Proteins as Mediators of the Association Between Diet Quality and Incident Cardiovascular Disease and All‐Cause Mortality: The Framingham Heart Study

Background Biological mechanisms underlying the association of a healthy diet with chronic diseases remain unclear. Targeted proteomics may facilitate the understanding of mechanisms linking diet to chronic diseases. Methods and Results We examined 6360 participants (mean age 50 years; 54% women) in the Framingham Heart Study. The associations between diet and 71 cardiovascular disease (CVD)‐related proteins were examined using 3 diet quality scores: the Alternate Healthy Eating Index, the modified Mediterranean‐style Diet Score, and the modified Dietary Approaches to Stop Hypertension diet score. A mediation analysis was conducted to examine which proteins mediated the associations of diet with incident CVD and all‐cause mortality. Thirty of the 71 proteins were associated with at least 1 diet quality score ( P <0.0007) after adjustment for multiple covariates in all study participants and confirmed by an internal validation analysis. Gene ontology analysis identified inflammation‐related pathways such as regulation of cell killing and neuroinflammatory response (Bonferroni corrected P <0.05). During a median follow‐up of 13 years, we documented 512 deaths and 488 incident CVD events. Higher diet quality scores were associated with lower risk of CVD ( P ≤0.03) and mortality ( P ≤0.004). After adjusting for multiple potential confounders, 4 proteins (B2M [beta‐2‐microglobulin], GDF15 [growth differentiation factor 15], sICAM1 [soluble intercellular adhesion molecule 1], and UCMGP [uncarboxylated matrix Gla‐protein]) mediated the association between at least 1 diet quality score and all‐cause mortality (median proportion of mediation ranged from 8.6% to 25.9%). We also observed that GDF15 mediated the association of the Alternate Healthy Eating Index with CVD (median proportion of mediation: 8.6%). Conclusions Diet quality is associated with new‐onset CVD and mortality and with circulating CVD‐related proteins. Several proteins appear to mediate the association of diet with these outcomes.

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Abstract P108: Metabolic Profile Of Diet Quality In The Multi-Ethnic Study Of Atherosclerosis

Circulation ◽

10.1161/circ.143.suppl_1.p108 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Meghana Gadgil ◽

Alexis F Wood ◽

Ibrahim Karaman ◽

Goncalo Gomes Da Graca ◽

Ioanna Tzoulaki ◽

...

Keyword(s):

Cardiovascular Disease ◽

Diet Quality ◽

Spectral Feature ◽

Healthy Eating Index ◽

Dietary Guidelines ◽

Elastic Net ◽

Dietary Quality ◽

Spectral Features ◽

Ethnic Study ◽

Diet Score

Introduction: Poor dietary quality is a well-known risk factor for diabetes and cardiovascular disease (CVD), however metabolites marking adherence to U.S. dietary guidelines are unknown. Our goal was to determine a pattern of metabolites associated with the Healthy Eating Index-2015 (HEI-2015). We hypothesize that there will be metabolites positively and negatively associated with the HEI-2015 score, including those previously linked to diabetes and CVD. Methods: Sample: 2269 adult men and women from the Multi-Ethnic Study of Atherosclerosis (MESA) longitudinal cohort study without known cardiovascular disease or diabetes. Data/specimens: Fasting serum specimens, diet and demographic questionnaires at baseline. Metabolomics: Untargeted 1 H NMR CPMG spectroscopy (600 MHz) annotated by internal and external reference data sets. Statistical analysis: Metabolome-wide association study (MWAS) using linear regression models specifying each spectral feature as the outcome in separate models, HEI-2015 score as the predictor, and adjustment for age, sex, race, and study site, accounting for multiple comparisons. Elastic net regularized regression was used to select an optimal subset of features associated with HEI-2015 score. Separately, hierarchical clustering defined discrete groups of correlated NMR features also tested for association with HEI-2015 score. Results: MWAS identified 1914 spectral features significantly associated with the HEI-2015 diet score. After elastic net regression, 35 metabolomic spectral features remained associated with HEI-2015 diet score. Cluster analysis identified seven clusters, three of which were significantly associated with HEI-2015 score after Bonferroni correction. (Table) Conclusions: Cholesterol moieties, proline betaine, proline/glutamate and fatty acyls chains were significantly associated with higher diet quality in the MESA cohort. Further analysis may clarify the link between dietary quality, metabolites, and pathogenesis of diabetes and CVD.

