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Improved diet quality may reduce risk for death
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Patients who improved their diet quality during a 12-year period had reduced risk for all-cause and CV mortality, according to a study published in The New England Journal of Medicine.
“Overall, our findings underscore the benefits of healthy eating patterns, including the Mediterranean diet and the [Dietary Approaches to Stop Hypertension] diet,” Mercedes Sotos-Prieto, PhD, assistant professor of food and nutrition science at Ohio University Heritage College of Osteopathic Medicine in Athens, said in a press release. “Our study indicates that even modest improvements in diet quality could meaningfully influence mortality risk, and conversely, worsening diet quality may increase the risk.”
Researchers analyzed data from 47,994 women from the Nurses’ Health Study aged 30 to 55 years and 25,745 men from the Health Professionals Follow-Up Study aged 40 to 75 years. Participants with a history of CVD at or before baseline were excluded. Changes in dietary scores were reviewed from 1986 to 1998, and the risk for total and cause-specific death was analyzed from 1998 to 2010.
Diet-quality scores
Participants completed a food frequency questionnaire at baseline and every 4 years, which was used to calculate three diet-quality scores: Alternate Healthy Eating Index, Alternate Mediterranean Diet score and the Dietary Approaches to Stop Hypertension (DASH) score. Higher scores in all three criteria were related to a healthier diet.
Those who greatly improved their diet quality were more likely to have a lower baseline diet score, to be younger, to consume less alcohol and to be more active than those with minimal change in diet quality. Participants who improved their diet quality reported an increased consumption of vegetables, whole grains and omega-3 fatty acids, along with a decreased intake of sodium.
During 12 years, the pooled risk for all-cause mortality in participants with a 13% to 33% improvement in diet quality was lower compared with those with a 0% to 3% improvement according to changes in the Alternate Mediterranean Diet score (HR = 0.84; 95% CI, 0.78-0.91), the Alternate Healthy Eating Index score (HR = 0.91; 95% CI, 0.85-0.97) and the DASH score (HR = 0.89; 95% CI, 0.84-0.95).
Reduced risk for death
Participants whose diet-quality scores increased by 20 percentile points had reduced risk for all-cause death by 8% to 17% across all three scores, and reduced risk for CV death by 7% to 15% according to the Alternate Healthy Eating Index score and the Alternate Mediterranean Diet score.
At 12 years, those with the largest score improvements from baseline had a 23% lower risk for all-cause death with the Alternate Mediterranean Diet score (95% CI, 12-32), 15% reduced risk with the Alternate Healthy Eating Index score (95% CI, 3-25) and 28% lower risk with the DASH score (95% CI, 16-38) compared with those with consistently low diet scores.
Participants with high scores throughout follow-up had a lower risk for death with the Alternate Mediterranean Diet score (11%; 95% CI, 5-18), Alternate Healthy Eating Index score (14%; 95% CI, 8-19) and the DASH score (9%; 95% CI, 2-15) compared with those with consistently low diet scores.
“Taken together, our findings provide support for the recommendations of the 2015 Dietary Guidelines Advisory Committee that it is not necessary to conform to a single diet plan to achieve healthy eating patterns,” Sotos-Prieto and colleagues wrote. “These three dietary patterns, although different in description and composition, capture the essential elements of a healthy diet. Common food groups in each score that contributed most to improvements were whole grains, vegetables, fruits and fish or [omega]-3 fatty acids.” – by Darlene Dobkowski
Disclosure: Sotos-Prieto reports receiving grants from Fundacion Alfonso Martin Escudero during the conduct of the study. Please see the full study for a list of the other researchers’ relevant financial disclosures.
Perspective
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Andrew M. Freeman, MD, FACC, FACP
This further strengthens some of the more recent work, which suggests that there are key dietary components that seem to continually improve outcomes overall. They reduce death and CVD.
These are predominately plant-based. If you look at this study, it talks a lot about the Alternative Healthy Eating Index, which measures things like intakes of vegetables, fruits, whole grains, limited sweets and limited red meat. When people follow that type of diet, they do better. There was recent work in the last year about how these healthful food components improve health outcomes.
This study shows us that when people eat better for a longer period of time or if people go from a significantly less good diet to a much better diet, they do better. This has very important health implications because it continues to underscore the importance of long-term not just diet, but a lifestyle of eating well. I suspect it’s difficult to perfectly capture because there are a lot of confounders, but the people who tend to push themselves to eat better and limit the less-good foods also probably exercise more and smoke less. Of course, many of these things were adjusted for in this study with their multivariate analysis and some is hard to fully capture.
I have a feeling that at some point, the insurance companies are going to start to pay attention here, because as you can imagine, the people who do best — and therefore the ones that they can make the most money from — are the ones who eat the best.
A recent publication of ours in The American Journal of Medicine, (Devries S, et al. Am J Med. 2017;doi:10.1016/j.amjmed.2017.04.043) showed an enormous gap in knowledge for health care providers on nutrition and lifestyle. Physicians get little if any training whatsoever during our schooling and training, and so we keep finding out that lifestyle seems to confer the best improvement.
If you look at some of the decreases in mortality that were quoted in the study here, a 20% increase in diet scores was associated with up to a 17% reduction in mortality.
These are not really achievable with most medicines that we use regularly. We have to better equip all health care providers with the knowledge and tools they need to counsel their patients, and on top of that, actually live this type of a lifestyle.
This study included doctors and nurses, as these were the cohorts from the Nurses’ Health Study and Health Professionals Follow-Up Study. I would argue that health care providers are some of the worst when it comes to eating well, and it’s something that we have to really strive to not only personally practice, but to learn more about so that we can counsel other patients by showing them how effective it is.
All three of the dietary recommendations from the U.S. Dietary Guidelines for Americans — one’s a plant-based diet, one’s a Mediterranean diet and one is the ‘Healthy’ American diet — are predominantly plant-based diets rich in fruits and vegetables, whole grains and legumes with limited amounts of meats and cheeses. It would be exciting to see a little bit more detail on specific dietary choices. For instance, could we repeat this exact analysis following people who are fully plant-based? Could we repeat this analysis with eliminating particular food groups and seeing what happens when we get rid of dairy products, which have been controversial, and when we eliminate eggs, which have been sort of controversial?
This study lays a lot of the groundwork for sustained healthful behaviors. We always talk about when people smoke cigarettes as pack-years. We often ask patients, ‘How many years did you smoke a pack a day for?’ Now we’re starting to find out that there seems to be an effect for obesity-years in the same vein. There seems to be an effect for how long were you eating healthy. I have a feeling what this is starting to show is it’s not just what you do in the short term, but what you also do in the long term.
The Alternative Healthy Eating Index participants did better, but how does that translate into actual advice for a patient? That’s where the next frontier is: translating eating healthier and healthy lifestyles into tangible menus and plans that patients can follow. Then we can see what really could happen. A lot of this work has been done, just not on such a large scale.
The evidence is becoming irrefutable, as a diet predominantly of plant-based foods seems to do well by people. The key take-home points are that eating well for a lifetime is important and that it’s not just a diet, but rather an entire lifestyle that’s important. We need to do a lot better now and train our health care providers and our team to reinforce that information.
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