The Healthy Eating Index-2005 (HEI-2005) measures adherence to the 2005 Dietary Guidelines for Americans, but the association between the HEI-2005 and risk of chronic disease is not known. The Alternative Healthy Eating Index (AHEI), which is based on foods and nutrients predictive of chronic disease risk, was associated inversely with chronic disease risk previously. We updated the AHEI, including additional dietary factors involved in the development of chronic disease, and assessed the associations between the AHEI-2010 and the HEI-2005 and risk of major chronic disease prospectively among 71,495 women from the Nurses' Health Study and 41,029 men from the Health Professionals Follow-Up Study who were free of chronic disease at baseline. During ≥24 y of follow-up, we documented 26,759 and 15,558 incident chronic diseases (cardiovascular disease, diabetes, cancer, or nontrauma death) among women and men, respectively. The RR (95% CI) of chronic disease comparing the highest with the lowest quintile was 0.84 (0.81, 0.87) for the HEI-2005 and 0.81 (0.77, 0.85) for the AHEI-2010. The AHEI-2010 and HEI-2005 were most strongly associated with coronary heart disease (CHD) and diabetes, and for both outcomes the AHEI-2010 was more strongly associated with risk than the HEI-2005 (P-difference = 0.002 and <0.001, respectively). The 2 indices were similarly associated with risk of stroke and cancer. These findings suggest that closer adherence to the 2005 Dietary Guidelines may lower risk of major chronic disease. However, the AHEI-2010, which included additional dietary information, was more strongly associated with chronic disease risk, particularly CHD and diabetes.

BackgroundPlant-based diets have been recommended to reduce the risk of type 2 diabetes (T2D). However, not all plant foods are necessarily beneficial. We examined the association of an overall plant-based diet and hypothesized healthful and unhealthful versions of a plant-based diet with T2D incidence in three prospective cohort studies in the US.Methods and FindingsWe included 69,949 women from the Nurses’ Health Study (1984–2012), 90,239 women from the Nurses’ Health Study 2 (1991–2011), and 40,539 men from the Health Professionals Follow-Up Study (1986–2010), free of chronic diseases at baseline. Dietary data were collected every 2–4 y using a semi-quantitative food frequency questionnaire. Using these data, we created an overall plant-based diet index (PDI), where plant foods received positive scores, while animal foods (animal fats, dairy, eggs, fish/seafood, poultry/red meat, miscellaneous animal-based foods) received reverse scores. We also created a healthful plant-based diet index (hPDI), where healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, tea/coffee) received positive scores, while less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, sweets/desserts) and animal foods received reverse scores. Lastly, we created an unhealthful plant-based diet index (uPDI) by assigning positive scores to less healthy plant foods and reverse scores to healthy plant foods and animal foods.We documented 16,162 incident T2D cases during 4,102,369 person-years of follow-up. In pooled multivariable-adjusted analysis, both PDI and hPDI were inversely associated with T2D (PDI: hazard ratio [HR] for extreme deciles 0.51, 95% CI 0.47–0.55, p trend < 0.001; hPDI: HR for extreme deciles 0.55, 95% CI 0.51–0.59, p trend < 0.001). The association of T2D with PDI was considerably attenuated when we additionally adjusted for body mass index (BMI) categories (HR 0.80, 95% CI 0.74–0.87, p trend < 0.001), while that with hPDI remained largely unchanged (HR 0.66, 95% CI 0.61–0.72, p trend < 0.001). uPDI was positively associated with T2D even after BMI adjustment (HR for extreme deciles 1.16, 95% CI 1.08–1.25, p trend < 0.001). Limitations of the study include self-reported diet assessment, with the possibility of measurement error, and the potential for residual or unmeasured confounding given the observational nature of the study design.ConclusionsOur study suggests that plant-based diets, especially when rich in high-quality plant foods, are associated with substantially lower risk of developing T2D. This supports current recommendations to shift to diets rich in healthy plant foods, with lower intake of less healthy plant and animal foods.

