Temporal trends in the planetary health diet index and its association with cardiovascular, kidney, and metabolic diseases: A comprehensive analysis from global and individual perspectives

Xie R., Herder C., Sha S., Peng L., Brenner H., Schöttker B.

Cai H., Talsma E.F., Chang Z., Wen X., Fan S., van't Veer P., Biesbroek S.

Teixeira B., Afonso C., Severo M., Oliveira A.

The prospective effect of healthy and planetary diets on cardiometabolic health at young ages remains unclear.

Zhang H., Zhou X., Shapiro M.D., Lip G.Y., Tilg H., Valenti L., Somers V.K., Byrne C.D., Targher G., Yang W., Viveiros O., Opio C.K., Mantzoros C.S., Ryan J.D., Kok K.Y., et. al.

Common metabolic diseases, such as type 2 diabetes mellitus (T2DM), hypertension, obesity, hypercholesterolemia, and metabolic dysfunction-associated steatotic liver disease (MASLD), have become a global health burden in the last three decades. The Global Burden of Disease, Injuries, and Risk Factors Study (GBD) data enables the first insights into the trends and burdens of these metabolic diseases from 1990 to 2021, highlighting regional, temporal and differences by sex.

de Oliveira Neta R.S., Lima S.C., Medeiros M.F., Araújo D.B., Bernardi N., de Araújo A.A., Jacob M.C., Neta A.D., Marchioni D.M., Lyra C.D., da Costa Oliveira A.G.

Abstract Background The EAT-Lancet diet is a diet aimed at promoting population and planetary health from the perspective of sustainable diets in terms of environmental and health aspects. This study aimed to assess the association between adherence to the EAT-Lancet diet and cardiometabolic risk factors among adults and elderly individuals in a capital city in the northeastern region of Brazil. Methods This is an analytical cross-sectional observational study from a population-based sample conducted between 2019 and 2020, involving 398 non-institutionalized adults and elderly people, of both sexes from “Brazilian Usual Consumption Assessment” study (Brazuca-Natal). There was a 38% response rate due to the suspension of data collection due to the covid-19 pandemic, but According to the comparative analysis of socioeconomic and demographic variables between the surveyed and non-surveyed sectors, losses were found to be random (p = 0.135, Little’s MCAR test). Socioeconomic and lifestyle data, anthropometric measurements, and dietary consumption were collected. We used the Planetary Health Diet Index (PHDI) and the Cardiovascular Health Diet Index (CHDI) for cardiovascular health to assess adherence to the diet’s sustainability. The evaluated cardiometabolic parameters included fasting blood glucose, triglycerides, total cholesterol, HDL-C, LDL-C, and systolic and diastolic blood pressure measurements. We also assessed the presence of type 2 diabetes mellitus, arterial hypertension, and dyslipidemia. For the data analyses, sample weights and the effect of the study design were taken into account. Pearson’s chi-square test was used to evaluate the statistical significance of frequencies. Multiple linear regression models assessed the associations between PHDI and CHDI and its components and the cardiometabolic parameters. Results The mean PHDI was 29.4 (95% CI 28.04:30.81), on a total score ranging from 0 to 150 points and the mean CHDI was 32.63 (95% CI 31.50:33.78), on a total score ranging from 0 to 110 points. PHDI showed a significant positive association with the final CHDI score and components of fruits, vegetables, and legumes, and a negative association with Ultra-processed Food (UPF) (p < 0.05). Notably, among the most consumed UPF, the following stand out: “packaged snacks, shoestring potatoes, and crackers” (16.94%), followed by margarine (14.14%). The PHDI exhibited a significant association with diabetes and dyslipidemia, as well as with systolic blood pressure, total cholesterol, and LDL-C. Conclusions The results suggest that adopting the EAT-Lancet diet is associated with the improvement of key cardiovascular health indicators.

Passarelli S., Free C.M., Shepon A., Beal T., Batis C., Golden C.D.

Inadequate micronutrient intakes and related deficiencies are a major challenge to global public health. Analyses over the past 10 years have assessed global micronutrient deficiencies and inadequate nutrient supplies, but there have been no global estimates of inadequate micronutrient intakes. We aimed to estimate the global prevalence of inadequate micronutrient intakes for 15 essential micronutrients and to identify dietary nutrient gaps in specific demographic groups and countries.