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Dietary Patterns And Risk Of Cancer: Current Evidence And Future Directions

10.2310/im.9017 ◽

2018 ◽

Author(s):

Fang Fang Zhang

Keyword(s):

Healthy Eating ◽

Cancer Incidence ◽

Diet Quality ◽

Dietary Patterns ◽

Healthy Eating Index ◽

Quality Indices ◽

Alternative Healthy Eating Index ◽

Incidence And Mortality ◽

Risk Of Cancer ◽

Diet Score

Dietary patterns capture the overall diet and its constituent foods and nutrients, representing a powerful approach to identifying the effect of nutrition on health and disease. In this review, we describe the two main approaches being used to characterize dietary patterns: a prior approach that defines dietary patterns using predefined diet quality indices, and a posterior approach that derives dietary patterns using factor or cluster analysis. Methods to define diet quality indices (Healthy Eating Index, Alternative Healthy Eating Index, Alternative Mediterranean Diet Score, Dietary Approaches to Stop Hypertension Score) are presented, and their similarities and differences are discussed among the different approaches. We review the recent evidence on the relationships between dietary patterns and cancer outcomes, including all-cancer incidence and mortality and the incidence of colorectal, breast, prostate, and lung cancers. Despite the different methods that are used to characterize dietary patterns in different studies, results consistently suggest that adherence to existing dietary guidelines is associated with a reduced risk of cancer incidence and mortality. Given the important role of dietary patterns in cancer prevention, clinicians need to consider providing appropriate nutrition counseling to improve patients’ dietary patterns. Continuous efforts need to be devoted to better characterize the relationships between dietary patterns and cancer risk by studying specific cancer types, different cancer subtypes, and population subgroups, with a better approach that can accurately assess dietary patterns throughout the life cycle. This review contains 3 figures, 6 tables and 91 references Key words: Alternative Healthy Eating Index, breast cancer, cancer incidence, cancer mortality, cluster analysis, colorectal cancer, Dietary Approaches to Stop Hypertension, dietary patterns, diet quality index, factor analysis, Healthy Eating Index, lung cancer, Mediterranean Diet Score, prostate cancer, Recommended Food Score

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Relative Validity of Dietary Total Antioxidant Capacity for Predicting All-Cause Mortality in Comparison to Diet Quality Indexes in US Adults

Nutrients ◽

10.3390/nu12051210 ◽

2020 ◽

Vol 12 (5) ◽

pp. 1210

Author(s):

Kyungho Ha ◽

Kijoon Kim ◽

Junichi R. Sakaki ◽

Ock K. Chun

Keyword(s):

Antioxidant Capacity ◽

Healthy Eating ◽

Diet Quality ◽

Total Antioxidant Capacity ◽

Healthy Eating Index ◽

Antioxidant Power ◽

Dietary Recall ◽

All Cause Mortality ◽

Total Antioxidant ◽

Dietary Total Antioxidant Capacity

While traditionally diet quality index scores (DQIS) as noted later in this abstract have been used to predict health outcomes, dietary total antioxidant capacity (TAC), a useful tool for assessing total antioxidant power in the diet, may also be a novel predictor. This study evaluated the associations between dietary TAC and DQIS and all-cause mortality. Based on the National Health and Nutrition Examination Survey (NHANES) 1988–1994 and 1999–2006, 23,797 US adults were followed-up until 2015. Dietary TAC and DQIS including the Healthy Eating Index-2015 (HEI-2015), Alternative Healthy Eating Index-2010 (AHEI-2010), alternate Mediterranean Diet (aMED), and Dietary Approaches to Stop Hypertension (DASH) were calculated using a 1-day 24 h dietary recall. US adults in the highest quintiles of DQIS had lower rates of all-cause mortality compared to those in the lowest quintiles (HEI-2015 hazard ratio (HR): 0.87, 95% confidence interval (CI): 0.77–0.98; AHEI-2010 HR: 0.84, 95% CI: 0.74–0.94; aMED HR: 0.79, 95% CI: 0.69–0.90; DASH HR: 0.80, 95% CI: 0.70–0.92). Similarly, those in the highest quintile of dietary TAC also had a lower all-cause mortality than those in the lowest quintile (HR: 0.88, 95% CI: 0.79–0.98). These findings suggest that dietary TAC might be a relatively valid predictor of all-cause mortality in the US population compared to the DQIS.