Eating patterns are increasingly varied. Typical breakfast, lunch, and dinner meals are difficult to distinguish because skipping meals and snacking have become more prevalent. Such eating styles can have various effects on cardiometabolic health markers, namely obesity, lipid profile, insulin resistance, and blood pressure. In this statement, we review the cardiometabolic health effects of specific eating patterns: skipping breakfast, intermittent fasting, meal frequency (number of daily eating occasions), and timing of eating occasions. Furthermore, we propose definitions for meals, snacks, and eating occasions for use in research. Finally, data suggest that irregular eating patterns appear less favorable for achieving a healthy cardiometabolic profile. Intentional eating with mindful attention to the timing and frequency of eating occasions could lead to healthier lifestyle and cardiometabolic risk factor management.T he patterns of meal and snack eating behavior in American adults have changed over the past 40 years. Based on NHANES (National Health and Nutrition Examination Survey) data from 1971 to 1974 to 2009 to 2010 (n=62 298), women 20 to 74 years of age reported a decrease in 24-hour meal-derived total energy intake (TEI) from 82% in the 1970s to 77% in 2009 to 2010 and an increase in the proportion of TEI consumed from snacks from 18% to 23%.1 Similar trends were reported among men. The proportion of men and women who reported consuming all 3 standard meals declined over this period (from 73% to 59% in men; from 75% to 63% in women), 1 reflecting changes in eating patterns rather than changes in eating frequency. Indeed, the traditional breakfast-lunch-dinner pattern was not observed in a population of healthy, non-shift-working adults. 2 In that study, the number of eating occasions, defined as consumption of any food or beverage providing at least 5 kcal, was ≈4.2 times a day in the lowest decile and 10.5 times a day for the top decile. There were only 5 hours during the 24-hour day when <1% of all eating occasions occurred: between 1 and 6 am. This study clearly demonstrated that adults in the United States eat around the clock. Because feeding and fasting entrain clock genes, which regulate all aspects of metabolism, meal timing can have serious implications for the development of cardiovascular disease (CVD), type 2 diabetes mellitus, and obesity. 3,4 The circadian rhythms of the body are controlled by the central clock located in the suprachiasmatic nucleus of the hypothalamus but also by clocks of peripheral organs. Although the master clock is strongly entrained by light, clocks of peripheral organs are additionally responsive to food supply, and temporal restriction of food can reset clock gene rhythms. In mice, food given in the normal sleeping period can uncouple peripheral clocks from the master clock. 5 In fact, time-restricted feeding CLINICAL STATEMENTS AND GUIDELINESin mice alters the robustness and coherence of rhythmic gene transcripts, 6 which may be relevant for cardiom...

Background Plant-based diets are recommended for coronary heart disease (CHD) prevention. However, not all plant foods are necessarily beneficial for health. Objectives To examine associations between plant-based diet indices and CHD incidence. Methods We included 73,710 women in Nurses’ Health Study (NHS) (1984–2012), 92,329 women in NHS2 (1991–2013), and 43,259 men in Health Professionals Follow-up Study (1986–2012), free of chronic diseases at baseline. We created an overall plant-based diet index (PDI) from repeated semi quantitative food-frequency questionnaire data, by assigning positive scores to plant foods and reverse scores to animal foods. We also created a healthful PDI (hPDI) where healthy plant foods (whole grains, fruits/vegetables, nuts/legumes, oils, tea/coffee) received positive scores, while less-healthy plant foods (juices/sweetened beverages, refined grains, potatoes/fries, sweets) and animal foods received reverse scores. To create an unhealthful PDI (uPDI), we gave positive scores to less-healthy plant foods and reverse scores to animal and healthy plant foods. Results Over 4,833,042 person-years of follow-up, we documented 8,631 incident CHD cases. In pooled multivariable analysis, higher adherence to PDI was independently inversely associated with CHD (HR comparing extreme deciles: 0.92, 95% CI: 0.83–1.01; p trend=0.003). This inverse association was stronger for hDPI (HR: 0.75, 95% CI: 0.68–0.83; p trend<0.001). Conversely, uPDI was positively associated with CHD (HR: 1.32, 95% CI: 1.20–1.46; p trend<0.001). Conclusions Higher intake of a plant-based diet index rich in healthier plant foods is associated with substantially lower CHD risk, while a plant-based diet index that emphasizes less-healthy plant foods is associated with higher CHD risk.

