
  • Red and processed meat – none
  • Nuts and legumes – > 1 serving per day
  • Long-chain omega-3 fats – > 250 milligrams/day
  • Polyunsaturated fatty acids – >10% of energy
  • Trans fat – < 0.5% of energy
  • Sugar-sweetened beverages and fruit juice – none
  • Sodium – lowest decile

Full article, Z Shan, F Wang, Y Li et al., JAMA Internal Medicine, 2023.1.9.