Meat intake and risk of hepatocellular carcinoma in two large US prospective cohorts of women and men

Abstract Background Epidemiological evidence on the associations between meat intake and risk of hepatocellular carcinoma (HCC) was limited and inconsistent. Methods We prospectively examined the association between consumption of meats and meat mutagens with HCC risk using data from the Nurses’ Health Study and the Health Professionals Follow-up Study. Cox proportional-hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) after adjusting for known liver-cancer risk factors. Results During up to 32 years of follow-up, we documented 163 incident HCC cases. The HRs of HCC for the highest vs the lowest tertile intake levels were 1.84 (95% CI: 1.16–2.92, Ptrend = 0.04) for processed red meats and 0.61 (95% CI: 0.40–0.91, Ptrend = 0.02) for total white meats. There was a null association between unprocessed red meats and HCC risk (HR = 1.06, 95% CI: 0.68–1.63, Ptrend = 0.85). We found both poultry (HR = 0.60, 95% CI: 0.40–0.90, Ptrend = 0.01) and fish (HR = 0.70, 95% CI: 0.47–1.05, Ptrend = 0.10) were inversely associated with HCC risk. The HR for HCC risk was 0.79 (95% CI: 0.61–1.02) when 1 standard deviation of processed red meats was substituted with an equivalent amount of poultry or fish intake. We also found a suggestive positive association of intake of meat-derived mutagenicity or heterocyclic amines with risk of HCC. Conclusions Processed red meat intake might be associated with higher, whereas poultry or possibly fish intake might be associated with lower, risk of HCC. Replacing processed red meat with poultry or fish might be associated with reduced HCC risk.

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Towards refining WCRF/AICR cancer prevention recommendations for red and processed meat intake: Insights from Alberta’s Tomorrow Project cohort

British Journal Of Nutrition ◽

10.1017/s0007114521001240 ◽

2021 ◽

pp. 1-38

Author(s):

Ala Al Rajabi ◽

Geraldine Lo Siou ◽

Alianu K. Akawung ◽

Kathryn L McDonald ◽

Tiffany R. Price ◽

...

Keyword(s):

Cancer Prevention ◽

Proportional Hazards ◽

Red Meat ◽

Cox Proportional Hazards ◽

Processed Meat ◽

Carcinogenic Effect ◽

Meat Intake ◽

Increased Risk ◽

Red Meats ◽

Red And Processed Meat

ABSTRACT Current cancer prevention recommendations advise limiting red meat intake to <500g/week and avoiding consumption of processed meat, but do not differentiate the source of processed meat. We examined the associations of processed meat derived from red vs. non-red meats with cancer risk in a prospective cohort of 26,218 adults who reported dietary intake using the Canadian Diet History Questionnaire. Incidence of cancer was obtained through data linkage with Alberta Cancer Registry with median (IQR) follow-up of 13.3 (5.1) years. Multivariable Cox proportional hazards regression models were adjusted for covariates and stratified by age and gender. The median (IQR) consumption (g/week) of red meat, processed meat from red meat and processed meat from non-red meat were 267.9 (269.9), 53.6 (83.3), and 11.9 (31.8), respectively. High intakes (4th Quartile) of processed meat from red meat was associated with increased risk of gastro-intestinal cancer Adjusted Hazard Ratio (AHR) (95% CI): 1.68 (1.09 – 2.57) and colorectal cancers AHR (95% CI): 1.90 (1.12 – 3.22), respectively in women. No statistically significant associations were observed for intakes of red meat or processed meat from non-red meat. Results suggests that the carcinogenic effect associated with processed meat intake may be limited to processed meat derived from red meats. The findings provide preliminary evidence toward refining cancer prevention recommendations for red and processed meat intake.

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Red meat consumption and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis

American Journal of Clinical Nutrition ◽

10.3945/ajcn.111.018978 ◽

2011 ◽

Vol 94 (4) ◽

pp. 1088-1096 ◽

Cited By ~ 341

Author(s):

An Pan ◽

Qi Sun ◽

Adam M Bernstein ◽

Matthias B Schulze ◽

JoAnn E Manson ◽

...

