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Association of dietary quality and risk of cardiovascular disease and mortality in 218,000

people from over 50 countries

Andrew Mente, on behalf of the PURE, ONTARGET, TRANSCEND, INTERHEART and INTERSTROKE investigators

Duality of Interests

None to declare with regards this presentation

Background• Most data on diet and health are from North America,

Europe, China, Japan; Consensus that fruits and vegetables are protective

• Recent cohort studies with all geographic regions of the world including South America, Middle East, Africa and South Asia also indicate:- Moderate intakes of whole-fat dairy, unprocessed

meat, fish, nuts (protective)- High starches (harmful)

Aims• To develop and validate a diet quality tool in

218,000 that is applicable globally

4 Large International Studies (N=218,005)PURE ONTARGET INTERHEART INTERSTROKE

N=138,527 N=31,546 N=27,098 N=20,834

Design Prospective cohort

Prospective cohort

Case-control Case-control

Follow-up, y 8.1 4.7 N/A N/ANo. of CVD events and total deaths

5466 CVD; 6821 deaths

5190 CVD; 3781 deaths

12,461 MI cases

10,402 stroke cases

Regions Global (21 countries)

N and S Amer/ Europe; Asia(40 countries)

Global (52 countries)

Global (36 countries)

• Based on intake of foods associated with lower risk of mortality:– Vegs, fruit, legumes, nuts, fish, dairy, unprocessed red meat

Scoring scheme• Each food receives a score of 1 (lowest), 2, 3, 4 or 5 (highest)

based on quintiles of intake• Total diet score: unweighted sum of each protective food• Min score = 7; Max score = 35

PURE Healthy Diet Score (N=138,527)

Healthy diet scoreQ1(Low)

Foods or nutrients

Q5(High)

1.8 Fruit & vegs 1 8.40.7 Nuts & legumes 1 2.5

0.2 Fish 1 0.30.6 Dairy 1 3.00.3 Red meat 1 1.4

69.1 Carb, %E 54.018.5 Fats, %E 28.311.9 Protein, %E 17.9

What a low & high PURE diet score looks like

1 servings/day

HealthyUnhealthy

Statistical Methods• Cox frailty analysis in PURE and ONTARGET/TRANSCEND• Logistic regression in INTERHEART and INTERSTROKE

accounting for clustering by centre• Adjusted for:

– Age and sex– Education, WHR, smoking, physical activity, energy– Diabetes, use of statin or BP lowering drugs

Risk of mortality by healthy diet score (PURE; N=138,527)

Diet Quality Score

≤11 12 to 13 14 to 15 16 to 17 ≥18 P-trend

No. events no. people (%)

1,43322,678(6.3)

1,54626,313 (5.9)

1,49029,241(5.1)

1,161 26,471(4.4)

1,19133,824(3.5)

Age, sex adj.

1.0 (ref) 0.90 (0.84-0.97)

0.76 (0.70-0.82)

0.69(0.63-0.75)

0.56 (0.51-0.61)

<0.0001

Fully adjusted

1.0 (ref) 0.94 (0.86-1.02)

0.82(0.76-0.90)

0.82(0.75-0.90)

0.75(0.68-0.83)

<0.0001

Risk of Mortality and Major CVD by healthy diet score (PURE; N=138,527)

Total mortality Major CVD

HR (95% CI) HR (95% CI)

P-trend<0.0001

P-trend=0.0413

Risk of Mortality and Major CVD by PURE healthy diet score (ONTARGET; N=31,546)

Total mortality Major CVD

HR (95% CI) HR (95% CI)

P-trend<0.0001

Risk of MI by PURE healthy diet score in INTERHEART (N=27,098)Diet Quality Score

≤11 12 to 14 15 to 16 17 to 18 ≥19 P-trend

N 3969 6087 5289 5162 6591

Cases (%) 2153 (54.3)

2909 (47.8)

2438 (46.1)

2245 (43.5)

2716 (41.2)

Age, sex adj.

1.0 (ref)

0.77(0.71-0.84)

0.72(0.66-0.78)

0.65(0.60-0.71)

0.60(0.55-0.65)

<0.0001

Fully adjusted

1.0 (ref)

0.86(0.79-0.94)

0.84(0.77-0.93)

0.81(0.73-0.89)

0.78(0.71-0.85)

<0.0001

Risk of stroke by PURE healthy diet score in INTERSTROKE (N=20,834)

Diet Quality Score

≤10 11 to 13 14 to 15 16 to 18 ≥19 P-trend

N 2712 4723 3597 4879 4923

Cases (%) 1420 (52.4)

2560 (54.2)

1878 (52.2)

2384 (48.9)

2160 (43.9)

Age, sex adj.

1.0 (ref)

1.07(0.98-1.18)

0.98(0.89-1.08)

0.85(0.78-0.94)

0.69(0.62-0.76)

<0.0001

Fully adjusted

1.0 (ref)

1.09(0.98-1.20)

0.95(0.86-1.06)

0.87(0.78-0.96)

0.75(0.68-0.84)

<0.0001

Conclusions• The PURE healthy diet score comprised of higher intakes of

fruit, vegs, nuts, legumes, fish, dairy, and meats is associated with lower mortality and CVD globally

• Consistency across 4 international studies using different designs involving 218,000 people from 50 countries

• Consistent results in those with and without prior CVD

• Some elements of the PURE healthy diet score (such as dairy and meats) differs from current advice derived from earlier studies & performed mostly in high-income countries

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