Danish Diet Research Articles

Temporal order of atrial fibrillation and acute myocardial infarction and associated prognosis in the Danish Diet, Cancer and Health cohort

BackgroundAtrial fibrillation (AF) and acute myocardial infarction (AMI) share risk factors and are bidirectionally associated. Several studies found higher risks of outcomes in individuals with both conditions. Whether the risks...

Alcohol consumption trajectories and risk of breast cancer among postmenopausal women: a Danish cohort study

Alcohol consumption is a risk factor for breast cancer (BC), yet little is known about longitudinal alcohol consumption patterns and risk of BC. This study aimed to investigate whether trajectory profiles of alcohol consumption across adulthood were associated with risk of first primary malignant BC in postmenopausal women. At baseline, 28,720 pre-and postmenopausal women aged 50–65 years from the Danish Diet, Cancer and Health Cohort reported their average alcohol intake over the past 12 months and their average alcohol intake at the ages of 20, 30, 40, and 50 years. Alcohol consumption trajectories were estimated using latent class mixed models. BC cases were identified through record linkage to the Danish Cancer Registry. To examine associations between alcohol consumption trajectories and BC, we fitted a proportional hazard model adjusted for potential confounding factors using data from 24,543 postmenopausal women without missing covariate information. We identified 4 alcohol consumption trajectory profiles. During a median follow-up of 16.5 years, 1,591 cases of BC occurred. A mean alcohol consumption trajectory of > 10 g/day was associated with higher risk of BC (HR: 1.65, 95%CI: 1.35–2.03) compared to a mean alcohol consumption trajectory of < 6 g/day. We found no association between trajectory profiles characterized by lower alcohol intakes in early adulthood followed by increasing consumption of alcohol in adulthood compared to a consistently low intake of alcohol. Postmenopausal women drinking consistently high amounts of alcohol throughout adulthood had a higher risk of BC compared to women with a consistently low intake of alcohol.

Substituting Potatoes with Other Food Groups and Type 2 Diabetes Risk: Findings from the Diet, Cancer, and Health Study

BackgroundAlthough potatoes are considered a dietary staple in some cultures, evidence suggests that their impact on type 2 diabetes (T2D) risk is nuanced, with preparation methods and dietary patterns playing crucial roles. Investigating the substitution effects of replacing potatoes with other foods is required to inform dietary recommendations for lowering T2D risk. ObjectiveThe objective of this was to investigate associations between the substitution of potatoes (excluding fries/chips) with other food groups (vegetables, whole grains, refined grains, red meat, processed meat, poultry, fish, and dairy) and the risk of T2D. MethodsThe diet of participants from the prospective Danish Diet, Cancer, and Health study (DCH) was measured at baseline (1993–1997) by a food frequency questionnaire. Participants were followed up for incident T2D from baseline until 2012. Associations between the substitution of potatoes (total, boiled, and mashed) with other food groups and incident T2D was assessed by multivariable Cox proportional hazards model. ResultsIn 54,793 DCH study participants, during a median follow-up of 16.3 y, 7693 incident T2D cases were recorded. A 26% lower risk of T2D was observed when 50 g/d of potatoes were substituted with the same amount of whole grains [hazard ratio and 95% confidence interval (CI): 0.74 (0.70, 0.79)]. Similarly, a lower risk of T2D was observed upon substituting 25 g/d of potatoes with an equivalent amount of green leafy [HR (95% CI): 0.79 (0.74, 0.83)], cruciferous [HR (95% CI): 0.87 (0.83, 0.92)], and yellow/orange/red vegetables [HR (95% CI): 0.97 (0.96, 0.99)]. Conversely, a higher risk of T2D was observed when potatoes were substituted with poultry [HR (95% CI): 1.08 (1.02, 1.15)], red meat [HR (95% CI): 1.06 (1.02, 1.10)], and processed meat [HR (95% CI): 1.17 (1.11, 1.23)]. Replacing boiled potatoes with red meat or poultry was associated with a higher risk of T2D compared with replacing mashed potatoes. ConclusionsSubstituting potatoes with whole grains and most types of vegetables was associated with a lower risk of T2D, whereas substituting potatoes with poultry, red meat, and processed meat was associated with a higher risk.

Dietary Minerals and Incident Cardiovascular Outcomes among Never-Smokers in a Danish Case-Cohort Study.

