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Part B. Section 2. Appendix: Dietary Patterns and Health Outcomes June 8, 2011

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Part B. Section 2. Appendix: Dietary

Patterns and Health Outcomes

 

 

 

 

 

Introduction

 

 

Across the world and within the United States, there are striking differences in diet. Concomitantly, there are substantial differences in health outcomes, many of which are related to diet. This section discusses several dietary patterns that are associated with desirable health outcomes. It focuses on total mortality, cardiovascular disease (CVD), and blood pressure, a major diet-related cardiovascular risk factor. The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR), recently reviewed the available evidence of the relationship of cancer with specific dietary factors and overall dietary patterns (WCRF/AICR, 2007). Although several dietary factors were associated with specific types of cancer, it concluded that no firm judgment can be made on the relationship of dietary patterns with cancer, in large

part, because variability in definitions precluded a formal synthesis of evidence.

 

The study of dietary patterns is complex. First, there is substantial heterogeneity even among diets that fall under a common rubric (e.g., Mediterranean diets). Second, dietary patterns are not static. Traditional diets known for their health benefits (e.g., Mediterranean and Okinawan diets) are being supplanted by versions that often reflect Western culture and that lead to worse not better health outcomes. For this reason, we focused on pre-transition dietary patterns. Third, with few exceptions, standardized assessment of diet is unavailable, making it difficult to compare diets.

Fourth, health outcomes are often unavailable and, when available, are not directly comparable across studies. Fifth, dietary patterns, even with proven health benefits, may not be ideal and could be improved. For example, traditional Japanese diets are associated with a low risk of coronary heart disease but a high risk of stroke, likely because of excessive sodium intake. Sixth, describing dietary patterns and evaluating their health outcomes often requires scoring systems based on adherence to specific aspects of the diets. This approach commonly relies on researchers who exercise best judgment in selecting biologically relevant aspects of

the diet and in developing a formula, which typically

weights each dimension as of equivalent importance. Seventh, in the interpretation of observational data, particularly ecologic data, it is difficult to separate the effects of diet from other factors, such as smoking and physical inactivity, that likely account for part of the observed differences in health outcomes.

 

Despite these caveats, the 2010 Dietary Guidelines Advisory Committee (DGAC) was able to identify dietary patterns that are associated with substantial beneficial health benefits (Table B2.5). Specifically, the Committee focused on the following dietary patterns for which there was research on health outcomes as well as information on nutrient and food group composition:

(1) Dietary Approaches to Stop Hypertension (DASH)- style dietary patterns, (2) Mediterranean-style dietary patterns, and (3) Vegetarian dietary patterns. The DASH dietary pattern is a Western-style dietary pattern for which a large and burgeoning literature documents its health benefits. The Committee also included Mediterranean and Japanese dietary patterns, which were associated with the lowest risk of coronary heart disease in the Seven Countries study (Keys, 1980). Subsequently, a substantial literature has documented the health benefits of Mediterranean-style diets. In contrast, while traditional Asian dietary patterns (e.g.,

Japanese and Okinawan dietary patterns) have also been associated with a reduced risk of coronary heart disease (Wilcox, 2007), documentation using contemporary research methods is scant. Finally, the Committee studied vegetarian diets, which have been associated with a reduced risk of coronary heart disease (Key,

1999).

 

 

 

DASH-style Dietary Patterns

 

 

DASH-style dietary patterns emphasize fruits, vegetables, and low-fat dairy products; include whole grains, poultry, fish and nuts; and are reduced in red meat, sweets, and sugar-containing beverages (Karanja,

1999; Craddick, 2003). The diets are rich in potassium, magnesium, calcium and fiber, and reduced in saturated fat and cholesterol. As originally tested, the DASH diet is reduced in total fat (27% kcal) with total protein

 

 

2010 Dietary Guidelines Advisory Committee Report                                                                                 27

 

intake of 18 percent of calories and carbohydrate intake of 55 percent of calories. However, other versions of the DASH diet are available, in which carbohydrate is partially replaced with protein (about half from plant sources) or unsaturated fat (predominantly monounsaturated fat) (Appel, 2005; Swain, 2008). The latter version is noteworthy because nutrient adequacy and a reduced saturated fat intake (6% kcal) were both achieved in the setting of high monounsaturated fat intake (21% kcal). Each of these DASH-style diets lowers blood pressure, improves blood lipids, and reduces CVD risk. Blood pressure reduction is the greatest when the DASH diet is consumed with reduced sodium intake (Sacks, 2001).

 

As originally developed, the DASH diet was designed to provide a nutrient profile that might lower blood pressure. As such, it is a derived dietary pattern. Nonetheless, it is based on foods that are routinely available in U.S. and was studied using foods purchased at local stores. At present, few adults, even those with hypertension, eat a diet that is consistent with the

DASH dietary pattern (Mellen, 2008).

 

 

 

Mediterranean-style Dietary Patterns

 

 

In view of the large number of cultures and agricultural patterns of countries that border the Mediterranean Sea, the “Mediterranean” diet is not a single dietary pattern. Countries included those of southern-most Europe, the Middle East, and northern-most Africa. Interest in traditional Mediterranean-style diets is substantial because such diets have been associated with considerable health benefits. Because of the multiplicity of dietary patterns termed “Mediterranean,” it has been challenging to characterize these diets. Although a traditional Mediterranean diet has no well-accepted set of criteria, it can be described as one that emphasizes breads and other cereal foods usually made from wheat, vegetables, fruits, nuts, unrefined cereals, and olive oil; includes fish and wine with meals (in non-Islamic countries); and is reduced in saturated fat, meat, and

full-fat dairy products (Kris-Etherton, 2001; Trichopoulou, 2003; WCRF/AICR, 2007). Table B2.5 displays the nutrient profile and food group composition of Mediterranean-style diets, as reported in three cohort studies (one from Greece, one from Spain, and one from the U.S.) (Fung, 2009; Karanja, 1999; Lin, 2003;

Nunez-Cordoba, 2008; Trichopoulou, 2003; Wilcox,

2007).