Keyword(s):

Type 2 Diabetes ◽

Meta Analysis ◽

Meat Consumption ◽

Red Meat ◽

Health Study ◽

Increased Risk ◽

Red Meats ◽

Processed Red Meat

ABSTRACT Background: The relation between consumption of different types of red meats and risk of type 2 diabetes (T2D) remains uncertain. Objective: We evaluated the association between unprocessed and processed red meat consumption and incident T2D in US adults. Design: We followed 37,083 men in the Health Professionals Follow-Up Study (1986–2006), 79,570 women in the Nurses’ Health Study I (1980–2008), and 87,504 women in the Nurses’ Health Study II (1991–2005). Diet was assessed by validated food-frequency questionnaires, and data were updated every 4 y. Incident T2D was confirmed by a validated supplementary questionnaire. Results: During 4,033,322 person-years of follow-up, we documented 13,759 incident T2D cases. After adjustment for age, BMI, and other lifestyle and dietary risk factors, both unprocessed and processed red meat intakes were positively associated with T2D risk in each cohort (all P-trend <0.001). The pooled HRs (95% CIs) for a one serving/d increase in unprocessed, processed, and total red meat consumption were 1.12 (1.08, 1.16), 1.32 (1.25, 1.40), and 1.14 (1.10, 1.18), respectively. The results were confirmed by a meta-analysis (442,101 participants and 28,228 diabetes cases): the RRs (95% CIs) were 1.19 (1.04, 1.37) and 1.51 (1.25, 1.83) for 100 g unprocessed red meat/d and for 50 g processed red meat/d, respectively. We estimated that substitutions of one serving of nuts, low-fat dairy, and whole grains per day for one serving of red meat per day were associated with a 16–35% lower risk of T2D. Conclusion: Our results suggest that red meat consumption, particularly processed red meat, is associated with an increased risk of T2D.

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Substitution of unprocessed and processed red meat with poultry or fish and total and cause-specific mortality

British Journal Of Nutrition ◽

10.1017/s0007114521001252 ◽

2021 ◽

pp. 1-15

Author(s):

Tine Bjerg Nielsen ◽

Anne Mette Lund Würtz ◽

Anne Tjønneland ◽

Kim Overvad ◽

Christina Catherine Dahm

Keyword(s):

Proportional Hazards ◽

Total Mortality ◽

Red Meat ◽

Cox Proportional Hazards ◽

Processed Meat ◽

Cox Proportional Hazards Models ◽

Total Death ◽

Baseline Information ◽

Processed Red Meat

Abstract Recent studies found positive associations between intake of red meat and processed meat and total mortality, however substitution of red meat with poultry and fish has been poorly investigated. We aimed to investigate associations for substitutions of red meat (unprocessed/processed) and total mortality and deaths due to cancer or cardiovascular disease (CVD). We used data from the Danish Diet, Cancer and Health cohort, including 57,053 participants aged 50-64y at baseline. Information on diet was collected through a validated 192-item food frequency questionnaire. Information regarding total mortality, deaths due to cancer and deaths due to CVD was obtained by record linkage. Cox proportional hazards models were used to estimate the HR of 150g/week substitutions of red meat with poultry or fish. During a follow-up (mean 16.1 years), 8,840 deaths occurred (4,567 were due to cancer; 1,816 due to CVD). The adjusted HR (95% CI) for total death when substituting 150g/week total red meat with poultry was 0.96 (0.95; 1.00) and with fish 0.99 (0.97; 1.01). Corresponding HRs for cancer death or CVD death were similar. Substitution of processed red meat with fish or poultry was more consistently associated with a lower mortality than substitution of unprocessed red meat. For example, the adjusted HR (95% CI) for total death when substituting 150g/week processed red meat with poultry was 0.95 (0.92; 0.98). We found that replacing processed red meat with poultry or fish was associated with a lower risk of total mortality and deaths due to cancer, but not deaths due to CVD.

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Meat intake and risk of diverticulitis among men

Gut ◽

10.1136/gutjnl-2016-313082 ◽

2017 ◽

Vol 67 (3) ◽

pp. 466-472 ◽

Cited By ~ 38

Author(s):

Yin Cao ◽

Lisa L Strate ◽

Brieze R Keeley ◽

Idy Tam ◽

Kana Wu ◽

...