Background: Diet is known to impact cardiovascular disease (CVD) risk, but evidence for the essential minerals of magnesium (Mg), calcium (Ca), and potassium (K) is inconsistent. Methods: We conducted a case-cohort study within a non-smoking subgroup of the Danish Diet, Cancer and Health cohort, a prospective study of 50-64-year-olds recruited between 1993-1997. We identified incident heart failure (HF), acute myocardial infarction (AMI) and stroke cases through 2015 with an 1135-member subcohort. We measured the dietary intake of minerals, also known as elements, and calculated a combined dietary intake (CDI) score based on joint Ca, Mg and K intakes (mg/d) from Food Frequency Questionnaires. We estimated adjusted hazard ratios (HRs) with Cox proportional hazard models. Results: Most HRs examining associations between CDI score and CVD were null. However, the third quartile of CDI was associated with a lower risk for heart failure (HR: 0.89; 95% CI: 0.67, 1.17), AMI (HR: 0.79; 95% CI: 0.60, 1.04), and stroke (HR: 0.63; 95% CI: 0.44, 0.88). Conclusions: We did not find consistent evidence to suggest that higher levels of essential minerals are associated with incident HF, AMI, and stroke, though results suggest a potential U-shaped relationship between select minerals and CVD outcomes.

Plant Omega-3 Fatty Acids May Lower Risk of Atrial Fibrillation in Individuals with a Low Intake of Marine Omega-3 Fatty Acids

BackgroundOmega-3 fatty acids derived from seafood acids may influence cardiac arrhythmogenesis, whereas the role of the major plant-derived omega-3 fatty acid, alpha-linolenic acid (ALA), on atrial fibrillation (AF) is largely unknown. ObjectivesWe aimed to investigate the association between ALA intake and risk of incident AF overall and in subjects with a low intake of marine omega-3 fatty acids. MethodsWe followed a total of 54,260 middle-aged men and women enrolled into the Danish Diet, Cancer, and Health cohort for development of AF using nationwide registries. Intake of ALA was assessed using a validated food frequency questionnaire and modeled as a restricted cubic spline. Statistical analyses were conducted using Cox proportional hazards regression. ResultsWe identified a total of 4902 incident AF events during a median of 16.9 y of follow-up. In multivariable analyses, we observed indications of a statistically nonsignificant inverse association between ALA intake and risk of AF up to an ALA intake of 2.5 g/d, whereas no appreciable association was found for higher intakes of ALA. A statistically significant dose-dependent negative association was found between ALA intake and risk of AF in individuals consuming < 250 mg marine omega-3 fatty acids daily, whereas no association was found in those with a higher intake of marine omega-3 fatty acids. ConclusionsIntake of ALA was associated with a lower risk of AF in individuals consuming a low intake of marine omega-3 fatty acids. This finding is novel and warrants further investigation.

Source-specific nitrate intake and all-cause mortality in the Danish Diet, Cancer, and Health Study

IntroductionNitrate and nitrite are naturally occurring in both plant- and animal-sourced foods, are used as additives in the processing of meat, and are found in water. There is growing evidence that they exhibit a spectrum of health effects, depending on the dietary source. The aim of the study was to examine source-dependent associations between dietary intakes of nitrate/nitrite and both all-cause and cause-specific mortality.MethodsIn 52,247 participants of the Danish Diet, Cancer and Health Study, associations between source-dependent nitrate and nitrite intakes––calculated using comprehensive food composition and national drinking water quality monitoring databases––and all-cause, cardiovascular disease (CVD)-related, and cancer-related mortality over 27 years were examined using restricted cubic splines within Cox proportional hazards models adjusting for demographic, lifestyle, and dietary confounders. Analyses were stratified by factors hypothesised to influence the formation of carcinogenic N-nitroso compounds (namely, smoking and dietary intakes of vitamin C, vitamin E, folate, and polyphenols).ResultsPlant-sourced nitrate intake was inversely associated with all-cause mortality [HRQ5vsQ1: 0.83 (0.80, 0.87)] while higher risks of all-cause mortality were seen for higher intakes of naturally occurring animal-sourced nitrate [1.09 (1.04, 1.14)], additive permitted meat-sourced nitrate [1.19 (1.14, 1.25)], and tap water-sourced nitrate [1.19 (1.14, 1.25)]. Similar source-dependent associations were seen for nitrite and for CVD-related and cancer-related mortality except that naturally occurring animal-sourced nitrate and tap water-sourced nitrate were not associated with cancer-related mortality and additive permitted meat-sourced nitrate was not associated with CVD-related mortality. No clear patterns emerged in stratified analyses.ConclusionNitrate/nitrite from plant sources are inversely associated while those from naturally occurring animal-sources, additive-permitted meat sources, and tap water-sources are positively associated with mortality.