Results from observational studies and clinical trials suggest that consumption of a traditional Mediterranean diet, similar to that of Crete in the 1960s, is associated with one of the lowest risks of coronary heart disease in the world. Over time, the diet of Crete has changed remarkably and is now characterized by higher intake of saturated fat and cholesterol, and reduced intake of monounsaturated fats. At the same time, total fat consumption has fallen. These trends have been accompanied by a steady rise in coronary heart disease risk (Menotti, 1999).

 

 

 

Vegetarian Dietary Patterns

 

 

In many observational studies, vegetarian diets and lifestyle have been associated with improved health outcomes. The types of vegetarian diets consumed in the U.S. vary considerably. Strict vegetarians (i.e., vegans), do not consume any animal products, while other types of vegetarians, such as lacto-ovo

vegetarians, consume milk and eggs. Although not strict vegetarians, many individuals consume small or

minimal amounts of animal products. On average, vegetarians consume fewer calories from fat than non- vegetarians, particularly saturated fat, and have a higher consumption of carbohydrates than non-vegetarians. In addition, vegetarians tend to consume fewer overall calories and have a lower body mass index than non- vegetarians. These characteristics, in addition to the dietary pattern per se, may contribute to the improved health outcomes of vegetarians.

 

Although no or minimal consumption of animal products is a hallmark of vegetarian diets, these diets have a clear potential for confounding, particularly from other dietary and non-dietary factors. Hence, the improved health experience of vegetarians may not only result from reduced consumption of saturated fats but also from greater consumption of vegetables, fruit, nuts, and grains or from other health attributes, such as not smoking cigarettes.

 

 

 

Other Dietary Patterns

 

 

In view of the increasing diversity of the U.S. population, interest in the health effects of non-Western diets is substantial. One group of diets with potential health benefits are those consumed in Asia. It is well- documented that in Southeast Asia, coronary heart disease rates have been among the lowest in the world.

 

 

28                                                                                      2010 Dietary Guidelines Advisory Committee Report

 

Lifestyle factors, especially diet, appear to be a major reason. However, contemporary evidence (e.g., prospective cohort studies and clinical trials) similar to the evidence available for the other types of diets is sparse.

 

Traditional Japanese dietary patterns emphasize soybean products, fish, seaweeds, vegetables, fruit, and green tea, and are reduced in meats (Shimazu, 2007). Nonetheless, it should be recognized that this diet is high in salt, likely accounting for the high incidence of stroke in this population. Similar to other dietary patterns, Japanese dietary patterns have evolved over time.

 

The longevity of Okinawans is among the highest in the world. Researchers attribute the longevity and health of Okinawans, in large part, to diet composition or some other aspect of their diet, such as energy restriction (Willcox, 2007). The indigenous Satsamu sweet potato, which is rich in nutrients, is the food staple that

provides the bulk of energy intake. Other prominent foods are a wide variety of seaweeds, Okinawan tofu, and herbaceous plants. Okinawan food culture also includes a modest amount of fish and pork. The estimated carbohydrate content of this diet is extremely high, at more than 80 percent of calories. Salt intake is the lowest of all Japan. However, the traditional Okinawan diet has changed such that fast foods and processed foods are increasingly consumed.

 

 

 

What is the Effect of Different Dietary Patterns (DASH, Mediterranean, Vegetarian, and Other) on Blood Pressure in Adults?

 

 

The 2010 DGAC performed a literature search to identify research, with no date limits, on the effect of the above dietary patterns on blood pressure in adults. Some articles were reviewed that included dietary patterns that were characterized using dietary cluster or

factor analysis. The NEL search identified 146 potential articles (11 reviews/meta-analyses and 135 primary studies). Of these, 126 were excluded. A total of 20 articles, all of them primary studies, met the eligibility criteria and were reviewed (Table B2.6).

 

Of the 12 studies that evaluated a DASH-style dietary pattern (Appel, 2005, 1997, 2003; Azadbakht, 2005; Dauchet, 2007; Forman, 2009; Miller, 2002; Nowson,

2009, 2005, 2004; Sacks, 2001; Schulze, 2003), nine were randomized controlled trials (Appel, 2005, 1997,

2003; Azadbakht, 2005; Miller, 2002; Nowson, 2009,

2005, 2004; Sacks, 2001), and three were prospective cohort studies (Dauchet, 2007; Forman, 2009; Schulze,

2003). In aggregate, the DASH diet lowered systolic blood pressure in 12 studies (Appel, 2005, 1997, 2003; Azadbakht, 2005; Dauchet, 2007; Forman, 2009; Miller, 2002; Nowson, 2009, 2005, 2004; Sacks, 2001;

Schulze, 2003) and diastolic blood pressure in 10 of the

12 studies that reported diastolic blood pressure (Appel,

2005, 1997, 2003; Azadbakht, 2005; Dauchet, 2007; Forman, 2009; Miller, 2002; Nowson, 2005, 2004; Schulze, 2003). In several instances, blood pressure reduction occurred as part of a multi-factorial intervention that tested the DASH dietary pattern concomitantly with other interventions (Appel, 2003; Miller, 2002; Sacks, 2001).

 

Few studies examined the effects of a Mediterranean- style diet on blood pressure. In the one available study (Núñez-Córdoba, 2009) a cohort study, a Mediterranean-style diet lowered systolic and diastolic blood pressure.

 

Four trials tested the effects of vegetarian diets on blood pressure (Hakala and Karvetti, 1989; Margetts, 1986; Rouse, 1983; Sciarrone 1993). Vegetarian-style dietary patterns lowered systolic blood pressure in all four trials and diastolic blood pressure in three trials (Hakala and Karvetti, 1989; Rouse, 1983; Sciarrone, 1993).

 

One randomized, cross-over trial found that, within the context of a traditional Japanese diet, increased vegetables and fruit intake and decreased sodium intake significantly reduced systolic blood pressure in normotensive and hypertensive free-living rural Japanese (Takahashi, 2006).

