N° 27 | December 2017

Healthy-eating attitudes and incidence of cardiovascular disease in middle-aged adults

Cardiovascular disease (CVD) is responsible of the largest proportion of worldwide deaths from non-communicable diseases under the age of 70 years. The American Heart Association and the American College of Cardiology have emphasized the importance of dietary patterns rather than individual dietary components, and encourage heart-healthy lifestyle behaviours. Dietary assessment is necessary for providing dietary advice, but it is complex in clinical care, thus there is an emerging interest for the use of brief dietary questionnaires capturing key attitudes and practices. The rationale is that attitudes toward nutrition and healthy eating are strong determinants of food choices and dietary quality.

Cardiovascular disease: a public health issue

The Seguimiento University of Navarra (SUN) is a prospective, dynamic, Spanish cohort study of university graduates started in 1999. (https://www.unav.edu/departamento/preventiva/sun).

The baseline questionnaire included a validated semi-quantitative food frequency questionnaire and collected information on a wide array of characteristics, including socio-demographic variables, health-related habits and clinical variables.

In this study, we prospectively assessed the association between certain attitudes toward healthy eating (yes/no) and incident CVD in 19,138
participants. We developed a Healthy-eating attitudes score assigning 1 point if the attitude was presumed to be healthy and 0 if it was presumed to be unhealthy. Thus, participants received 1 point for each “Yes” answer if they tried to eat more fruit, more vegetables, more fish, less meat, less sweets and pastries, more fiber and less fat, and if they tried to avoid the consumption of butter, removed fat from meat, and did not add sugar to drinks and 0 otherwise. Thereafter, we grouped participants into four categories according to their baseline score: 0 to 5 points, 6 to 7 points, 8 points, and 9 to 10 points.

CVD events were confirmed by a panel of expert physicians and National Death Index.

Participants in the highest category of the 10-item healthy eating attitudes score had higher adherence to the Mediterranean diet, and in general, exhibited more favourable food patterns and macronutrient profile. We observed 139 incident cases of CVD (59 non-fatal myocardial infarctions, 31 non-fatal strokes and 49 cardiovascular deaths) during a mean-follow up of 9.2 years. We found that a higher score was independently associated with a lower risk of CVD [3-5 points, adjusted Hazard Ratio (HR): 0.38 (95% confidence interval: 0.18-0.81); 6-8 points: 0.57 (95 % CI:0.29-1.12); 9-10 points: 0.31 (95% CI: 0.15-0.67), compared to 0-2 points].

Fruit, vegetables and whole grains and prevention of CVD

In our study, a better general attitude towards healthy-eating was associated with lower incidence of CVD.
As shown in Table 1 participants who tried to consume more fruit, vegetables and fiber had, respectively, a 41%, 38% and 31% lower risk of CVD comparing to those who did not. Higher fruit and vegetable consumption are known to improve carbohydrate quality and fiber intake, and to provide beneficial elements (potassium, folate, antioxidants, flavonoids), associated with a reduced risk of stroke. Furthermore, fiber intake and whole grain consumption are inversely associated with CVD, which is probably mediated by improvements in BMI, blood glucose control, inflammatory biomarkers, lipid profiles and antioxidant effects. We did not find any association between other attitudes (not adding sugar to beverages, avoiding butter, removing fat from meat or eating less fat, meat, sweets or pastries) and CVD risk.

Eating attitudes questionnaire: a useful tool to investigate diethealth relation

A brief questionnaire about attitudes toward healthy-eating (particularly fruit, vegetables and fiber) may be an easy and useful tool for the primary prevention of CVD in the setting of primary health care and it could also be helpful to identify those patients with a probable higher risk of developing CVD in the future.

Table 1: Multivariable-adjusted hazard ratios (and 95% confidence intervals) for incident cardiovascular disease on each healthy-eating attitude question (yes vs. no). The answer ‘no’ is given as the reference (zero values)

Healthy-eating attitude question HR (95% CI)
Do you try to eat more fruit? 0.59 (0.40-0.87)
Do you try to eat more vegetables? 0.62 (0.41-0.94)
Do you try to eat more fish? 0.82 (0.57-1.19)
Do you avoid the consumption of butter? 1.37 (0.85-2.20)
Do you try to eat less meat? 1.07 (0.74-1.53)
Do you try to remove fat from meat? 0.97 (0.67-1.42)
Do you try to eat less sweets and pastries? 0.99 (0.68-1.45)
Do you try to increase your fiber intake? 0.69 (0.48-0.98)
Do you try to reduce your fat intake? 1.06 (0.67-1.67)
Do you add sugar to some beverages? 0.97 (0.65-1.46)


Based upon: Santiago S, Zazpe I, Gea A, de la Rosa PA, Ruiz-Canela M, Martínez-González MA. Healthy-eating attitudes and the incidence of cardiovascular disease: the SUN cohort. Int J Food Sci Nutr. 2017 Aug;68(5):595-604. DOI: 10.1080/09637486.2016.1265100. Epub 2016 Dec 28.

England CY, Andrews RC, Jago R, Thompson JL. 2015. A systematic review of brief dietary
questionnaires suitable for clinical use in the prevention and management of obesity,
cardiovascular disease and type 2 diabetes. Eur J Clin Nutr. 69:977–1003.
Hu D, Huang J, Wang Y, Zhang D, Qu Y. 2014. Fruit and vegetables consumption and risk
of stroke: a meta-analysis of prospective cohort studies. Stroke. 45:1613–1619.
National Cancer Institute. 2017. Division of Cancer Control & Population Sciences.
Epidemiology and Genomics Research Program Register of validated short dietary
assessment instruments. [cited 2017 Nov 3]. Available from: http://appliedresearch.cancer.

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