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

Abstract

Importance: The current Dietary Guidelines for Americans recommend multiple healthy eating patterns. However, few studies have examined the associations of adherence to different dietary patterns with long-term risk of total and cause-specific mortality.

Objective: To examine the associations of dietary scores for 4 healthy eating patterns with risk of total and cause-specific mortality.

Design, setting, and participants: This prospective cohort study included initially healthy women from the Nurses' Health Study (NHS; 1984-2020) and men from the Health Professionals Follow-up Study (HPFS; 1986-2020).

Exposures: Healthy Eating Index 2015 (HEI-2015), Alternate Mediterranean Diet (AMED) score, Healthful Plant-based Diet Index (HPDI), and Alternate Healthy Eating Index (AHEI).

Main outcomes and measures: The main outcomes were total and cause-specific mortality overall and stratified by race and ethnicity and other potential risk factors.

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). During a total of 3 559 056 person-years of follow-up, 31 263 women and 22 900 men died. When comparing the highest with the lowest quintiles, the pooled multivariable-adjusted HRs of total 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). All dietary scores were significantly inversely associated with death from cardiovascular disease, cancer, and respiratory disease. The AMED score and AHEI were inversely associated with mortality from neurodegenerative disease. The inverse associations between these scores and risk of mortality were consistent in different racial and ethnic groups, including Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

Conclusions and relevance: In this cohort study of 2 large prospective cohorts with up to 36 years of follow-up, greater adherence to various healthy eating patterns was consistently associated with lower risk of total and cause-specific mortality. These findings support the recommendations of Dietary Guidelines for Americans that multiple healthy eating patterns can be adapted to individual food traditions and preferences.

Figure.. Hazard Ratios of Death From Any Cause According to 4 Healthy Eating Scores Across Racial and Ethnic Groups in the Nurses’ Health Study

Multivariable analysis was adjusted for age, calendar year, marriage status (married; divorced, separated, or single; or widowed), living status (alone or not alone), family history of myocardial infarction (yes or no), family history of diabetes (yes or no), family history of cancer (yes or no), menopausal status (pre- or postmenopausal [never, past, or current menopausal hormone use]; Nurses’ Health Study only), multivitamin use (yes or no), aspirin use (yes or no), total energy intake (quintile), smoking status (never, former, or current smoker [1-14, 15-24, or ≥25 cigarettes/d]), alcohol drinking (0, 0.1-4.9, 5.0-14.9, 15.0-19.9, 20.0-29.9, or ≥30 g/d), physical activity (quintile), history of hypertension (yes or no), history of hypercholesterolemia (yes or no), and body mass index (<21, 21-24.9, 25-29.9, 30-34.9, or ≥35 [calculated as weight in kilograms divided by height in meters squared]). AHEI indicates Alternate Healthy Eating Index; AMED, Alternate Mediterranean Diet; HEI-2015, Healthy Eating Index 2015; HPDI, Healthful Plant-based Diet Index.