 

 

 

What is the Effect of Different Dietary Patterns (DASH, Mediterranean, Vegetarian, and Other) on Cardiovascular Disease, Stroke, and Total Mortality in Adults?

 

 

The 2010 DGAC performed a literature search to identify research, with no date limits, on the effect of these dietary patterns on cardiovascular disease, stroke, and total mortality in adults. Some articles were reviewed that included dietary patterns that were characterized using dietary clusters or factor analysis. The search identified 197 potential articles (11 reviews/meta-analyses and 186 primary studies). Of

 

 

2010 Dietary Guidelines Advisory Committee Report                                                                                 29

 

these, 168 were excluded. A total of 29 articles (27 primary studies, one systematic review/meta-analysis, and one systematic review), met the eligibility criteria and were reviewed. Of the 27 primary studies, two were randomized controlled trials, 20 were prospective

cohort studies (two were follow-up of RCTs and one was non-concurrent), three were case-control studies, one was a med adherence analysis, and one was a time series (Table B2.7).

 

Of the 10 studies that evaluated a DASH-style dietary pattern, nine were prospective cohort studies (Folsom,

2007; Fung, 2001, 2008; Heidemann, 2008; Hu, 2000; Levitan, 2009; Osler, 2001; Parikh, 2009; Singman,

1980) and one was a randomized trial in which estimated coronary heart disease risk was the outcome (Appel, 2005). Of the 10 that evaluated a relationship of a DASH-style dietary pattern with CVD, nine studies documented that consumption of a DASH-style diet was associated with a reduced risk of CVD (Appel, 2005; Fung, 2001, 2008; Heidemann, 2008; Hu, 2000;

Levitan, 2009; Osler, 2001; Parikh, 2009; Singman,

1980), and one (Folsom, 2007) found no such relationship. For total mortality, six of seven studies that reported data on mortality documented an inverse relation (Fung, 2008; Heidemann, 2008; Hu, 2000; Levitan, 2009; Osler, 2001; Parikh, 2009) and one (Folsom, 2007) found no such relationship. In the two available studies with stroke (Fung, 2008; Parikh,

2009), consumption of a DASH-style pattern prevented stroke.

 

Several studies examined the effects of a Mediterranean style diet on CVD and total mortality. Of the 13 studies, one was a systematic review/meta-analysis (Mente,

2009), one was a meta-analysis (Sofi, 2008), nine were prospective cohort studies (Fidanza, 2004; Fung, 2009; Harriss, 2007; Knoops, 2004; Mitrou, 2007; Panagiotakos, 2009; Trichopoulou, 2003, 2009; Waijers, 2006), one was an adherence analysis (Alberti,

2008), and one was a case-control study (Panagiotakos,

2005). Of the 10 studies that evaluated a relationship of a Mediterranean-style dietary pattern with CVD, each documented a beneficial effect (Fidanza, 2004; Fung,

2009; Harriss, 2007; Knoops, 2004; Mente, 2009; Mitrou, 2007; Panagiotakos, 2009, 2005; Sofi, 2008; Trichopoulou, 2003). Likewise, of the 10 studies with data on total mortality, each documented an inverse relation (Alberti, 2008; Fidanza, 2004; Fung, 2009; Harriss, 2007; Knoops, 2004; Mitrou, 2007; Sofi, 2008; Trichopoulou, 2003, 2009; Waijers, 2006). In the one available study with stroke, consumption of a

Mediterranean-style pattern prevented stroke (Fung,

2009).

 

Five studies examined the effects of a vegetarian diet on CVD and total mortality. Of the five studies, three were prospective cohort studies (Chang-Claude, 2005; Key,

1996; Mann, 1997), one was a meta-analysis (Key,

1998), and one was a time series analysis (Fraser,

2005). Of the five studies with CVD as the study outcome, all found that vegetarian diets were associated with a reduced risk of CVD compared to non-vegetarian diets (Chang-Claude, 2005; Fraser, 2005; Key, 1998,

1996; Mann, 1997). For total mortality, four studies (Fraser, 2005; Key, 1998, 1996; Mann, 1997) documented that a vegetarian diet was associated with a reduced risk of death, and one study (Chang-Claude,

2005) did not detect an association.

 

One prospective cohort study (Shimazu, 2007) assessed the association between dietary patterns among the Japanese and CVD mortality. Three diet patterns were identified: (1) Japanese pattern including soybean products, fish, seaweed, vegetables, fruit and green tea, (2) animal food pattern, and (3) high-dairy, high-fruit and vegetable, low alcohol (DFA) pattern. The Japanese pattern was associated with a decreased risk of CVD mortality, while the animal food pattern was associated with increased risk. The DFA pattern was not significantly associated with a change in CVD risk.

 

 

 

Conclusion

 

 

The totality of evidence documenting a beneficial impact of plant-based, lower-sodium dietary patterns on CVD risk is remarkable. Indeed, several distinct dietary patterns are associated with lower blood pressure and a reduced risk of CVD and total mortality. When explicitly tested, a reduced sodium intake further lowers blood pressure. A common feature of these diets is an emphasis on plant-based foods. Accordingly, fiber

intake is high while saturated fat typically low. When total fat intake is high, that is, over 30 percent of calories, the predominant fat is monounsaturated or polyunsaturated fat. Carbohydrate intake is often, but not necessarily high; the predominant forms appear to be complex carbohydrates, often from whole grain products with minimal processing.

 

 

 

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2006 Mar;24(3):451-8.

 

Trichopoulou A, Bamia C, Trichopoulos D. Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ. 2009 Jun 23;338:b2337.

 

 

Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003 Jun

26;348(26):2599-608.

 

2010 Dietary Guidelines Advisory Committee Report                                                                                 33

 

Trichopoulou A, Kouris-Blazos A, Vassilakou T, Gnardellis C, Polychronopoulos E, Venizelos M, Lagiou P, Wahlqvist ML, Trichopoulos D. Diet and survival of elderly Greeks: a link to the past. Am J Clin Nutr. 1995 Jun;61(6 Suppl):1346S-1350S.

