Highlight
- Higher adherence to the EAT-Lancet Planetary Health Diet Index (PHDI) correlates with a 13% reduced risk of total cardiovascular disease (CVD).
- A 20-point increase in PHDI score is associated with markedly lower risks of coronary heart disease, stroke, heart failure, CVD death, and all-cause mortality.
- This observational study encompassing 13,444 US middle-aged adults with a median 29-year follow-up underscores the cardiovascular and longevity benefits of sustainable diets.
- Integrating planetary health considerations into dietary patterns may offer dual benefits for individual health and environmental sustainability.
Study Background and Disease Burden
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide. Modifiable lifestyle factors including diet critically influence CVD risk. Concurrently, dietary patterns exert substantial impact on environmental sustainability. The EAT-Lancet Commission proposed a global reference diet designed to promote human health while reducing environmental degradation, yet epidemiologic evidence linking this sustainable diet to cardiovascular outcomes has been limited.
Addressing the intersection of planetary health and individual well-being, this study investigates whether adherence to the EAT-Lancet diet is associated with reduced cardiovascular morbidity and mortality in a large community-based United States cohort. Establishing evidence-based dietary recommendations that simultaneously optimize cardiovascular health and environmental sustainability is a crucial emerging public health priority.
Study Design
This prospective observational analysis leveraged data from the ARIC (Atherosclerosis Risk in Communities) study, including 13,444 US middle-aged adults free of CVD at baseline. Dietary intakes were assessed at study visits 1 (1987–1989) and 3 (1993–1995) using validated food frequency questionnaires.
Adherence to the EAT-Lancet reference diet was quantified by the Planetary Health Diet Index (PHDI), which ranges from 0 to 135; higher scores indicate greater compliance with recommended food groups emphasizing plant-based foods, moderate animal source consumption, and limited processed foods. Outcomes evaluated included composite total CVD events—comprising coronary heart disease, stroke, and heart failure—along with CVD-specific deaths and all-cause mortality.
Associations between PHDI and endpoints were estimated using Cox proportional hazards regression models adjusted for demographic, lifestyle, and clinical covariates. Median follow-up duration was 29 years, permitting robust estimation of long-term risk.
Key Findings
During follow-up, 5,074 total CVD events, 2,512 CVD deaths, and 8,436 total deaths occurred. Mean PHDI was 76 (range 30–113). After multivariable adjustment, participants in the highest versus lowest quintile of adherence had a 13% lower risk of total CVD (P-trend <0.001).
A 20-point higher PHDI was associated with:
– 13% lower risk of coronary heart disease (P ≤ 0.02)
– 16% lower risk of stroke (P ≤ 0.02)
– 9% lower risk of heart failure (P ≤ 0.02)
– 13% lower risk of CVD death (P ≤ 0.003)
– 10% lower risk of all-cause death (P ≤ 0.003)
These associations were consistent across subgroups stratified by age, sex, and baseline cardiovascular risk factors. The findings support a meaningful dose–response relationship between sustainable dietary adherence and cardiovascular as well as overall mortality risk reduction.
Expert Commentary
This study adds pivotal long-term observational evidence to the field, linking the globally recognized EAT-Lancet dietary goals with significantly lower incidence of cardiovascular events and mortality. Its strengths include large sample size, multiethnic US population, comprehensive dietary assessment, and extended follow-up duration.
Nevertheless, residual confounding inherent to observational epidemiology cannot be entirely excluded. Dietary data collected at two time points may not capture changes over time fully. Further intervention trials are warranted to establish causality. Importantly, this research aligns with current guideline trends advocating plant-forward, whole food–based diets that confer cardiometabolic health benefits.
Mechanistically, plant-based diets rich in fiber, antioxidants, unsaturated fats, and low in red and processed meats may mitigate inflammation, endothelial dysfunction, and atherogenesis—key pathways underlying CVD.
Conclusion
Adhering to a diet designed to promote planetary health as delineated by the EAT-Lancet Commission is associated with significantly reduced risks of cardiovascular morbidity, cardiovascular mortality, and all-cause death in a general US population sample. This dietary approach offers an integrative framework achieving dual goals: improving human cardiovascular health while supporting environmental sustainability.
Future research should focus on implementation strategies to increase adherence, elucidate biological mechanisms, and validate these findings across diverse global populations. Clinicians and public health policymakers are encouraged to consider dietary recommendations that harmonize health promotion with planetary stewardship to curb the CVD global burden sustainably.
References
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2. Willett W et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;393(10170):447–492.
3. Estruch R et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279–1290.
4. Satija A et al. Plant-based diets and incidence of cardiovascular disease: a systematic review and meta-analysis. J Am Heart Assoc. 2017;6(1):e005125.
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