Co-benefits from sustainable dietary shifts for population and environmental health: an assessment from a large European cohort study.

BACKGROUND: Unhealthy diets, the rise of non-communicable diseases, and the declining health of the planet are highly intertwined, where food production and consumption are major drivers of increases in greenhouse gas emissions, substantial land use, and adverse health such as cancer and mortality. To assess the potential co-benefits from shifting to more sustainable diets, we aimed to investigate the associations of dietary greenhouse gas emissions and land use with all-cause and cause-specific mortality and cancer incidence rates. METHODS: Using data from 443 991 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC) study, a multicentre prospective cohort, we estimated associations between dietary contributions to greenhouse gas emissions and land use and all-cause and cause-specific mortality and incident cancers using Cox proportional hazards regression models. The main exposures were modelled as quartiles. Co-benefits, encompassing the potential effects of alternative diets on all-cause mortality and cancer and potential reductions in greenhouse gas emissions and land use, were estimated with counterfactual attributable fraction intervention models, simulating potential effects of dietary shifts based on the EAT-Lancet reference diet. FINDINGS: In the pooled analysis, there was an association between levels of dietary greenhouse gas emissions and all-cause mortality (adjusted hazard ratio [HR] 1·13 [95% CI 1·10-1·16]) and between land use and all-cause mortality (1·18 [1·15-1·21]) when comparing the fourth quartile to the first quartile. Similar associations were observed for cause-specific mortality. Associations were also observed between all-cause cancer incidence rates and greenhouse gas emissions, when comparing the fourth quartile to the first quartile (adjusted HR 1·11 [95% CI 1·09-1·14]) and between all-cause cancer incidence rates and land use (1·13 [1·10-1·15]); however, estimates differed by cancer type. Through counterfactual attributable fraction modelling of shifts in levels of adherence to the EAT-Lancet diet, we estimated that up to 19-63% of deaths and up to 10-39% of cancers could be prevented, in a 20-year risk period, by different levels of adherence to the EAT-Lancet reference diet. Additionally, switching from lower adherence to the EAT-Lancet reference diet to higher adherence could potentially reduce food-associated greenhouse gas emissions up to 50% and land use up to 62%. INTERPRETATION: Our results indicate that shifts towards universally sustainable diets could lead to co-benefits, such as minimising diet-related greenhouse gas emissions and land use, reducing the environmental footprint, aiding in climate change mitigation, and improving population health. FUNDING: European Commission (DG-SANCO), the International Agency for Research on Cancer (IARC), MRC Early Career Fellowship (MR/M501669/1).

To what extent do dietary costs explain socio-economic differences in dietary behavior?

BACKGROUND: Low socio-economic position is associated with consumption of lower quality diets, which may be partly explained by the cost of healthier diets. Therefore, we aimed to investigate the mediating role of dietary costs in the association between educational level and diet quality. METHODS: We used cross-sectional data from Dutch older adults (N = 9399) in the EPIC-NL cohort. Participants provided information about their own and their partners' highest attained educational level (as proxy for socio-economic position). Dietary behavior was assessed using a food frequency questionnaire from which we derived two diet-quality scores, including the Dutch Healthy Diet index 2015 (DHD15-index) and the Dietary Approaches to Stop Hypertension (DASH) diet. Dietary cost estimates were based on food price data from food stores, and linked to reported consumption of food items. Multiple regression analyses and bootstrapping were used examine the mediating role of dietary cost in the association between educational level and diet quality. RESULTS: Mean age of participants was 70 (SD: 10) years and 77% were women. Dietary costs significantly mediated the association between educational level and diet quality, except for high versus middle individual educational level and the DHD15-index. Depending on the dietary and educational indicator, dietary costs explained between 2 and 7% of the association between educational level and diet quality. Furthermore, associations were found to be modified by sex and age. For the DHD15-index, mediation effects were only present in females and adults older than 65 years, and for the DASH diet mediation effects were only present in females and strongest amongst adults older than 65 years compared to adults younger than 65 years. CONCLUSION: Dietary costs seems to play a modest role in explaining educational differences in diet quality in an older Dutch population. Further research is needed to investigate which other factors may explain SEP differences in diet quality.

Predicted burden could replace predicted risk in preventive strategies for cardiovascular disease.

OBJECTIVES: The objective of this study was to explore the extent of the differences in definitions of composite end points and assess how these differences influence estimates of cardiovascular disease (CVD) burden. STUDY DESIGN AND SETTINGS: Data from a Dutch cohort study (n = 19,484) was used to calculate 10-year risks according to four CVD risk prediction models: Adult Treatment Panel (ATP) III, Framingham Global Risk Score (FRS), Pooled Cohort Equations (PCE), and SCORE. Health loss was estimated based on the impact of event types included in the corresponding composite end points. Finally, each prediction model was used to estimate the expected CVD burden in high-risk individuals, expressed as Quality-Adjusted Life Years (QALYs) lost. RESULTS: The definition of the composite end points varied widely across the four models. FRS predicted the highest CVD risks, and the composite end point used in SCORE was associated with the highest health burden. The predicted CVD burden in high-risk individuals was 0.23, 0.74, 0.43, and 0.39 QALYs lost per individual when using ATP, FRS, PCE, and SCORE, respectively. CONCLUSION: The investigated CVD risk prediction models showed huge variation in definition of composite end points and associated health burden. Therefore, health consequences related to predicted risks cannot be readily compared across prediction models, and estimates of burden of disease depend crucially on the prediction model used.