 

Waijers PM, Ocké MC, van Rossum CT, Peeters PH, Bamia C, Chloptsios Y, van der Schouw YT, Slimani N, Bueno-de-Mesquita HB. Dietary patterns and survival in older Dutch women. Am J Clin Nutr. 2006

May;83(5):1170-6.

Willcox BJ, Willcox DC, Todoriki H, Fujiyoshi A, Yano K, He Q, Curb JD, Suzuki M. Caloric restriction, the traditional Okinawan diet, and healthy aging: the diet of the world’s longest-lived people and its potential impact on morbidity and life span. Ann N Y Acad Sci.

2007 Oct;1114:434-55.

 

World Cancer Research Fund and American Institute for Cancer Research Report (WCRF/AICR). Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR,

2007.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34                                                                                      2010 Dietary Guidelines Advisory Committee Report

 

Table B2.5. Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)

 

 

 

Dietary Pattern

DASH with

Reduced Sodium

Mediterranean

Diet (Greece)

Mediterranean

Diet (Spain)

Mediterranean

Diet (U.S.)

 

 

Japanese

 

 

Okinawan

Citation Karanja et al, 1999 Trichopoulou et al, Nunez-Cordoba Fung et al, 2009 Wilcox et al, 2007 Wilcox et al, 2007
  and Lin et al, 2003 NEJM 2003 2008 (SUN Study;   (Circa 1950) (Circa 1949)
      MAI high score)      
Qualitative            
Description

Emphasizes

 

Potassium-rich

 

Plant- foods,

 

Plant- foods,

 

Plant foods,

 

Rice, legumes, soy

 

Plant-foods,

  vegetables, fruits, vegetables, fruits, vegetables, fruits, vegetables, fruits, foods, vegetables, primarily
  and low-fat dairy grains, beans, nuts breads, other cereals whole grains, seaweed, and fish Okinawan sweet
  products and seeds, olive oil, potatoes, beans, nuts legumes,   potatoes, rice,
    and fish and seeds, olive oil, fish   legumes, soy foods,
      and fish     other vegetables,
            and nutrient rich
            foods of low energy
            density
Includes Whole grains, Lean meat Cheese, yogurt Lean meat Fruit  
  poultry, fish, and Red wine Red wine   Meat and eggs  
  nuts          
Limits (small Red meats, sweets,   Red meat Potatoes Milk products Fruit
amount) and sugar-   Sweets     Meat, eggs
  containing         Milk products
  beverages          
Nutrients

Calories (kcal)

 

2000

 

2000

 

2000

 

2000

 

2000

 

2000

Carbohydrates 58% nd 47% 39.1% 79% 85%
(% total kcal)            
Protein 18% nd 18% 15.1% 13% 9%
(% total kcal)            
Total Fat 27% ~42.7 (summed) 33% nd 8% 6%
(% total kcal)            
Saturated Fat 7% 13.1 % 10% 10% (Incl. trans) 2.0% 1.9%
(% total kcal)            
Monounsaturated 10% 22.7% 15 % 9.5% 2.3% 1.8%

(% total kcal)

 

Table B2.5 (continued). Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)

 

 

 

 

Dietary Pattern

 

 

DASH with

Reduced Sodium

 

 

Mediterranean

Diet (Greece)

 

 

Mediterranean

Diet (Spain)

Mediterranean

Diet

(U.S.)

 

 

 

Japanese

 

 

 

Okinawan

Polyunsaturated 8% 6.9% 5.1 % nd 3.5% 2.4%
(% total kcal)            
Cholesterol (mg) 143 nd nd nd nd nd
Fiber (g) 29 nd 29 20 22 26
Potassium (mg) 4371 nd 4589 nd 2623 5826
Sodium (mg) 1095 nd 2532 nd 2370 1269
 

Food Groups

           
Vegetables: total 2.1 4.1 1.2 2.2 nd nd
(c)            
– Dark Green  (c) nd nd nd nd <0.1 (seaweed) <0.1 (sea weed)
– Legumes2(c) nd <0.1 0.4 0.3 0.3 0.5
– Red Orange (c) nd nd nd nd 0.5 (Asian sweet 6.6  (Asian sweet
          potatoes) potatoes)
– Other Veg (c) nd nd nd nd 1.3; 0.9
          + 0.3 (pickled veg)  
– Starchy Veg (c) nd 0.6 nd No potatoes 0.3  (other potatoes) <0.1 (other
            potatoes)
 

Fruit & juices (c)

 

2.5

 

1.0 (fruit & nuts)

 

1.3 (fruit & juice)

 

1.6

 

0.2  (papaya & tomato

 

<0.1  (papaya &

    1.5 (juice & other 0.1 (dried fruit &   = veg) tomato = veg)
    bev) nuts)      
 

Grains: total (oz)

 

7.3

 

5.4

 

2.0

 

nd

 

2.4;

 

1.1;

          1.7 (rice) 0.9 (rice)
– Whole grains 3.9 nd nd 1.6 nd nd
(oz)            
 

Milk & milk

 

0.7

 

1.0

 

0.8

 

nd

 

<0.1

 

<0.1

products, Whole            
– Low-fat (c) 1.9 nd 1.3 nd nd nd

 

Table B2.5 (continued). Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dietary Pattern

 

 

DASH with

Reduced Sodium

 

 

Mediterranean

Diet (Greece)

 

 

Mediterranean

Diet (Spain)

Mediterranean

Diet

(U.S.)

 

 

 

Japanese

 

 

 

Okinawan

Animal Proteins:

– Meat (oz)

 

1.4

 

3.5

 

3.6

 

2.4

 

0.4

 

0.1

– Poultry (oz) 1.7 nd nd nd nd nd
– Eggs (oz) nd nd 1.9 nd 0.3 <0.1
– Fish (total) (oz) 1.4 0.8 2.4 1.5 2.1 0.6
— Hi n3 (oz) nd nd nd nd nd nd
— Low n3 (oz) nd nd nd nd nd nd
 

–  Legumes (oz)

 

0.4

 

nd

 

0.4

 

nd

 

0.4 (Incl soy)

 

0.3 (Incl soy)

– Nuts & seeds 0.9 See fruit above. See fruit above. 0.5 < 1 g <0.1
 

– Soy products

(oz)

 

nd

 

nd

   

nd

 

See legumes.