Sawicki C.M., Ramesh G., Bui L., Nair N.K., Hu F.B., Rimm E.B., Stampfer M.J., Willett W.C., Bhupathiraju S.N.

In 2019, the EAT-Lancet Commission on healthy diets from sustainable food systems proposed a Planetary Health Diet that seeks to optimise both chronic disease prevention as well as global environmental health. In this study, we aimed to examine the association between a dietary index based on the Planetary Health Diet and risk of cardiovascular disease.

Chen Y., Tang H., Nan L., Liang X., Yang P., Zhang X., Huang J., Yang Q., Huang S., Lin L.

Basic research shows that flavonoids have anti-inflammatory effects that influence rheumatoid arthritis (RA) in rats. Investigating potential dietary interventions for RA helps prevent the onset and progression of the disease. Clinical evidence on the association of- flavonoid and subclass intake with RA is lacking. Using three survey cycles of 2007–2008, 2009–2010 and 2017–2018 from the National Health and Nutrition Survey and the United States Department of Agriculture's Food and Nutrient Database for Dietary Studies (FNDDS), we analyzed 7,419 American adults (≥20 years old). The values of flavonoid and subclass intake were calculated using FNDDS. The status questions for self-reported RA were from the NHANES codebook. Weighted analyses, revealed that among the 7,419 participants included in this study (mean age of 44.69 years [standard error, 0.40] and3,584 [48.31%] were female), 408 met the classification criteria for RA. According to the multivariable logistic regression model, compared with the risk of RA in the first quartile (Q1), the risks of RA in the second quartile (Q2), the third quartile (Q3) and the fourth quartile (Q4))were lower (Q2: OR=0.55, 95% CI: 0.38–0.80; Q3: OR=0.66, 95% CI: 0.44–0.97; Q4: OR=0.64, 95% CI: 0.46–0.89;trend: P=0.03). The association between total flavonoids and RA remained significant after full consideration of confounding factors. With regard to the subclasses of flavonoids, high flavanones intake was associated with low RA prevalence in Model 3 (Q3: OR= 0.60, 95% CI:0.39–0.92; Q4: OR = 0.56 95% CI: 0.32–0.99, trend:P =0.02) but no such association was found in the other subclasses. Total flavonoids intake protected against RA, and the risk of developing RA decreased significantly with increasing intake of total flavonoids. Total flavonoids and flavanones were significantly associated with reduced RA risk for the American adult population. We highlighted the importance of employing diverse methodologies to assess the health effects of flavonoids.

Sotos-Prieto M., Ortolá R., Maroto-Rodriguez J., Carballo-Casla A., Kales S.N., Rodríguez-Artalejo F.

Abstract Background The Planetary Health Diet index (PHDI) prioritizes the well-being of both individuals and the planet but has yielded mixed results on cardiovascular disease (CVD). Our aim was to assess the association between the PHDI and risk of CVD. Methods A cohort of 118,469 individuals aged 40-69 years from the UK Biobank, who were free of CVD at 2009-2012 and followed-up to 2021. The PHDI was calculated using at least two 24-h dietary assessments and included 14 food groups, with a possible range from 0 to130 points. CVD incidence was defined as primary myocardial infarction or stroke and obtained from clinical records and death registries. Results During a 9.4-year follow-up, 5,257 incident cases of CVD were ascertained. When comparing the highest (89.9-128.5 points) versus the lowest quartile (21.1-71.1 points) of PHDI adherence, the multivariable-adjusted hazard ratio (95% confidence interval) was 0.86 (0.79, 0.94) for CVD, 0.88 (0.80, 0.97) for myocardial infarction, and 0.82 (0.70, 0.97) for stroke. The association was linear until a plateau effect was reached at 80 points of adherence to PHDI. Results remained robust when excluding participants with type 2 diabetes, including only those with three or more diet assessments, or excluding CVD cases in the first three years of follow-up. The food group components of the PHDI more strongly associated with reduced CVD risk were higher consumption of whole grains, whole fruits, fish and lower consumption of added sugars and fruit juices. Conclusion In this large cohort of middle-aged and older British adults, adherence to the PHDI was associated with lower risk of CVD. These results provide empirical evidence that this dietary pattern, thought to be environmentally sustainable, benefits cardiovascular health.