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Diet quality, change in diet quality and risk of incident CVD and diabetes

Public Health Nutrition ◽

10.1017/s136898001900212x ◽

2019 ◽

Vol 23 (2) ◽

pp. 329-338 ◽

Cited By ~ 1

Author(s):

Zhe Xu ◽

Lyn M Steffen ◽

Elizabeth Selvin ◽

Casey M Rebholz

Keyword(s):

Diet Quality ◽

Cox Regression ◽

Healthy Eating Index ◽

Quality Score ◽

Diabetes Risk ◽

Cvd Risk ◽

Community Based ◽

Prospective Association ◽

Diet Score

AbstractObjective:The objective of this study was to assess the prospective association between diet quality, as well as a 6-year change in diet quality, and risk of incident CVD and diabetes in a community-based population.Design:We used Cox regression models to estimate the prospective association between diet quality, assessed using the Healthy Eating Index (HEI)-2015 and the Alternative HEI (AHEI)-2010 scores, as well as change in diet quality, and incident CVD and diabetes.Setting:The ARIC Study recruited 15 792 black and white men and women (45–64 years) from four US communities.Participants:We included 10 808 study participants who reported usual dietary intake via FFQ at visit 1 (1987–1989) and who had not developed CVD, diabetes, or cancer at baseline.Results:Overall, 3070 participants developed CVD (median follow-up of 26 years) and 3452 developed diabetes (median follow-up of 22 years) after visit 1. Higher diet score at the initial visit was associated with a significantly lower risk of CVD (HR per 10 % higher HEI-2015 diet quality score: 0·90 (95 % CI: 0·86, 0·95) and HR per 10 % higher AHEI-2010 diet quality score: 0·96 (95 % CI: 0·93, 0·99)). We did not observe a significant association between initial diet score and incident diabetes. There were no significant associations between change in diet score and CVD or diabetes risk in the overall study population.Conclusions:Higher diet quality assessed using HEI-2015 and AHEI-2010 was strongly associated with lower CVD risk but not diabetes risk within a middle-aged, community-based US population.

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Diet Quality and Incident Non-Communicable Disease in the 1946–1951 Cohort of the Australian Longitudinal Study on Women’s Health

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph182111375 ◽

2021 ◽

Vol 18 (21) ◽

pp. 11375

Author(s):

Hlaing Hlaing-Hlaing ◽

Xenia Dolja-Gore ◽

Meredith Tavener ◽

Erica L. James ◽

Allison M. Hodge ◽

...

Keyword(s):

Longitudinal Study ◽

Women’S Health ◽

Women's Health ◽

Healthy Eating ◽

Diet Quality ◽

Communicable Disease ◽

Healthy Eating Index ◽

Lower Odds ◽

All Cause Mortality ◽

Non Communicable Disease

Diet quality indices (DQIs) can be useful predictors of diet–disease relationships, including non-communicable disease (NCD) multimorbidity. We aimed to investigate whether overall diet quality (DQ) predicted NCD, multimorbidity, and all-cause mortality. Women from the 1945–51 cohort of the Australia Longitudinal Study on Women’s Health (ALSWH) were included if they: responded to S3 in 2001 and at least one survey between 2004 (S4) and 2016 (S8), and had no NCD history and complete dietary data at S3. DQ was summarized by the Healthy Eating Index for Australian Adults-2013 (HEIFA-2013), Mediterranean Diet Score (MDS), and Alternative Healthy Eating Index-2010 (AHEI-2010). Outcomes included each NCD (diabetes mellitus (DM), coronary heart disease (CHD), hypertension (HT), asthma, cancer (except skin cancer), depression and/or anxiety) independently, multimorbidity, and all-cause mortality. Repeated multivariate logistic regressions were used to test associations between DQIs and NCD outcomes across the 15 years of follow-up. The mean (±sd) of DQIs of participants (n = 5350) were 57.15 ± 8.16 (HEIFA-2013); 4.35 ± 1.75 (MDS), and 56.01 ± 10.32 (AHEI-2010). Multivariate regressions indicated that women reporting the highest quintile of AHEI-2010 had lower odds of DM (42–56% (S5–S8)), HT (26% (S8)), asthma (35–37% (S7, S8)), and multimorbidity (30–35% (S7, S8)). The highest quintile of HEIFA-2013 and MDS had lower odds of HT (26–35% (S7, S8); 24–27% (S6–S8), respectively) and depression and/or anxiety (30% (S6): 30–34% (S7, S8)). Our findings support evidence that DQ is an important predictor of some NCDs and a target for prevention in middle-aged women.