 

See legumes.

 

Oils (g)

 

24.8

 

40.3  (olive oil)

 

19.0  (olive oil)

 

nd

 

nd

 

nd

Solid Fats (g) nd nd nd nd nd nd
Added Sugar (g) 12 24.3 nd nd 7.7 3.4
Alcohol (g) Nd 7.92 7.1 (red wine) 7.3 30.0  (flavors and

alcohol)

7.8  (flavors and

alcohol)

 

Plant Proteins:

 

 

(oz)

 

Table B2.6. Dietary patterns and blood pressure in adults

 

 

Author and Year

 

Study Type

 

Quality

 

Population/Location

Sig SBP

Reduction

Sig DBP

Reduction

 

Caveats

DASH N = 12

(9 RCT, 3

prospective cohort)

12

Positive

2 Neutral

  12 + 10 +

1 Ø

1 n/d

 
Appel LJ et al., 2005 RCT

(OmniHeart)

Positive N = 164 adult with

prehypertension or stage 1 hypertension

 

U.S.

+ + Overall Between Diet Differences –

SBP:

Pro vs.Cho diet: P =0.002; Unsat Fat vs. Cho: P = 0.005

DBP:

Pro vs.Cho diet: P <0.001; Unsat Fat vs. Cho: P = 0.02

Appel LJ et al., 1997 RCT Positive N = 459; 234 males;

225 females Normo and hypertensive subjects

 

U.S.

+ + SBP: P< 0.001

DBP: Males P <0.001; Females P = 0.003

Appel LJ et al., 2003 RCT Positive N = 810 free living

adults Normo  and Hypertensive

 

U.S.

+ + SBP and DBP:

P <0.001

Azadbakht L et al.,

2005

RCT Neutral N =116 subjects with

metabolic syndrome

BP > 130/85

 

Iran

+ + For both  men and women P<0.001
Dauchet L et al., 2007 Longitudinal

and cross- sectional analysis

Positive N= 6,119 (2596 men,

3523 women); free living

 

France

+ + SBP: P <0.05

DBP: P < 0.01

Longitudinal results: DASH score: SBP: P<0.002; DBP: P<0.02

 

Table B2.6 (continued). Dietary patterns and blood pressure in adults

 

 

Author and Year

 

Study Type

 

Quality

 

Population/Location

Sig SBP

Reduction

Sig DBP

Reduction

 

Caveats

Forman JP et al., 2009 Prospective

cohort study

Positive N = 83,882 females;

Nurse’s Health Study

II Normotensive

 

U.S.

+ + Outcome in  multivariate HR (95%

CI) for incident HTN

Miller ER et al., 2002 RCT Positive N = 43

 

U.S.

+ + SBP, DBP: P <0.001
Nowson CA et al., 2009 RCT Positive N = 111 females

(menopausal)

 

Australia

+

+ **

Ø

+**

SBP: P = 0.38, 0.21**

DBP: P = 0.61, 0.27**

** With HTN meds

DASH N = 12

(9 RCT, 3

prospective cohort)

12

Positive

2

Neutral

  12 + 10 +

1 Ø

1 n/d

 
Nowson CA et al., 2004 RCT Positive N = 94 males and

females

 

Australia

+ + SBP: P = 0.001

DBP: P = 0.05

Sacks FM et al., 2001 RCT (cross-

over)

Positive N = 390 (males,

females; black and white)

 

U.S.

+ n/d SBP: P < 0.001
Schulze MB et al., 2003 Prospective

cohort study

Positive N = 8,552 females

Normotensive

 

Germany

+ + HR (95% CI) for incident HTN

 

Table B2.6 (continued). Dietary patterns and blood pressure in adults

 

 

Author and Year

 

Study Type

 

Quality

 

Population/Location

Sig SBP

Reduction

Sig DBP

Reduction

 

Caveats

MEDITERRANEAN N = 1 cohort 1 Positive   1+ 1+  
Núñez-rdoba JM et al., AJE 2009 Prospective cohort study (6 yr f/u) Positive N = 9,408 adults;

3,583 males, 5,825 females

 

Spain

+ + SBP: P = 0.01

DBP: P = 0.05

VEGETARIAN N = 4 RCT 3Positive

1 Neutral

  4+ 3 +

1 Ø

 
Hakala P and Karvetti RL,

1989

RCT Positive N = 110 adults

 

Finland

+ + SBP: P = 0.05

DBP: P = 0.01

Margetts BM et al., 1986 RCT (cross-

over)

Neutral N = 58; 42 males, 16

females Untreated mild hypertensives

 

Australia

+ Ø SBP: P , 0.05
Rouse IL et al., 1983 RCT (cross-

over)

Positive N = 59 males and

females

 

Australia

+ + SBP, DBP: P <0.01
Sciarrone SE et al., 1993 RCT Positive N = 21 males

 

Australia

+ + Ovo-lacto vegetarian
JAPANESE/OKINAWAN N = 1 RCT 1 Positive   1+ 1 Ø  
Takahashi Y 2006 RCT Positive N = 550 (202 males,

348 females) Japan

+ Ø SBP: P = 0.007

Japanese diet with

↑Vitamin C, carotene, Fruits and

vegetables

↓ Sodium intake

 

Table B2.7. Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

DASH and DASH Variations N=10

1 RCT

9 Cohort

       
Appel et al., 2005

 

Randomized, 3-period

Crossover Trial

 

Positive

N=164

(mean age = 53.6 yr; 45% women)

 

Omni-Heart

 

U.S.

+ nd Compared with baseline, all diets lowered estimated

CHD risk. Compared with the high carbohydrate

diet, estimated 10-yr CHD risk was lower and similar on the high protein and high unsaturated fat diets.