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Background Prior studies on intake of linoleic acid (LA), the predominant n-6 fatty acid, and coronary heart disease (CHD) risk have generated inconsistent results. We performed a systematic review and meta-analysis of prospective cohort studies to summarize the evidence regarding the relation of dietary LA intake and CHD risk. Methods and Results We searched MEDLINE and EMBASE databases through June, 2013 for prospective cohort studies that reported the association between dietary LA and CHD events. In addition, we utilized unpublished data from cohort studies in a previous pooling project. We pooled the multivariate-adjusted relative risk (RR) comparing the highest with the lowest categories of LA intake using fixed-effect meta-analysis. We identified 13 published and unpublished cohort studies with a total of 310,602 individuals and 12,479 total CHD events including 5,882 CHD deaths. Comparing the highest to the lowest category, dietary LA was associated with a 15% lower risk of CHD events (pooled RR, 0.85; 95% confidence intervals (95% CI): 0.78–0.92; I2=35.5%) and a 21% lower risk of CHD deaths (pooled RR, 0.79; 95% CI, 0.71–0.89; I2=0.0%). A 5% of energy increment in LA intake replacing energy from saturated fat intake was associated with a 9% lower risk of CHD events (RR, 0.91; 95% CI, 0.86–0.96) and a 13% lower risk of CHD deaths (RR, 0.87; 95% CI, 0.82–0.94). Conclusion In prospective observational studies, dietary LA intake is inversely associated with CHD risk in a dose-response manner. These data provide support for current recommendations to replace saturated fat with polyunsaturated fat for primary prevention of CHD.

Background The associations between dietary saturated fat and risk of coronary heart disease (CHD) remain controversial, but few studies have compared saturated with unsaturated fats and sources of carbohydrates in relation to CHD risk. Objective This study sought to investigate associations of saturated fats as compared with unsaturated fats and different sources of carbohydrates in relation to CHD risk. Methods We followed 84,628 women (Nurses’ Health Study, 1980 to 2010), and 42,908 men (Health Professionals Follow-up Study, 1986 to 2010) who were free of diabetes, cardiovascular disease, and cancer at baseline. Diet was assessed by semiquantitative food frequency questionnaire every 4 years. Results During 24 to 30 years of follow-up, we documented 7,667 incident cases of CHD. Higher intakes of polyunsaturated fatty acids (PUFAs) and carbohydrates from whole grains were significantly associated with lower risk of CHD (hazard ratios [HR] (95% confidence intervals [CI]) comparing the highest to the lowest quintile for PUFA: 0.80 [0.73 to 0.88], p trend <0.0001; and for carbohydrates from whole grains: 0.90 [0.83 to 0.98], p trend = 0.003). In contrast, carbohydrates from refined starches/added sugars were positively associated with risk of CHD (1.10 [1.00 to 1.21], p trend = 0.04). Replacing 5% of energy intake from saturated fats with equivalent energy intake from either PUFAs, monounsaturated fats (MUFAs), or carbohydrates from whole grains was associated with 25%, 15%, and 9% lower risk of CHD, respectively (PUFAs: 0.75 [0.67 to 0.84]; p < 0.0001; MUFAs: 0.85 [0.74 to 0.97]; p = 0.02; carbohydrates from whole grains (0.91 [0.85 to 0.98]; p = 0.01). Replacing saturated fat with carbohydrates from refined starches/added sugars was not significantly associated with CHD risk (p > 0.10). Conclusions Our findings indicate that unsaturated fats, especially PUFAs, and/or high-quality carbohydrates should replace dietary saturated fats to reduce CHD risk.

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