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Higher Protein Intake During Energy Restriction Alters Dietary Patterns and Maintains Diet Quality

Current Developments in Nutrition ◽

10.1093/cdn/nzab038_050 ◽

2021 ◽

Vol 5 (Supplement_2) ◽

pp. 438-438

Author(s):

Anna Ogilvie ◽

Yvette Schlussel ◽

Sue Shapses

Keyword(s):

Weight Loss ◽

Dietary Intake ◽

Energy Intake ◽

Healthy Eating ◽

Diet Quality ◽

Dietary Patterns ◽

Protein Intake ◽

Healthy Eating Index ◽

Quality Score ◽

Obese Adults

Abstract Objectives A higher protein diet can be a successful approach to weight loss and improved health outcomes. However, the effect of a higher protein diet on other foods in the diet is not known. Evidence suggests diet quality scores provide a comprehensive representation of dietary intake and the complex interconnected nature of nutrient intake. In this study, the objective was to examine the effect of protein intake during moderate weight loss using four diet quality scores in overweight and obese adults. Methods Overweight and obese adults (n = 235) were counseled, bimonthly, to reduce energy intake over 6 months following the ADA food lists. The diets were individualized so range of macronutrient intake varied, but all individuals were encouraged to consume > 0.8 g/kg protein. Dietary intake was assessed and validated at baseline and ≥ 6 days during the intervention. In addition to the Healthy Eating Index (HEI), the Alternative Healthy Eating Index (AHEI), Mediterranean Diet Quality Score (MDS), and Dietary Approaches to Stop Hypertension diet quality score (DASH) were adjusted for energy intake and used to calculate diet quality. Results Subjects (55 ± 11 years) were overweight and obese (BMI 28.9 ± 4.0 kg/m2) and consumed 17.5 ± 5.3% energy from protein at baseline. During the intervention, subjects lost 4.5 ± 5.4% body weight, with a 333 ± 605 kcal deficit and 18.7 ± 3.5% protein intake. During the intervention, only the HEI score correlated with protein intake (r = 0.240, P < 0.001); however, all scoring methods (HEI AHEI, MDS, DASH) showed consistent patterns of food groups changing with higher protein intake. As expected, there was greater intake of meat, but also intake of vegetables. In addition, diet quality scores that measured dairy (HEI, DASH, MDS), unsaturated fatty acids (AHEI, MDS) and sodium (HEI, AHEI) showed an increase with higher protein intake. Conclusions In individuals following a weight loss diet, higher protein intake consistently altered dietary patterns of low-protein food components including higher intake of vegetables, unsaturated fat, and sodium. In an overweight and obese population with no comorbidities, HEI, AHEI, MDS, and DASH diet scores are effective methods of measuring diet quality and food patterns during moderate weight loss. Funding Sources Financial support by North American Branch-ILSI and National Institute of Health-NIA is appreciated.

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Diet quality assessment indexes

Revista de Nutrição ◽

10.1590/1415-52732014000500009 ◽

2014 ◽

Vol 27 (5) ◽

pp. 605-617 ◽

Cited By ~ 10

Author(s):

Kênia Mara Baiocchi de Carvalho ◽

Eliane Said Dutra ◽

Nathalia Pizato ◽

Nádia Dias Gruezo ◽

Marina Kiyomi Ito

Keyword(s):

General Population ◽

Quality Assessment ◽

Healthy Eating ◽

Diet Quality ◽

Dietary Patterns ◽

Nutritional Quality ◽

Quality Index ◽

Healthy Eating Index ◽

Risk Of Disease ◽

Diet Score

Various indices and scores based on admittedly healthy dietary patterns or food guides for the general population, or aiming at the prevention of diet-related diseases have been developed to assess diet quality. The four indices preferred by most studies are: the Diet Quality Index; the Healthy Eating Index; the Mediterranean Diet Score; and the Overall Nutritional Quality Index. Other instruments based on these indices have been developed and the words 'adapted', 'revised', or 'new version I, II or III' added to their names. Even validated indices usually find only modest associations between diet and risk of disease or death, raising questions about their limitations and the complexity associated with measuring the causal relationship between diet and health parameters. The objective of this review is to describe the main instruments used for assessing diet quality, and the applications and limitations related to their use and interpretation.