Li J., Lei L., Wang W., Ding W., Yu Y., Pu B., Peng Y., Li Y., Zhang L., Guo Y.

Background Poor cardiovascular‐kidney‐metabolic (CKM) health is associated with premature mortality and excess morbidity in the United States. Adverse social conditions have a prominent impact on cardiometabolic diseases during the life course. We aim to examine the association between social risk profile (SRP) and CKM multimorbidity among US adults. Methods and Results We used data from the National Health and Nutrition Examination Survey from 1999 to 2018. The definition of CKM syndrome is the coexistence of subclinical or clinical cardiovascular disease, chronic kidney disease, and metabolic disorders. We classified participants by 4 CKM stages according to the different clinical severity of different forms of CKM syndrome. We calculated the summed number of positive SRP measures, including employed, high‐income level, food secure, high education attainment, private insurance, owning a house, and married, as SRP scores and classified them into 4 levels by quartiles: low (0–2), lower‐middle (3–4), upper‐middle (5–6), and high (7–8). A total of 18 373 US adults, aged 20 to 79 years, were included in our analyses. There were 2567 (9.4%) participants with low SRP score level. Most individual SRP measures and a combined SRP score were associated with CKM stages. Compared with high SRP score level, low SRP level was associated with higher odds of having CKM stage 1 (odds ratio [OR], 1.34 [95% CI, 1.06–1.70]), CKM stage 2 (OR, 2.03 [95% CI, 1.59–2.58]), CKM stage 3 (OR, 5.28 [95% CI, 3.29–8.47]), and CKM stage 4 (OR, 5.97 [95% CI, 4.20–8.49]). Conclusions Cumulative social disadvantage, denoted by higher SRP burden, was associated with higher odds of CKM multimorbidity, independent of demographic and lifestyle factors.

Chen H., Wang X., Ji J.S., Huang L., Qi Y., Wu Y., He P., Li Y., Bodirsky B.L., Müller C., Willett W.C., Yuan C.

Plant-based diets (PBDs) and planetary-health diets (PHDs) are recommended for their potential health and environmental benefits, but population-based evidence in diverse cultures is scarce.

Zhang S., Yan Y., Zeng X., Gu Y., Wu H., Zhang Q., Liu L., Huo Z., Luo X., Zhang R., Sonestedt E., Borné Y., Qi L., Huang T., Zheng M., et. al.

Background & Aims: The EAT-Lancet Commission devised a globally sustainable dietary pattern to jointly promote human health and sustainability. However, the extent to which this diet supports metabolic dysfunction-associated steatotic liver disease (MASLD) has not yet been assessed. This study aimed to investigate the association between the EAT-Lancet diet and risk of MASLD and its severity. Approach & Results: This prospective multi-cohort study included 15,263 adults from the Tianjin Chronic Low-grade Systemic Inflammation and Health (TCLSIH) cohort, 1,137 adults from the Guangzhou Nutrition and Health Study (GNHS) cohort, and 175,078 adults from the UK Biobank. Additionally, 228 Chinese adults from the Prospective Epidemic Research Specifically of Non-alcoholic Steatohepatitis (PERSONS) with biopsy-proven MASLD were included. An EAT-Lancet diet index was created to reflect adherence to the EAT-Lancet reference diet. The TCLSIH cohort recorded 3,010 MASLD cases during 53,575 person-years of follow-up, the GNHS cohort documented 624 MASLD cases during 6,454 person-years of follow-up, and the UK Biobank 1,350 developed MASLD cases during 1,745,432 person-years of follow-up. In multivariable models, participants in the highest tertiles of the EAT-Lancet diet index had a lower risk of MASLD compared with those in the lowest tertiles (TCLSIH: HR=0.87, 95% CI: 0.78, 0.96; GNHS: HR=0.79, 95% CI: 0.64, 0.98; UK Biobank: HR=0.73, 95% CI: 0.63, 0.85). Moreover, liver controlled attenuation parameter decreased with increasing the diet index in individuals with biopsy-proven MASLD (β=−5.895; 95% CI: −10.014, −1.775). Conclusions: Adherence to the EAT-Lancet reference diet was inversely associated with risk of MASLD as well as its severity.