Moderate alcohol consumption is associated with lower chronic disease burden expressed in disability-adjusted life years: a prospective cohort study.

The relation of alcohol consumption with disease burden remains debated partly due to opposite associations with cardiovascular disease (CVD) and cancer. The relation of alcohol consumption with disease burden expressed in disability-adjusted life years (DALYs) summarizes opposing associations of alcohol consumption on chronic diseases. This study aimed to investigate the association of alcohol consumption with chronic disease burden expressed in DALYs based on individual-participant data. The study was a prospective study among 33,066 men and women from the EPIC-NL cohort. At baseline, alcohol consumption was assessed with a validated food-frequency questionnaire. Participants were followed for occurrence of and mortality from chronic diseases and DALYs were calculated. After 12.4 years follow-up, 6647 disease incidences and 1482 deaths were documented, resulting in 68,225 healthy years of life lost (6225 DALYs). Moderate drinkers (women 5-14.9 g/day, men 5-29.9 g/day) had a lower chronic disease burden (mean DALYs -0.27; 95% CI -0.43; -0.11) than light drinkers (0-4.9 g/day), driven by a lower disease burden due to CVD (-0.18: -0.29; -0.06) but not cancer (-0.05: -0.16; 0.06). The associations were most pronounced among older participants (≥50 years; -0.32; -0.53; -0.10) and not observed among younger women (-0.08; -0.43; 0.35), albeit non-significant (pinteraction > 0.14). Substantial drinking (women 15-29.9 g/day, men 30-59.9 g/day) compared to light drinking was not associated with chronic disease burden. Our results show that moderate compared to light alcohol consumption was associated with living approximately 3 months longer in good health. These results were mainly observed among older participants and not seen among younger women.

Dietary patterns in relation to disease burden expressed in Disability-Adjusted Life Years.

BACKGROUND: Although diet is related to chronic disease risk and mortality, its association with total disease burden is not clear. OBJECTIVE: We investigated the minimum impact of different dietary patterns on disability-adjusted life years (DALYs) by using individual longitudinal data. DESIGN: A prospective cohort study was conducted in 33,066 healthy men and women aged 20-70 y recruited into the European Prospective Investigation into Cancer and Nutrition-Netherlands study during 1993-1997. We measured adherence to 3 a priori dietary patterns [the modified Mediterranean diet score (mMDS), the WHO-based Healthy Diet Indicator, and the Dutch Healthy Diet index] and 2 a posteriori dietary patterns. Two a posteriori methods were used to extract Western and prudent patterns. Participants were followed until the end of 2007 for the occurrence of and mortality from the most important chronic diseases. The disease burden was expressed in DALYs, which are the sum of Years Lost due to Disability and Years of Life Lost because of premature mortality. The associations between dietary patterns (per SD change in score) and DALYs were estimated by using a 2-part model and adjusted for relevant confounders (sex, age at recruitment, smoking status and intensity, educational level, marital status, job status, energy intake, and physical activity). RESULTS: After an average follow-up of 12.4 y, higher adherence to the mMDS or prudent pattern was most strongly associated with healthy survival; per SD higher adherence to the mMDS or prudent pattern, fewer healthy life years were lost [51 d (-0.14 DALYs; 95% CI: -0.21, -0.08 DALYs) and 58 d (-0.16 DALYs; 95% CI: -0.23, -0.09 DALYs), respectively]. CONCLUSION: In this Dutch study, of various dietary patterns evaluated, higher adherence to the mMDS or prudent dietary pattern was associated with a lower disease burden as assessed by DALYs.

Evaluation of cardiovascular risk predicted by different SCORE equations: the Netherlands as an example.

BACKGROUND: In Europe, for primary prevention of cardiovascular diseases (CVD), the Systematic COronary Risk Evaluation (SCORE) risk charts for high-risk and low-risk regions (SCORE-high and SCORE-low, respectively) are used. For the Dutch 'Clinical Practice Guideline for Cardiovascular Risk Management' an adapted SCORE risk chart (SCORE-NL) was developed in collaboration with the SCORE group. We evaluated these three SCORE equations using Dutch risk factor and mortality data. DESIGN: Prospective cohort study with 10-year follow-up. METHODS: Baseline data were collected between 1987 and 1997 in 32 885 persons aged 37.5-62.5 years. Vital status was checked and causes of death were obtained from Statistics Netherlands. On the basis of the level of risk factors, the expected number of CVD deaths was calculated by applying the three SCORE equations and compared with the observed number. RESULTS: The observed CVD mortality was three-fold higher in men (n=242; 1.6%) than in women (n=83; 0.5%). On the basis of SCORE-NL, 8.5% of the men and 0.8% of the women had a CVD mortality risk of 5% or more. The ratio of the observed-to-expected number of CVD deaths was 0.75 for men and 0.55 for women using SCORE-NL, 0.54 and 0.56 using SCORE-high, and 1.11 and 0.95 using SCORE-low. CONCLUSION: At the population level, SCORE-low predicts the number of CVD deaths well, whereas both SCORE-NL and SCORE-high overestimate the number of CVD deaths by a factor 1.5-2.