 

Compared to high carbohydrate diet, high UFA diet decreased SBP; increased HDL-C; decreased TG, no change in LDL-C

Addresses total fat question:

High UFA diet replaced 10% energy from CHO (total fat=37% E; 21% MUFA; 10% PUFA; 6% SFA). High UFA improved CHD risk, BP, and serum lipids, compared to high CHO (SFA constant).

Folsom et al., 2007

 

Prospective Cohort

Study

 

Neutral

N = 20,993, 55-

69 yrs at baseline

 

Iowa Women’s

Health Study

Non-hypertensive

Ø Ø Incidence of hypertension inversely associated w/

degree of concordance with DASH diet (P for trend

= 0.02),

 

After adjustment for additional risk factors, little evidence that any endpoint assoc w/ DASH score

DASH diet concordance score

calculated w/ baseline FFQ in

1986, subjects followed through

2002.

 

Fung et al., 2001

 

 

 

Prospective Cohort

Study

 

Positive

 

N = 69,017, 38 –

63 yrs at baseline

 

Nurses’ Health

Study

 

U.S.

 

+

 

nd

 

Higher Prudent-pattern score assoc w/ lower risk total CHD (RR Q5 vs Q1=0.61, 95% CI: 0.49-0.76, P for trend <0.001); after adjustment for BMI, smoking, caloric intake, supplemental use, hormone replacement therapy, and other coronary risk factors (RR=0.76, 95% CI: 0.60-0.98, P for trend = 0.03). Higher Western-pattern score assoc w/ higher risk total MI after adjusting for age (RR Q5 versus Q1=

1.44, 95% CI: 1.16-1.78, P for trend <.001);

remained sig. after multivariate adjustment

(RR=1.46, 95% CI: 1.07-1.99).

 

12 y follow-up: 1984-1996

 

Baseline=1984

All FQQs using 1984 format

(116 item)

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

Fung et al., 2008

 

 

Prospective Cohort

Study

 

Positive

N = 88,517, 34 –

59 yrs at baseline

 

Nurses’ Health

Study

 

U.S.

+

 

 

 

and

Stroke

+ RR of CHD across quintiles of DASH score = 1.0,

0.99, 0.86, 0.87 and 0.76 (95% CI: 0.67 – 0.85, P for trend <0.001)

 

Magnitude of risk difference was similar for nonfatal

MI and fatal CHD

 

DASH score assoc w/ ↓ risk of stroke

24y follow-up: 1980-2004

 

Baseline=1980

Included data from older 1980

FFQ (61 item) and 1984 FFQ

Heidemann et al.,

2008

 

Prospective Cohort

Study

 

Positive

N = 72,113

 

Nurses’ Health

Study

 

U.S.

+ + Prudent pattern assoc w/ 28% lower risk of

cardiovascular mortality and 17% lower risk of all- cause mortality,

 

Western pattern assoc w/ 22% higher risk of cardiovascular mortality, 16% higher risk of cancer, and 21% higher risk of all-cause mortality.

18 y follow-up: 1984-2002

 

Baseline=1984

All FQQs using 1984 format

(116 item)

DASH and DASH

Variations

N=10

1 RCT

9 Cohort

       
Hu et al., 2000

 

Prospective Cohort

Study

 

Positive

N=44,875 men,

40-75 y at baseline

 

Health Professionals Follow-up Study

+ + Two patterns explaining < 20% of the variance identified by factor analysis: Prudent and Western

 

Higher Prudent score assoc w/ monotonic lower risk of CHD (RR across quintiles: 1.0, 0.84, 0.76,

0.71, 0.66 (95% CI: 0.54-0.80, P for trend < 0.0001

For fatal CHD after adjustment for age, smoking, BMI, and other CHD risk factors (RR across increasing quintiles: 1.0, 0.83, 0.78, 0.81, 0.70 (95% CI: 0.54, 0.91, P for trend=0.03

 

Higher Western score assoc w/ monotonic higher risk of CHD (RR across quintiles (P<0.0001)

 

CHD RR (highest Prudent vs lowest Western) = 0.50 (95% CI: 0.34, 0.74).

8 y follow-up from 1986

 

Authors conclude dietary patterns derived from their FFQ predict CHD risk independent of other lifestyle factors.

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

Levitan et al., 2009

 

Prospective Cohort

Study

 

Neutral

36,019 women,

48-83 y at baseline

 

Swedish Mammography Cohort

+ + Top quartile of DASH score had 37% lower rate of

heart failure (HF); rate ratios across quartiles = 1 (ref), 0.85 (95% CI: 0.66-1.11), 0.69 (95% CI: 0.54-

0.88), and 0.63 (95% CI: 0.48-0.81), P for trend

<0.001.

 

Both HF-assoc hospitalization and death were determined

7 y follow-up; dietary intake

only measured at baseline

 

Hypertension was based on self-report.

Osler et al., 2001

 

Prospective Cohort

Study

 

Neutral

N= 5,872 (2,994

men, 2,878 women) Random equal- sized samples

30,40,50, 60-y at baseline

 

Danish World Health Organization MONICA survey

+ + Prudent pattern inversely assoc w/ all-cause (hazard

ratios =0.63 in women =0.75 in men) and cardiovascular mortality

 

Western pattern not associated w/ mortality

 
Parikh et al., 2009

 

Prospective Cohort

Study

 

Neutral

N=5532 adults w/

hypertension NHANES III (1988-1994) U.S.

+ +

 

and

Stroke

DASH-like group had lower unadjusted mortality

rates per 1,000 person-yrs for all-cause mortality (P=0.02), stroke mortality (P<0.001), and cancer mortality (P=0.05).

 

DASH-like group, after adjusting for multiple confounders, assoc w/ lower mortality from all causes (HR=0.69, 95% CI 0.52-0.92, P=0.01) and stroke (HR=0.11, 95% CI 0.03-0.47, P=0.003).