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Abstract P524: Protein Biomarkers Mediate the Association Between Diet Quality and Incident Cardiovascular Disease and All-cause Mortality

Circulation ◽

10.1161/circ.141.suppl_1.p524 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

Jiantao Ma ◽

Sophia Lu ◽

Jennifer E Ho ◽

Chen Yao ◽

Tianxiao Huan ◽

...

Keyword(s):

Cardiovascular Disease ◽

Diet Quality ◽

Smoking Status ◽

Sandwich Elisa ◽

Activity Level ◽

Bonferroni Correction ◽

Protein Biomarkers ◽

All Cause Mortality ◽

Associated Proteins ◽

Diet Score

Objectives: Molecular mechanism underlying diet and cardiovascular disease (CVD) remains unclear. We aimed to examine the association between habitual diet and protein biomarkers and test whether these proteins mediate the association between diet and incident CVD and mortality. Methods: We included 6,596 participants (mean age 50 years; 54% women) of the Framingham Heart Study. A panel of 71 CVD-related circulating protein biomarkers were measured using a modified Sandwich ELISA method, multiplexed on a Luminex xMAP platform. We used three diet scores to represent overall diet quality: Alternate Health Eating Index (AHEI), a Mediterranean-style Diet Score (MDS), and the Dietary Approaches to Stop Hypertension (DASH). Primary outcomes were incident CVD (coronary heart disease, myocardial infarction, stroke, and others), CVD death, and all-cause mortality with median follow-up 14 years. Results: After adjusting for sex, age, and energy intake, 40 proteins were associated with at least one diet score at P <0.0007 (Bonferroni correction for 71 proteins) and with P <0.05 for the other diet scores. Additional adjustments for smoking status, physical activity level, and alcohol intake did not materially change these associations. Further adjustment for BMI attenuated association; however, the association remained significant for 36 of 40 proteins (P <0.001 with at least one diet score). Pathway analysis using coding genes of the 36 diet-associated proteins showed, after Bonferroni correction, enrichment of 157 Gene Ontology (GO) biological processes such as regulation of immune response (GO:0050776; P=0.003) and regulation of vasoconstriction (GO:0019229; P=0.03). All three diet scores were significantly associated with incident CVD and all-cause mortality. Among the 36 diet-associated proteins, four proteins (GDF15, UCMGP, ADM, and sICAM1) significantly mediated the association between at least one diet score and all-cause mortality at P <0.001 and with P <0.05 for other diet scores, after adjustment for covariates including BMI and cardiometabolic risk factors at baseline. GDF15 significantly mediated the association of diet scores and incident CVD (fatal and nonfatal). The proportion of mediation by GDF15 ranged from 11% to 21% for diet scores and incident CVD and from 30% to 34% for diet scores and all-cause mortality. In addition, we observed that nine proteins were nominally significant in mediation analyses for incident CVD or all-cause mortality (0.001< P <0.05). Conclusions: The present study demonstrates that diet quality is associated with 36 of 71 selected CVD-related circulating protein markers. Our study sheds light into potential pathways underlying the association of diet and CVD and mortality.

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Whole Blood DNA Methylation Signatures of Diet Are Associated With Cardiovascular Disease Risk Factors and All-Cause Mortality

Circulation Genomic and Precision Medicine ◽

10.1161/circgen.119.002766 ◽

2020 ◽

Vol 13 (4) ◽

Author(s):

Jiantao Ma ◽

Casey M. Rebholz ◽

Kim V.E. Braun ◽

Lindsay M. Reynolds ◽

Stella Aslibekyan ◽

...