Temporal order of atrial fibrillation and acute myocardial infarction and associated prognosis in the Danish Diet, Cancer, and Health cohort

Abstract Background Atrial fibrillation (AF) and acute myocardial infarction (AMI) share risk factors and are bidirectionally associated. Several studies found higher risks of outcomes in individuals with both conditions. Whether the risks of outcomes differ according to temporal order of AF and AMI is unclear. Purpose We aimed to assess the risks of heart failure (HF), ischemic stroke (IS) and all-cause mortality in individuals with both AF and AMI compared to only one. In addition, we assessed risks of outcome according to the temporal order of AF and AMI in individuals with both conditions. Methods The study was based on the Danish Diet, Cancer and Health cohort in which 57,053 men and women aged 50-64 years, with no diagnosis of cancer, participated. Assessment of AF, AMI and outcomes were based on diagnosis codes from the Danish National Patient Registry. We examined the risks of HF, IS and all-cause mortality during 10 years of follow-up in participants with both AF and AMI compared to only one and according to the temporal order of AF and AMI in participants with both conditions using Cox regression models. Results We identified 5,816 participants with newly diagnosed AF only, 3,448 with first AMI only, 348 with AF before AMI and 721 participants with AMI before AF. The multivariable-adjusted risks of HF, IS and all-cause mortality were higher among participants with both AF and AMI compared to participants with only AF or AMI (Figure 1). In participants with both AF and AMI, there was no difference in risk of HF (HR=0.92, 95% CI 0.72-1.17) or IS (HR=1.12, 95% CI 0.76-1.66) between participants with AF before AMI compared to AMI before AF. AMI before AF was associated with lower all-cause mortality compared to AF before AMI (HR=0.70, 95% CI 0.54-0.90) (Figure 2). Conclusions Risks of adverse outcomes were higher among participants with both AF and AMI compared to only AF or AMI. All-cause mortality, but not risk of HF or IS, differed according to temporal order with a lower mortality among participants with AMI before AF.Figure 1Figure 2

Whole-grain intake in mid-life and healthy ageing in the Danish Diet, Cancer and Health cohort.

Growing elderly populations worldwide have sparked interest in factors promoting healthy aging. Diet and other lifestyle patterns are key factors for healthy ageing; however, evidence is sparse for specific dietary guidelines that are easily implemented in everyday life. Whole grains constitute specific dietary components with unexplored potential in healthy ageing. We applied an illness-death multistate model to assess the association between whole-grain intake and life expectancy, both with and without disease, over a 20-year period. Healthy ageing was defined as absence of cancer, ischemic heart disease, stroke, type 2 diabetes, asthma, chronic obstructive pulmonary disease, and dementia during follow-up. Based on information from 22,606 men and 25,468 women in the Danish Diet, Cancer and Health cohort, followed for an average of 13.8 and 17.5 years, respectively, a doubling in whole-grain intake was associated with 0.43 (95% CI: 0.33-0.52) and 0.15 (0.06-0.24) additional years without disease for men and women, respectively. Comparing the highest and lowest quartiles of whole-grain intake, with a special emphasis on men, we found that those with the highest intake lived, on average, one year longer without disease compared to those with the lowest intake. Additionally, although a high intake of whole grains yielded longer life expectancy, the duration of living with disease was shorter. Intake of whole grains in mid-life was associated with healthy ageing looking 20 years ahead.

Source-specific nitrate and nitrite intakes and associations with sociodemographic factors in the Danish Diet Cancer and Health cohort.

