Abstract

Background: Plant-based dietary pattern consumption, especially the Mediterranean Diet, have consistently shown inverse risk associations with mortality due to cardiovascular disease (CVD). In agreement, adherence to a vegetarian diet has been associated with reduced CVD risk compared to non-vegetarian; however, the proportion of vegetarians in the population is low. The Pro-vegetarian food pattern (PVEG) has recently been proposed as an intermediate dietary pattern towards vegetarianism which consists in favouring only plant-based foods while concomitantly reducing animal-derived foods.

Hypothesis: We aimed to investigate the associations between the a priori defined PVEG score and CVD mortality across 10 different European countries.

Methods: Included in the analysis were 451,256 participants (130,370 men and 320,886 women) between 35 and 70 years from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort study. At recruitment, between 1992 and 2000, dietary, anthropometric and lifestyle data was collected. CVD mortality was defined as death from circulatory cause (I00–I99 according to the ICD 10th revision). An a priori PVEG dietary score was constructed comprising 12 components. The consumption of 7 plant-based food groups (vegetables, fruit, legumes, cereals, potatoes, nuts, olive oil) were categorized into quintiles, positively rated, and 5 animal-based food groups (meats/meat products, animal fats, eggs, fish and other seafood and dairy products) were inversely rated for a total score ranging from 12 to 60. Five categories of the total score were created: very low (<30), low (30-34), moderate (35-39), high (40-44), and very high (>45) adherence to a PVEG diet. Associations with the PVEG dietary score and CVD mortality were estimated using Cox regression analysis using age as the primary time metrics providing Hazard Ratios (HR) and 95% Confidence Intervals (95%CI). The fully adjusted models included total energy intake, body mass index, physical activity, educational level and stratified by centre, sex and age at baseline. Restricted cubic splines were used to assess the shape of the association in continuous.

Results: Over follow-up (median: 12.8 years), 5083 CVD deaths occurred. Compared to very low adherence to a PVEG diet (reference category), the fully-adjusted HRs (95%CI) were: 0.92 (0.85-1.01) in the low, 0.88 (0.80-0.74) in the moderate, 0.81 (0.74-0.90) in the high and 0.80 (0.70-0.93) in the very high adherence categories. The suggested floor effect for a score >=40 was also seen by restricted cubic spline.

Conclusion: Adherence to the plant-based PVEG food pattern was associated with overall decreased risks of CVD mortality up to 20% risk reduction, although no further risk reduction was obtained from a very strong compared to a strong adherence.