Morcel J., Béghin L., Michels N., De Ruyter T., Drumez E., Cailliau E., Polito A., Le Donne C., Barnaba L., Azzini E., De Henauw S., Miguel Berges M.L., Cacau L.T., Moreno L.A., Gottrand F.

Cardiovascular diseases are the leading cause of mortality worldwide, originating in the first decades of life. A better understanding of their early determinants would allow for better prevention. This study aimed to evaluate the impact of nutritional and activity-related characteristics during adolescence on young adult cardiovascular risk factors.

Bui L.P., Pham T.T., Wang F., Chai B., Sun Q., Hu F.B., Lee K.H., Guasch-Ferre M., Willett W.C.

In 2019, the EAT-Lancet Commission proposed a healthy dietary pattern that, along with reductions in food waste and improved agricultural practices, could feed the increasing global population sustainably. We developed a Planetary Health Diet Index (PHDI) to quantify adherence to the EAT-Lancet reference diet. We aimed to assess associations between PHDI and total and cause-specific mortality in 3 prospective cohorts of males and females in the United States. We followed 66,692 females from the Nurses' Health Study (1986–2019), 92,438 females from the Nurses' Health Study II (1989–2019), and 47,274 males from the Health Professionals Follow-up Study (1986–2018) who were free of cancer, diabetes, and major cardiovascular diseases at baseline. The PHDI was calculated every 4 y using a semiquantitative food frequency questionnaire. Hazard ratios (HRs) were calculated using multivariable proportional-hazards models. During follow-up, we documented 31,330 deaths among females and 23,206 among males. When comparing the highest with the lowest quintile of PHDI, the pooled multivariable-adjusted HRs were 0.77 [95% confidence interval (CI): 0.75, 0.80] for all-cause mortality (P-trend < 0.0001). The PHDI was associated with lower risk of deaths from cardiovascular diseases (HR: 0.86; 95% CI: 0.81, 0.91), cancer (HR: 0.90; 95% CI: 0.85, 0.95), respiratory diseases (HR: 0.53; 95% CI: 0.48, 0.59), and neurodegenerative diseases (HR: 0.72; 95% CI: 0.67, 0.78). In females, but not males, the PHDI was also significantly associated with a lower risk of deaths from infectious diseases (HR: 0.62; 95% CI: 0.51, 0.76). PHDI scores were also associated inversely with greenhouse gas emissions and other environmental impacts. In 3 large United States-based prospective cohorts of males and females with up to 34 y of follow-up, a higher PHDI was associated with lower risk of total and cause-specific mortality and environment impacts.

Zhang S., Marken I., Stubbendorff A., Ericson U., Qi L., Sonestedt E., Borné Y.

The landmark EAT-Lancet Commission proposed that a planetary health diet is comprised mainly of plant-based foods. However, studies examining whether this diet is associated with heart failure (HF) are currently lacking. In addition, the potential proteomics mechanism on the association between diet and HF warrants further elucidation. This study aims to both examine the association between the EAT-Lancet diet index and risk of HF and identify plasma proteins underlying such an association. This prospective cohort study included 23,260 participants. HF cases during the follow-up were identified through the Swedish national register. An EAT-Lancet diet index (score range: 0-42) was created to assess adherence to the EAT-Lancet reference diet. In a subcohort (n = 4,742), fasting plasma proteins were quantified. During a median follow-up of 25.0 years, 1,768 incident HF cases were documented. After adjusting for sociodemographic, lifestyle, diabetes, hypertension, use of lipid-lowering drugs, and body mass index, the HR per 3-point increase of the EAT-Lancet diet index was 0.93 (95% CI: 0.88-0.97). This association was robust in several sensitivity analyses. Among the included 136 plasma proteins, a total of 8 proteins (AM, GDF15, IL6, TIM, CTSD, CCL20, FS, and FUR) were both inversely associated with the EAT-Lancet diet index and positively associated with risk of HF; the overall proteomic score mediated 9.4% (95% CI: 2.2%-32.1%) of the association. Higher adherence to the EAT-Lancet diet was associated with a lower risk of HF. The identified eight plasma proteins provide information on potential pathways mediating such an association.