Keyword(s):

Proportional Hazards ◽

Red Meat ◽

Cox Proportional Hazards ◽

Common Disease ◽

Processed Meat ◽

Meat Intake ◽

Relative Risks ◽

Cox Proportional Hazards Models ◽

Increased Risk

ObjectiveDiverticulitis is a common disease with a substantial clinical and economic burden. Besides dietary fibre, the role of other foods in the prevention of diverticulitis is underexplored.DesignWe prospectively examined the association between consumption of meat (total red meat, red unprocessed meat, red processed meat, poultry and fish) with risk of incident diverticulitis among 46 461 men enrolled in the Health Professionals Follow-Up Study (1986–2012). Cox proportional hazards models were used to compute relative risks (RRs) and 95% CIs.ResultsDuring 651 970 person-years of follow-up, we documented 764 cases of incident diverticulitis. Compared with men in the lowest quintile (Q1) of total red meat consumption, men in the highest quintile (Q5) had a multivariable RR of 1.58 (95% CI 1.19 to 2.11; p for trend=0.01). The increase in risk was non-linear, plateauing after six servings per week (p for non-linearity=0.002). The association was stronger for unprocessed red meat (RR for Q5 vs Q1: 1.51; 95% CI 1.12 to 2.03; p for trend=0.03) than for processed red meat (RR for Q5 vs Q1: 1.03; 95% CI 0.78 to 1.35; p for trend=0.26). Higher consumption of poultry or fish was not associated with risk of diverticulitis. However, the substitution of poultry or fish for one serving of unprocessed red meat per day was associated with a decrease in risk of diverticulitis (multivariable RR 0.80; 95% CI 0.63 to 0.99).ConclusionsRed meat intake, particularly unprocessed red meat, was associated with an increased risk of diverticulitis. The findings provide practical dietary guidance for patients at risk of diverticulitis.

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Association of oral contraceptives and tubal ligation with risk of early natural menopause

Human Reproduction ◽

10.1093/humrep/deab054 ◽

2021 ◽

Author(s):

C R Langton ◽

B W Whitcomb ◽

A C Purdue-Smithe ◽

L L Sievert ◽

S E Hankinson ◽

...

Keyword(s):

Oral Contraceptives ◽

Proportional Hazards ◽

Reproductive Factors ◽

Cox Proportional Hazards ◽

Tubal Ligation ◽

Health Study ◽

Early Menopause ◽

Natural Menopause ◽

Increased Risk

Abstract STUDY QUESTION What is the association of oral contraceptives (OCs) and tubal ligation (TL) with early natural menopause? SUMMARY ANSWER We did not observe an association of OC use with risk of early natural menopause; however, TL was associated with a modestly higher risk. WHAT IS KNOWN ALREADY OCs manipulate hormone levels, prevent ovulation, and may modify the rate of follicular atresia, while TL may disrupt the blood supply to the ovaries. These mechanisms may be associated with risk of early menopause, a condition associated with increased risk of cardiovascular disease and other adverse health outcomes. STUDY DESIGN, SIZE, DURATION We examined the association of OC use and TL with natural menopause before the age of 45 years in a population-based study within the prospective Nurses’ Health Study II (NHSII) cohort. Participants were followed from 1989 to 2017 and response rates were 85-90% for each cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants included 106 633 NHSII members who were premenopausal and aged 25-42 years at baseline. Use, duration and type of OC, and TL were measured at baseline and every 2 years. Menopause status and age were assessed every 2 years. Follow-up continued until early menopause, age 45 years, hysterectomy, oophorectomy, death, cancer diagnosis, or loss to follow-up. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs adjusted for lifestyle, dietary, and reproductive factors. MAIN RESULTS AND THE ROLE OF CHANCE Over 1.6 million person-years, 2579 members of the analytic cohort experienced early natural menopause. In multivariable models, the duration, timing, and type of OC use were not associated with risk of early menopause. For example, compared with women who never used OCs, those reporting 120+ months of OC use had an HR for early menopause of 1.01 (95% CI, 0.87-1.17; P for trend=0.71). TL was associated with increased risk of early menopause (HR = 1.17, 95% CI, 1.06-1.28). LIMITATIONS, REASONS FOR CAUTION Our study population is homogenous with respect to race and ethnicity. Additional evaluation of these relations in more diverse populations is important. WIDER IMPLICATIONS OF THE FINDINGS To our knowledge, this is the largest study examining the association of OC use and TL with early natural menopause to date. While TL was associated with a modest higher risk of early menopause, our findings do not support any material hazard or benefit for the use of OCs. STUDY FUNDING/COMPETING INTEREST(S) The study was sponsored by UO1CA176726 and R01HD078517 from the National Institutes of Health and Department of Health and Human Services. The work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors have no competing interests to report. TRIAL REGISTRATION NUMBER N/A