 

CVD mortality risk (HR=0.92, 95% CI 0.63-1.35, P=0.67), IHD (HR=0.77, 95% CI 0.47-1.14, P=0.28), and cancer (HR=0.51, 95% CI 0.23-1.10, P=0.09) not stat significant

8.2 person-years follow-up

 

Secondary outcomes included specific causes of mortality CVD, ischemic heart disease, stroke, and cancer

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

DASH and DASH Variations N=10

1 RCT

9 Cohort

       
Singman et al., 1980

 

Prospective Cohort

Study

 

Neutral

N=1,113 men experimental and

467 men control

 

U.S.

+ nd Prudent diet group in both age categories (40-49 y

& 50-59 y) had lower CHD incidence rates

 
MEDITERRANEAN N=13

1 Index

1 Systematic Rev

1 Meta Analysis

9 Cohort

1 Case Control

       
Alberti et al., 2008

 

Analysis of Mediterranean Adequacy Index (MAI)

 

Neutral

5 data sets on 23

populations

ND + Inverse correlation between MAI and 25 y CHD

death rate and total mortality

MAI: divide the sum of the

percentages of dietary energy from food groups typical of a healthy reference Mediterranean diet, by the sum of the percentages of dietary energy of food groups that are not characteristic of a healthy reference Mediterranean diet

Fidanza et al., 2004

 

Prospective Cohort

Study

 

Neutral

N=12,763 men,

40-59 yrs at baseline

 

U.S.

+ + The coefficient of linear correlation between the

MAI and CHD death rates in the 16 cohorts was –

0.72 (P=0.001)

MAI Index

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

Fung et al., 2009

 

Prospective Cohort

Study

 

Neutral

N = 76,522 , 38 –

63 yrs at baseline

 

Nurses’ Health

Study

 

U.S.

+

 

 

 

and

Stroke

+ Top aMed quintile ↓risk CHD and stroke: RR CHD

= 0.71, 95% CI: 0.62-0.82, P for trend < 0.0001, RR

stroke = 0.87, 95% CI: 0.73-1.02, P for trend = 0.03

 

CVD mortality ↓: top quintile RR=0.61, 95%

CI:0.49-0.76, P for trend <0.0001

20 y follow-up: 1984-2004

 

Baseline=1984

All FQQs using 1984 format

Harriss et al., 2007

 

Prospective Cohort

Study

 

Neutral

N= 40,653

(16,673 men,

23,908 women)

 

Melbourne Collaborative Study

+ + Mediterranean dietary factor inversely assoc w/ CVD

and IHD mortality

 

IHD, HR (highest compared w/ lowest quartile) =

0.59 (95% CI: 0.39-0.89, P for trend=0.03)

 

Excluding subjects w/ prior CVD (HR=0.51, 95% CI: 0.30-0.88, P for trend = 0.03)

Mean follow-up = 10.4 y

 

Involved migrants to Australia from Mediterranean countries (24% of subjects were Mediterranean born)

MEDITERRANEAN N=13

1 Index

1 Systematic Rev

1 Meta Analysis

9 Cohort

1 Case Control

       
Knoops et al., 2004

 

Prospective Cohort

Study

 

Neutral

N= 40,653 (1,507

men, 832 women)

 

HALE cohort

 

Netherlands

+ + Mediterranean diet (HR = 0.77, 95% CI: 0.68 – 0.88)

assoc w/ ↓ risk all-cause mortality

 

Similar results were observed for mortality from coronary heart disease, cardiovascular diseases, and cancer

10 y mortality from all causes

(CVD, CHD, and Cancer)

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

Mente et al., 2009

 

Systematic Review/ Meta-analysis

 

Positive

146 prospective

cohort studies

+ 43 RCTs

(pub1950-2007)

 

Europe, Asia, U.S.

+ nd Among the dietary exposures with strong evidence of

causation from cohort studies, only the Mediterranean dietary pattern is related to CHD in RCTs

Used Bradford Hill guidelines

to derive causation score based on 4 criteria (strength, consistency, temporality, and coherence) for each dietary exposure in cohort studies and examined for consistency with the findings of RCTs.

Mitrou et al, 2007

 

Prospective Cohort

Study

 

Positive

N= 352,497

(196,158 men,

156,339  women)

median age = 62

 

NIH-AARP Diet and Health Study

 

U.S.

+ + Men: multivariate HR all-cause mortality = 0.79

(95% CI: 0.76 – 0.83), CVD mortality = 0.78 (95% CI: 0.69 – 0.87), cancer mortality = 0.83 (95% CI:

0.76 – 0.91).

 

Women: ↓ risks = 12% cancer mortality (P for trend

= 0.04); = 20% all-cause mortality (P for trend <

0.001).

5 y follow-up

 

Used 9-point score to assess conformity with Mediterranean dietary pattern (components included vegetables, legumes, fruits, nuts, whole grains, fish,

monounsaturated fat-saturated fat ratio, alcohol, and meat)

Panagiotakos et al.,

2005

 

Case-control Study

 

Positive

N= 848 w/ 1st

CHD event and

1,078 age- and sex-matched controls (aged 49

– 75)

 

CARDIO2000

Study

 

Greece

+ nd 10-unit increase in Mediterranean diet score assoc w/

27% (95% CI: 0.66 – 0.89) decrease odds of non- fatal acute coronary syndromes

Secondary prevention

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

Panagiotakos et al.,

2009

 

Prospective Cohort

Study

 

Neutral

N = 2,101

 

ATTICA Study

 

Greece

+ nd Pattern characterized by cereals, small fish, and olive

oil assoc w/ ↓ CVD risk (HR = 0.72, 95% CI: 0.52 –

1.00)

 

Pattern characterized by fruit and vegetables using olive oil in cooking (HR = 0.80, 95% CI: 0.66 –

0.97)

 

Patterns characterized by sweets, red meat, margarine, salty nuts, hard cheese and alcohol assoc w/ ↑ CVD risk

5 y follow-up

 

Exclusion of CVD done by detailed clinical evaluation

Trichopoulou et al.,

2003

 

Prospective Cohort

Study

 

Neutral

N = 22,043, 38-

63 yrs at baseline EPIC Study Greece

+ + Higher adherence to Med diet assoc w/ ↓ total

mortality (adjusted HR =0.75, 95% CI: 0.64 – 0.87);

inverse assoc w/ CHD death (adjusted HR = 0.67,

95% CI: 0.47 – 0.94) and cancer death (adjusted HR

= 0.76, 95% CI: 0.59 – 0.98).