The dietary source and intake levels of nitrate and nitrite may govern its deleterious versus beneficial effects on human health. Existing evidence on detailed source-specific intake is limited. The objectives of this study were to assess nitrate and nitrite intakes from different dietary sources (plant-based foods, animal-based foods, and water), characterize the background diets of participants with low and high intakes, and investigate how sociodemographic and lifestyle factors associate with intake levels. In the Danish Diet, Cancer and Health Cohort, sociodemographic and lifestyle information was obtained from participants at enrolment (1993-1997). Source-dependent nitrate and nitrite intakes were calculated using comprehensive food composition databases, with tap water nitrate intakes estimated via the national drinking water quality monitoring database linked with participants' residential addresses from 1978 to 2016. Underlying dietary patterns were examined using radar plots comparing high to low consumers while sociodemographic predictors of source-dependent nitrate intakes were investigated using linear regression models. In a Danish cohort of 55,754 participants aged 50-65 at enrolment, the median [IQR] intakes of dietary nitrate and nitrite were 58.13 [44.27-74.90] mg/d and 1.79 [1.43-2.21] mg/d, respectively. Plant-based foods accounted for ~76% of nitrate intake, animal-based foods ~10%, and water ~5%. Nitrite intake was sourced roughly equally from plants and animals. Higher plant-sourced nitrate intake was associated with healthier lifestyles, better dietary patterns, more physical activity, higher education, lower age and lower BMI. Females and participants who had never smoked also had significantly higher plant-sourced nitrate intakes. Higher water-sourced nitrate intake was linked to sociodemographic risk factors (smoking, obesity, lower education). Patterns for animal-sourced nitrate were less clear. Participants with higher plant-sourced nitrate intakes tend to be healthier while participants with higher water-sourced nitrate intakes tended to be unhealthier than their low consuming counterparts. Future research in this cohort should account for the sociodemographic and dietary predictors of source-specific nitrate intake we have identified.

Dietary Vitamin K1 Intake and Incident Aortic Valve Stenosis.

Leaflet calcification contributes to the development and progression of aortic valve stenosis. Vitamin K activates inhibitors of vascular calcification and may modulate inflammation and skeletal bone loss. Therefore, we aimed to determine whether higher dietary intakes of vitamin K1 are associated with a lower incidence of aortic stenosis. In the Danish Diet, Cancer and Health study, participants aged 50 to 64 years completed a 192-item food frequency questionnaire at baseline, from which habitual intakes of vitamin K1 were estimated. Participants were prospectively followed using linkage to nationwide registers to determine incident aortic valve stenosis (primary outcome) and aortic stenosis with subsequent complications (aortic valve replacement, heart failure, or cardiovascular disease-related mortality; secondary outcome). In 55 545 participants who were followed for a maximum of 21.5 years, 1085 were diagnosed with aortic stenosis and 615 were identified as having subsequent complications. Participants in the highest quintile of vitamin K1 intake had a 23% lower risk of aortic stenosis (hazard ratio, 0.77 [95% CI, 0.63-0.94]) and a 27% lower risk of aortic stenosis with subsequent complications (hazard ratio, 0.73 [95% CI, 0.56-0.95]), compared with participants in the lowest quintile after adjusting for demographics and cardiovascular risk factors. In this study, a high intake of vitamin K1-rich foods was associated with a lower incidence of aortic stenosis and a lower risk of aortic stenosis with subsequent complications.

Interaction of genetic risk and lifestyle on the incidence of atrial fibrillation

BackgroundThe relationship between combined genetic predisposition and lifestyle and the risk of incident atrial fibrillation (AF) is unclear. Therefore, we aimed to assess a possible interaction between lifestyle and genetics...

Intake of Marine n-3 Polyunsaturated Fatty Acids and Risk of Hemorrhagic Stroke and Its Subtypes: A Danish Follow-Up Study

