Exploring Environmental and Cardiometabolic Impacts Associated with Adherence to the Sustainable EAT-Lancet Reference Diet: Findings from the China Health and Nutrition Survey

Abstract

Background: To contribute to the growing evidence on the potential co-benefits of the EAT-Lancet reference diet for cardiometabolic health and sustainability, we investigated this topic in a nationwide prospective cohort of Chinese adults. Adherence to this diet has been measured using several indices, including the World Index for Sustainability and Health (WISH) and the Planetary Health Diet Index (PHDI).

Objectives: We aimed to investigate the associations between adherence to the EAT-Lancet reference diet, as evaluated by WISH and PHDI, with risk of new-onset cardiometabolic diseases (CMDs), risk of all-cause mortality, and greenhouse gas (GHG) emissions.

Methods: We included adults ($n=\mathrm{14,652}$ for CMDs and 15,318 for all-cause mortality) from the China Health and Nutrition Survey (1997-2015) in the analysis. Dietary intake data were collected, and WISH and PHDI scores were computed with established methods. CMDs included myocardial infarction (MI), type 2 diabetes mellitus (T2DM), and stroke. We used Cox proportional hazard regression models to analyze data with a mean of 10 years of follow-up from the date of baseline to the end of study or until the occurrence of the event of interest, whichever came first. We adjusted for sociodemographic, anthropometric, lifestyle, and dietary characteristics of participants as confounders.

Results: Greater adherence to the EAT-Lancet reference diet, as reflected by higher WISH or PHDI scores, was inversely associated with risk of MI {Q4 vs. Q1: $\text{hazard ratio}\left(\text{HR}\right)=0.68$ [95% confidence interval (CI): 0.48, 0.96] for WISH and 0.14 (95% CI: 0.07, 0.29) for PHDI}, T2DM [Q4 vs. Q1: $\text{HR}=0.81$ (95% CI: 0.67, 0.96) for WISH and 0.68 (95% CI: 0.57, 0.82) for PHDI], and all-cause mortality [Q4 vs. Q1: $\text{HR}=0.80$ (95% CI: 0.68, 0.95) for WISH and 0.60 (95% CI: 0.46, 0.80) for PHDI] in fully adjusted models (all $p$-trend $<0.05$). Both WISH and PHDI were inversely associated with GHG emissions in fully adjusted models (all $p$-trend $<0.05$). WISH and PHDI were not significantly associated with risk of stroke.

Conclusions: Our findings supported the co-benefits of the EAT-Lancet reference diet for both cardiometabolic health and environmental sustainability. Long-term adherence to this reference diet as effectively indicated by either higher WISH or PHDI scores may reduce the risk and burden of CMDs and all-cause mortality in Chinese adults. https://doi.org/10.1289/EHP15006.