44 month follow-up
Trichopoulou et al.,

2009

 

Prospective Cohort

Study

 

Neutral

N = 23,349

 

EPIC Study

 

Greece

nd + Higher adherence to a Med diet assoc w/ ↓ total

mortality (adjusted mortality ratio = 0.864, 95% CI:

0.802 – 0.932).

8.5 y follow-up
Waijers et al., 2006

 

Prospective Cohort

Study

 

Neutral

N = 5,427 women

(aged >60 years) EPIC Study

Netherlands

nd + Principal component analysis identified 3 diet

patterns: Mediterranean, Traditional Dutch, and

Healthy Dutch

Healthy trad Dutch pattern assoc w/ ↓ mortality rate;

women in highest tertile 30% ↓mortality risk

8.2 y follow-up

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

VEGETARIAN N=5

4 Cohort

1 Time series

       
 

ChangClaude et al.,

2005

 

Prospective Cohort

Study

 

Neutral

 

N = 1,904 ; 858 males, 1,046 females

 

1,165 lacto-ovo,

679 non-veg, 60 vegans.

 

Germany

 

+

 

Ø

 

↓ risk ischemic heart disease (RR = 0.70, 95% CI:

0.41 – 1.18)

 

No effect on mortality (RR = 1.10, 95% CI: 0.89 –

1.36)

 

A cohort study of vegetarians and health-conscious persons in Germany was followed-up prospectively for 21 years, including 1,225 vegetarians and 679 health-conscious nonvegetarians

Fraser et al., 2005

 

Time series

 

Neutral

(N=30,292 males,

N=50,562 females) California Seventh Day Adventists

(N=297,126 male,

344,401 female) Stanford Five- City Project

 

U.S.

+ + Rate ratio (RR) (Adventist/Stanford study)

1st event fatal CHD = 0.59 (95% CI, 0.43-0.80) men and 0.49 (0.32-0.76) women.

Vegetarian Adventists, RR = 0.45 (0.24-0.84) and

0.20 (0.06-0.63) men and women, respectively.

1st event MI RR = 0.60 (0.47-0.78) and 0.46 (0.33-

0.65).

Vegetarian Adventists RR = 0.37 (0.20-0.66) and

0.62 (0.35-1.09) men and women, respectively.

Two concurrent California

observational studies, one with unusual dietary habits, are compared. Similar diagnostic criteria were used in both the Adventist Health Study and

the Stanford Five-City Project.

VEGETARIAN N=5

4 Cohort

1 Time series

       

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

Key et al., 1996

 

Prospective Cohort

Study

 

Neutral

N = 10,771;

4,336 males,

6,435 females

 

UK

+ + Daily consumption of fresh fruit assoc w/ ↓

mortality ischemic heart disease (rate ratio = 0.76,

95% CI: 0.60 – 0.97), cerebrovascular disease (rate ratio = 0.68, 95% CI: 0.47 – 0.98), and all causes (rate ratio = 0.79, 95% CI: 0.70 – 0.90)

Mortality ratios measured for

vegetarianism and for daily versus less than daily consumption of wholemeal bread, bran cereals, nuts or dried fruit, fresh fruit, and raw salad in relation to all cause mortality and mortality from ischemic heart disease, cerebrovascular disease, all malignant neoplasms, lung cancer, colorectal cancer, and breast cancer.

Key et al., 1998

 

Meta-analysis: 5

Prospective Cohort

Studies

 

Neutral

N = 76,172  men

and women

 

U.S.

+ + Compared to non-vegetarians, vegetarians had 24% ↓

IHD mortality (rate ratio = 0.76, 95% CI:0.62-0.94)

 

Reduction in mortality among vegetarians varied significantly with age at death.

 

Regular meat consumers compared to semi- vegetarians (fish or meat <1X/wk), IHD rate ratios=0.78 (95% CI:0.68-0.89) in semi-vegetarians and 0.66 (95% CI:0.53-0.83) in vegetarians (P for trend <0.001).

Vegetarians were those who

did not eat any meat or fish (n

= 27,808). Non-vegetarians were from a similar background to the vegetarians within each study.

Mann et al., 1997

 

Prospective Cohort

Study

 

Neutral

N = 10,802;

4,102 males,

6,700 females

 

Health conscious, mean age=33-34

 

United Kingdom

+ + An increase in mortality for IHD was observed with

increasing intakes of total and saturated animal fat and dietary cholesterol-death rate ratios in the third tertile compared with the first tertile: 329, 95% confidence interval (CI) 150 to 721; 277, 95% CI

125 to 613; 353, 95% CI 157 to 796, respectively.

 

No protective effects for dietary fiber, fish or alcohol

13.3 y follow-up

 

Prospective observation of vegetarians, semi-vegetarians, and meat eaters

 

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

 

Author and Year/

Quality/Study Type

Population/

Location

 

CVD

 

Mortality

 

Outcomes

 

Comments/Caveats

 

JAPANESE/ OKINAWAN

 

 

N=1 Cohort

       
Shimazu et al., 2007

 

Prospective Cohort

Study

 

Neutral

N=40,547, 40-79 yrs at baseline Japan + + 3 patterns identified by principal components analysis: i) a Japanese dietary pattern highly correlated with soybean products, fish, seaweeds, vegetables, fruits and green tea, (ii) an ‘animal food’ dietary pattern and (iii) a high-dairy, high-fruit-and- vegetable, low-alcohol (DFA) dietary pattern.

 

Japanese pattern assoc w/ ↓ risk CVD mortality (HR

= 0.73, 95% CI 0.59-0.92, P for trend=0.003)

7 y follow-up

 

ND = Not determined.

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