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Red meat intake and risk of coronary heart disease among US men: prospective cohort study

BMJ ◽

10.1136/bmj.m4141 ◽

2020 ◽

pp. m4141

Author(s):

Laila Al-Shaar ◽

Ambika Satija ◽

Dong D Wang ◽

Eric B Rimm ◽

Stephanie A Smith-Warner ◽

...

Keyword(s):

Dairy Products ◽

Whole Grains ◽

Red Meat ◽

Meat Intake ◽

Protein Sources ◽

Chd Risk ◽

Red Meat Intake ◽

Meat And Eggs ◽

Processed Red Meat

AbstractObjectivesTo study total, processed, and unprocessed red meat in relation to risk of coronary heart disease (CHD) and to estimate the effects of substituting other protein sources for red meat with CHD risk.DesignProspective cohort study with repeated measures of diet and lifestyle factors.SettingHealth Professionals Follow-Up Study cohort, United States, 1986-2016.Participants43 272 men without cardiovascular disease or cancer at baseline.Main outcome measuresThe primary outcome was total CHD, comprised of acute non-fatal myocardial infarction or fatal CHD. Cox models were used to estimate hazard ratios and 95% confidence intervals across categories of red meat consumption. Substitution analyses were conducted by comparing coefficients for red meat and the alternative food in models, including red meat and alternative foods as continuous variables.ResultsDuring 1 023 872 person years of follow-up, 4456 incident CHD events were documented of which 1860 were fatal. After multivariate adjustment for dietary and non-dietary risk factors, total, unprocessed, and processed red meat intake were each associated with a modestly higher risk of CHD (hazard ratio for one serving per day increment: 1.12 (95% confidence interval 1.06 to 1.18) for total red meat, 1.11 (1.02 to 1.21) for unprocessed red meat, and 1.15 (1.06 to 1.25) for processed red meat). Compared with red meat, the intake of one serving per day of combined plant protein sources (nuts, legumes, and soy) was associated with a lower risk of CHD (0.86 (0.80 to 0.93) compared with total red meat, 0.87 (0.79 to 0.95) compared with unprocessed red meat, and 0.83 (0.76 to 0.91) compared with processed red meat). Substitutions of whole grains and dairy products for total red meat and eggs for processed red meat were also associated with lower CHD risk.ConclusionsSubstituting high quality plant foods such as legumes, nuts, or soy for red meat might reduce the risk of CHD. Substituting whole grains and dairy products for total red meat, and eggs for processed red meat, might also reduce this risk.

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Statin Use is Associated With a Lower Risk of Recurrence After Curative Resection in BCLC Stage 0-a Hepatocellular Carcinoma

10.21203/rs.3.rs-111369/v1 ◽

2020 ◽

Author(s):

Shih-Yu Yang ◽

Chih-Chi Wang ◽

Kuang-Den Chen ◽

Yueh-Wei Liu ◽

Chih-Che Lin ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Curative Resection ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Chang Gung Memorial Hospital ◽

