A substantial proportion of deaths in the United States due to heart disease, stroke, and diabetes is associated with suboptimal diet, a new study suggests.

The largest number of diet-related cardiometabolic disease (CMD) deaths are related to high sodium intake, followed by low intake of nuts/seeds, high processed meats, low seafood omega-3 fats, low vegetables, low fruits, and high sugar-sweetened beverages, the researchers found.

"These results should help identify priorities, guide public health planning, and inform strategies to alter dietary habits and improve health," first author, Renata Micha, RD, PhD, assistant research professor, Tufts Friedman School of Nutrition Science & Policy in Boston, Massachusetts, told Medscape Medical News.

"Increased intakes of specific minimally processed foods, such as fruits, vegetables, nuts, whole grains, fish, vegetable oils, and decreased intakes of salt, processed meats and sugar-sweetened beverages appear to be key relevant priorities for dietary and policy recommendations," she noted. "Future studies should evaluate the potential effects of specific interventions to address the diet-related cardiometabolic mortality and reduce disparities."

The study was published March 7 in JAMA and presented at the American Heart Association Epidemiology and Prevention – Lifestyle and Cardiometabolic Health (EPI-Lifestyle) 2017 Scientific Sessions.

The researchers used comparative risk assessment models, leveraging multiple data sources, including nationally representative data on population demographics, dietary habits, and mortality, to estimate the number and fraction of CMD deaths in the United States related to suboptimal diet.

They estimated that 318,656 (45.4%) of the 702,308 CMD deaths in the United States in 2012 were associated with 10 dietary factors that have "probable or convincing evidence" for causality with CMD: fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, and sodium.

The highest proportion of CMD deaths was estimated to be related to excess sodium intake (9.5%), followed by low intake of nuts/seeds (8.5%), high intake of processed meats (8.2%), low seafood omega-3 fats (7.8%), low intake of vegetables (7.6%) and fruits (7.5%), high sugar-sweetened beverages(7.4%), low intake of whole grains (5.9%) and polyunsaturated fats (2.3%), and high intake of unprocessed red meats (0.4%).

The research team identified differences in the fraction of diet-related CMD deaths across key subgroups. A greater fraction of mortality from suboptimal diet was observed among men compared with women, among blacks and Hispanics compared with whites, and among adults with low education compared with those with high education, they report.

The researchers also noted some positive changes in the fraction of CMD deaths related to dietary factors over time.

As a percentage of annual CMD deaths, from 2002 to 2012, fewer diet-associated CMD deaths were related to insufficient polyunsaturated fats (–21%) and nuts/seeds (–18%) and to excess sugar-sweetened beverages (–14.5%). However, deaths remained relatively stable for whole grains, fruits, vegetables, seafood omega-3 fats, and processed meats and increased for sodium (+5.8%) and unprocessed red meats (+14%), they report.

Nutrition Crisis

"Our findings suggest that nearly half of all deaths from heart disease, stroke, and diabetes are directly caused by poor diet," Dariush Mozaffarian, MD, dean, Tufts Friedman School of Nutrition Science & Policy, who worked on the study, told Medscape Medical News.

"And, it wasn't just too much 'bad' in the diet — much of the burden was caused by too few healthy foods, which should be emphasized as an important positive message to the public, policy makers, scientists, and industry," said Dr Mozaffarian.

"Our country is facing a nutrition crisis. Few other challenges cause more deaths, disability, and associated preventable health costs. Congress is actively debating how to improve health and reduce costs — fixing our food system is among the most essential priorities, a win-win for all," he added.

Noel T. Mueller, PhD, MPH, coauthor of an editorial published with the study, told Medscape Medical News these findings "could help to guide prevention policies that reduce the burden of cardiometabolic disease in US adults, particularly among groups that face health disparities."

"On a clinical level, the findings remind practitioners to not only counsel their patients to decrease intake of poor dietary factors, such as sodium, processed meats, and sugar-sweetened beverages but also augment good dietary behaviors such as increasing intake of nuts and seeds and fruits and vegetables," said Dr Mueller, from the Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention Epidemiology, Baltimore, Maryland.

"On a policy level, these findings emphasize the need to view diet as a cornerstone of prevention policy. The finding that high sodium intake is the largest contributor to cardiometabolic disease deaths in the US validates the decision by the USDA [US Department of Agriculture] to voluntarily reduce sodium targets for industry, but more policy work remains to be done as the proportion of deaths due to high sodium continues to rise in the US," he added.

"The results from this study also, importantly, highlight the role diet policy can play in reducing health disparities. Federal programs, such as the Supplemental Nutrition Assistance Program, could for example help address the disproportionate number of deaths occurring among less educated US adults by expanding the incentives for the purchase of fruits, nuts and seeds," Dr Mueller said.

This research was supported by the National Institutes of Health and the National Heart, Lung, and Blood Institute. Dr Mozaffarian has received personal fees from Boston Heart Diagnostics, Haas Avocado board, AstraZeneca, GOED, DSM, Life Sciences Research Organization, and UpToDate. Dr Mueller has disclosed no relevant financial relationships.

JAMA. 2017;317:908-909, 912-924. Abstract, Editorial


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