Keyword(s):

Cardiovascular Disease ◽

Dna Methylation ◽

Disease Risk ◽

Cardiovascular Disease Risk ◽

Healthy Eating Index ◽

Cardiovascular Disease Risk Factors ◽

European Ancestry ◽

Alternative Healthy Eating Index ◽

All Cause Mortality ◽

Diet Score

Background: DNA methylation patterns associated with habitual diet have not been well studied. Methods: Diet quality was characterized using a Mediterranean-style diet score and the Alternative Healthy Eating Index score. We conducted ethnicity-specific and trans-ethnic epigenome-wide association analyses for diet quality and leukocyte-derived DNA methylation at over 400 000 CpGs (cytosine-guanine dinucleotides) in 5 population-based cohorts including 6662 European ancestry, 2702 African ancestry, and 360 Hispanic ancestry participants. For diet-associated CpGs identified in epigenome-wide analyses, we conducted Mendelian randomization (MR) analysis to examine their relations to cardiovascular disease risk factors and examined their longitudinal associations with all-cause mortality. Results: We identified 30 CpGs associated with either Mediterranean-style diet score or Alternative Healthy Eating Index, or both, in European ancestry participants. Among these CpGs, 12 CpGs were significantly associated with all-cause mortality (Bonferroni corrected P <1.6×10 −3 ). Hypermethylation of cg18181703 ( SOCS3 ) was associated with higher scores of both Mediterranean-style diet score and Alternative Healthy Eating Index and lower risk for all-cause mortality ( P =5.7×10 −15 ). Ten additional diet-associated CpGs were nominally associated with all-cause mortality ( P <0.05). MR analysis revealed 8 putatively causal associations for 6 CpGs with 4 cardiovascular disease risk factors (body mass index, triglycerides, high-density lipoprotein cholesterol concentrations, and type 2 diabetes mellitus; Bonferroni corrected MR P <4.5×10 −4 ). For example, hypermethylation of cg11250194 ( FADS2 ) was associated with lower triglyceride concentrations (MR, P =1.5×10 −14 ).and hypermethylation of cg02079413 ( SNORA54 ; NAP1L4 ) was associated with body mass index (corrected MR, P =1×10 −6 ). Conclusions: Habitual diet quality was associated with differential peripheral leukocyte DNA methylation levels of 30 CpGs, most of which were also associated with multiple health outcomes, in European ancestry individuals. These findings demonstrate that integrative genomic analysis of dietary information may reveal molecular targets for disease prevention and treatment.

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Diet Indices Reflecting Changes to Dietary Guidelines for Americans from 1990 to 2015 Are More Strongly Associated with Risk of Coronary Heart Disease

Current Developments in Nutrition ◽

10.1093/cdn/nzz123 ◽

2019 ◽

Author(s):

Casey M Rebholz ◽

Hyunju Kim ◽

Jiantao Ma ◽

Paul F Jacques ◽

Daniel Levy ◽

...

Keyword(s):

Heart Failure ◽

Cardiovascular Disease ◽

Coronary Heart Disease ◽

Heart Disease ◽

Healthy Eating ◽

Diet Quality ◽

Healthy Eating Index ◽

Dietary Guidelines ◽

Disease Outcomes ◽

Dietary Guidelines For Americans

Abstract Background The Dietary Guidelines for Americans (DGAs) provide dietary recommendations for the general population with the intent of preventing chronic disease such as cardiovascular disease. An evaluation of whether updated versions of the DGAs accomplish this goal is lacking. Objective The objective of this project was to determine whether updates to DGAs over time, reflected in subsequent versions of diet quality indices, strengthened the associations between diet quality and risk of cardiovascular disease outcomes. Methods Dietary data collected using a food frequency questionnaire in the Framingham Heart Study Offspring cohort was used to assess adherence to sequential versions of the Healthy Eating Index (1990, 2005, 2010, and 2015) and Alternative Healthy Eating Index (2000 and 2010) (N = 3,267). We conducted prospective analyses using Cox regression to estimate the association between diet indices and incident cardiovascular disease outcomes. Results Among the 3,267 study participants, 54% were female, mean age was 55 years, and mean body mass index was 27 kg/m2. There were a total of 544 events for the composite outcome of cardiovascular diseases (324 coronary heart disease events, 153 stroke events, and 187 heart failure events). Adherence to any dietary index was inversely associated with risk of cardiovascular disease, coronary heart disease, and heart failure, but not stroke. Compared to HEI-1990, scores for the more recent diet indices were more strongly associated with coronary heart disease risk, but not cardiovascular disease, heart failure, or stroke. Conclusions More recent iterations of diet indices, reflecting updates to the DGAs over time, are more strongly associated with risk of incident coronary heart disease than the original diet index (HEI-1990).

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