Statin Group ◽

Independent Risk Factors ◽

Hcc Recurrence ◽

Statin Use

Abstract BackgroundUse of statins is associated with a reduced risk of hepatocellular carcinoma (HCC). However, the effect of statin use on HCC recurrence is unclear. This study aimed to evaluate the effect of statin use on recurrence after curative resection among patients with HCC.MethodsWe retrospectively assessed 820 patients with Barcelona Clinic Liver Cancer (BCLC) stage 0 or A HCC who underwent primary resection between January 2001 and June 2016 at Kaohsiung Chang Gung Memorial Hospital. Exposure to statins was defined as use of a statin for at least 3 months before HCC recurrence. Factors that influenced overall survival (OS) and recurrence-free survival (RFS) were analyzed using Cox proportional hazards models.ResultsOf the 820 patients, 46 (5.6%) used statins (statin group) and 774 (94.4%) did not (non-statin group). During the mean follow-up of 76.5 months, 440 (53.7%) patients experienced recurrence and 146 (17.8%) patients died. The cumulative incidence of HCC recurrence was significantly lower in the statin group than the non-statin group (p = 0.001); OS was not significantly different between groups. In multivariate analysis, age (hazard ratio [HR]: 1.291; p = 0.010), liver cirrhosis (HR: 1.743; p < 0.001), diabetes (HR:1.418; p = 0.001), number of tumors (HR: 1.750; p < 0.001), tumor size (HR: 1.406; p = 0.004) and vascular invasion (HR: 1.659; p < 0.001) were independent risk factors for HCC recurrence, whereas statin use (HR: 0.354; p < 0.001) and antiviral therapy (HR: 0.613; p < 0.001) significantly reduced the risk of HCC recurrence. The statin group still had lower RFS than the non-statin group after one-to-four propensity score matching.ConclusionStatins may exert a chemo-preventive effect on HCC recurrence after curative resection.

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Prediabetes, Diabetes, and the Risk of All-Cause and Cause-Specific Mortality in a Japanese Working Population: Japan Epidemiology Collaboration on Occupational Health Study

10.2337/figshare.13483515 ◽

2021 ◽

Author(s):

Zobida Islam ◽

Shamima Akter ◽

Yosuke Inoue ◽

Huan Hu ◽

Keisuke Kuwahara ◽

...

Keyword(s):

Proportional Hazards ◽

Cox Proportional Hazards ◽

World Health ◽

Health Study ◽

Expert Committee ◽

Risk Of Mortality ◽

Japanese Workers ◽

Increased Risk ◽

Health Organization

Objective: Prediabetes has been suggested to increase mortality risk; however, the definitions of prediabetes that can predict mortality remain elusive. We prospectively investigated the association of multiple definitions of prediabetes with the risk of mortality from all-causes, cardiovascular disease (CVD), and cancer in Japanese workers. Research design and methods: The study included 62,785 workers who underwent a health checkup in 2010 or 2011 and were followed up for mortality from 2012 to March 2019. <a>Prediabetes was defined according to fasting plasma glucose (FPG) or glycated hemoglobin (HbA1c) level or a combination of both using the American Diabetes Association (ADA) or World Health Organization (WHO)/International Expert Committee (IEC) criteria. </a>The Cox proportional hazards regression model was used to investigate the associations. Results: Over a 7-year follow-up, 229 deaths were documented. <a>Compared with normoglycemia, prediabetes defined according to ADA criteria was associated with a higher risk of all-cause (hazard ratio [HR] 1.53; 95% confidence interval [CI] 1.12–2.09) and cancer (HR 2.37; 95% CI 1.45–3.89) mortality but not with CVD mortality. </a>The results were materially unchanged when prediabetes was defined according to ADA FPG, ADA HbA1c, WHO FPG, or combined WHO/IEC criteria. Diabetes was associated with the risk of all-cause, CVD, and cancer mortality. Conclusion: In a cohort of Japanese workers, FPG- and HbA1c-defined prediabetes according to ADA or WHO/IEC was each associated with a significantly increased risk of mortality from all-causes and cancer but not CVD.

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The Fate of Indeterminate Liver Lesions: What Proportion Are Precursors of Hepatocellular Carcinoma? A Retrospective Follow-up Study

10.21203/rs.3.rs-959313/v1 ◽

2021 ◽

Author(s):

Sara Cococcia ◽

Priti Dutta ◽

Melika Moghim ◽

Brian Hogan ◽

Sudeep Tanwar ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Platelet Count ◽

Proportional Hazards ◽

High Serum ◽

Cox Proportional Hazards ◽

Liver Lesions ◽

Electronic Patient Records ◽

Follow Up Study ◽

Low Platelet Count

Abstract BackgroundThe natural history and incidence of hepatocellular carcinoma (HCC) arising from indeterminate liver lesions is not well characterised. We aimed to define the incidence of HCC in a cohort of patients undergoing surveillance by magnetic resonance imaging (MRI) and estimate any associations with incident HCC.MethodsWe performed a retrospective follow-up study, identifying MRI scans in which indeterminate lesions had been reported between January 2006 and January 2017. Subsequent MRI scan reports were reviewed for incident HCC arising from indeterminate lesions, data were extracted from electronic patient records and survival analysis performed to estimate associations with baseline factors.ResultsOne hundred and nine patients with indeterminate lesions on MRI were identified. HCC developed in 19 (17%) patients over mean follow up of 4.6 years. Univariate Cox proportional hazards analysis found incident HCC to be significantly associated with baseline low platelet count (hazard ratio (HR) = 7.3 (95% confidence intervals (CI); 2.1 – 24.9), high serum alpha-fetoprotein level (HR = 2.7 (95% CI; 1.0 – 7.1)) and alcohol consumption above fourteen units weekly (HR = 3.1 (95% CI; 1.1 – 8.7)). Multivariate analysis, however, found that only low platelet count was independently associated with HCC (HR = 5.5 (95% CI; 0.6 – 5.1)).ConclusionsHCC arises in approximately one fifth of indeterminate liver lesions over 4.6 years and is associated with a low platelet count at the time of first diagnosis of an indeterminate lesion. Our data support a strategy of enhanced surveillance in patients with indeterminate lesions.

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Changes in Plant-Based Diet Quality and Total and Cause-Specific Mortality

Circulation ◽

10.1161/circulationaha.119.041014 ◽

2019 ◽

Vol 140 (12) ◽

pp. 979-991 ◽

Cited By ~ 11

Author(s):

Megu Y. Baden ◽

Gang Liu ◽

Ambika Satija ◽

Yanping Li ◽

Qi Sun ◽

...

Keyword(s):

Diet Quality ◽

Lower Risk ◽

Proportional Hazards ◽

Total Mortality ◽

Cox Proportional Hazards ◽

Environmental Benefits ◽

Health Study ◽

Specific Mortality ◽

Cvd Mortality

Background: Plant-based diets have been associated with lower risk of type 2 diabetes mellitus and cardiovascular disease (CVD) and are recommended for both health and environmental benefits. However, the association between changes in plant-based diet quality and mortality remains unclear. Methods: We investigated the associations between 12-year changes (from 1986 to 1998) in plant-based diet quality assessed by 3 plant-based diet indices (score range, 18–90)—an overall plant-based diet index (PDI), a healthful PDI, and an unhealthful PDI—and subsequent total and cause-specific mortality (1998–2014). Participants were 49 407 women in the Nurses’ Health Study (NHS) and 25 907 men in the Health Professionals Follow-Up Study (HPFS) who were free from CVD and cancer in 1998. Multivariable-adjusted Cox proportional-hazards models were used to estimate hazard ratios (HRs) and 95% CIs. Results: We documented 10 686 deaths including 2046 CVD deaths and 3091 cancer deaths in the NHS over 725 316 person-years of follow-up and 6490 deaths including 1872 CVD deaths and 1772 cancer deaths in the HPFS over 371 322 person-years of follow-up. Compared with participants whose indices remained stable, among those with the greatest increases in diet scores (highest quintile), the pooled multivariable-adjusted HRs for total mortality were 0.95 (95% CI, 0.90–1.00) for PDI, 0.90 (95% CI, 0.85–0.95) for healthful PDI, and 1.12 (95% CI, 1.07–1.18) for unhealthful PDI. Among participants with the greatest decrease (lowest quintile), the multivariable-adjusted HRs were 1.09 (95% CI, 1.04–1.15) for PDI, 1.10 (95% CI, 1.05–1.15) for healthful PDI, and 0.93 (95% CI, 0.88–0.98) for unhealthful PDI. For CVD mortality, the risk associated with a 10-point increase in each PDI was 7% lower (95% CI, 1–12%) for PDI, 9% lower (95% CI, 4–14%) for healthful PDI, and 8% higher (95% CI, 2–14%) for unhealthful PDI. There were no consistent associations between changes in plant-based diet indices and cancer mortality. Conclusions: Improving plant-based diet quality over a 12-year period was associated with a lower risk of total and CVD mortality, whereas increased consumption of an unhealthful plant-based diet was associated with a higher risk of total and CVD mortality.

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