Introduction: A diet rich in marine n-3 polyunsaturated fatty acids (PUFAs) may lower the risk of coronary heart disease and ischemic stroke. However, the association between intake of marine n-3 PUFAs and risk of hemorrhagic stroke has only been sparsely explored. We aimed to investigate the associations between intake of the major marine n-3 PUFAs, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and their sum, in relation to incident hemorrhagic stroke and its subtypes, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Methods: We analyzed data from the Danish Diet, Cancer and Health Cohort, which was established between 1993 and 1997. Information on dietary intake of marine n-3 PUFAs was obtained through a validated food frequency questionnaire. Potential hemorrhagic stroke cases were identified by linkage to the Danish National Patient Register and subsequently validated. Hazard ratios obtained by Cox proportional hazard regression analyses were used as measures of association. Results: A total of 394 subjects among 55,519 individuals developed hemorrhagic stroke during a median follow-up period of 13.5 years. In multivariable analyses including adjustment for established risk factors, we observed weak and statistically nonsignificant inverse associations between intake of EPA, DHA, and EPA + DHA and the rate of incident hemorrhagic stroke. In analyses of hemorrhagic stroke subtypes, we found indications of lower rates of ICH among participants in the highest quartile of EPA, DHA, and EPA + DHA compared with those in the lowest quartile and indications of lower rates of SAH in the highest quartile of EPA intake compared to the lowest quartile, but the findings were statistically nonsignificant. Conclusions: Inversely statistically nonsignificant associations were found between EPA, DHA, and EPA + DHA and hemorrhagic stroke.

Five-year changes in weight and risk of atrial fibrillation in women and men from the Danish diet, cancer, and health cohort

Abstract Background Overweight and obesity are causal risk factors for atrial fibrillation (AF).(1) Mendelian randomization studies indicated a higher risk of AF with each unit increase in body mass index (BMI).(1) In observational studies, weight gain was associated with a higher risk of incident AF compared to stable weight.(2,3) However, the results are conflicting regarding the association between weight loss and risk of incident AF.(4,5). Purpose We aimed to assess the association between five-year changes in weight and absolute and relative rates of incident AF in women and men from the Danish Diet, Cancer, and Health Cohort. Methods In the Danish cohort study Diet, Cancer, and Health, participants were invited to attend a recruitment research examination and a second examination 5 years later. Height, weight, and several lifestyle factors were assessed at both examinations. We calculated BMI and BMI changes between first and second examination. BMI changes were categorized into following groups: &amp;lt;-5 kg/m2, ≥-5 to &amp;lt;-2.5 kg/m2, ≥-2.5 to &amp;lt;2.5 kg/m2, ≥2.5 to &amp;lt;5 kg/m2 and ≥5 kg/m2. Diagnoses of AF and comorbidities were retrieved from the Danish National Patient Registry. We used multivariable-adjusted Cox proportional hazards models to assess hazard ratios (HR) of AF according to changes in BMI. Results 43,758 participants without prior AF were included in the study. The median age was 62 (25th-75th percentile, 58-66) years and 54% were women. Over 15.7 years median follow-up time 5,312 participants had incident AF. From the first to the second measure, 39,076 (89%) of participants had stable weight, 2,627 (6%) lost weight, and 2,055 (5%) gained weight. The incidence rates of AF per 1,000 person-years were 8.4 (95% CI 8.1-8.6) among participants with stable weight, 12.4 (95% CI 9.6-16.1) among those with weight loss ≥5 kg/m2, and 15.4 (95% CI 11.7-20.2) among those who gained ≥5 kg/m2. Compared to participants with stable weight, individuals who gained ≥2.5 to &amp;lt;5 kg/m2 had a higher hazard of AF (HR 1.24, 95% CI 1.09-1.41). Among participants who gained ≥5 kg/m2 the rate of AF was also higher compared to stable weight (HR 1.95, 95% CI 1.48-2.56). There was no statistically significant association between weight loss, regardless of degree, and rate of AF. Figure 1 shows the HR of AF by BMI changes from first to second measure compared to stable weight using restricted cubic splines. In sex-stratified analyses, the association between weight gain of ≥5 BMI units (kg/m2) and higher AF rate was present for both women and men. Conclusions In this cohort study, five-year weight gain was associated with higher long-term risk of AF compared to stable weight. However, we found no associations between weight loss and long-term risk of AF.Figure 1

Genetic risk, modifiable risk factors, and atrial fibrillation in the Danish diet, cancer, and health cohort

Abstract Background The etiology of AF is multifactorial. Genetic susceptibility and lifestyle contribute to atrial fibrillation (AF) risk.(1,2) However, the relationship between combined genetic predisposition and lifestyle risk factors on AF risk is unclear. Purpose We aimed to assess a possible interaction between modifiable risk factors and genetics on AF risk. Methods We included AF cases and a randomly drawn subcohort of 4,040 participants from the Danish Diet, Cancer, and Health study. Modifiable risk factors were assessed including smoking, body mass index, physical activity, diet, alcohol consumption, total cholesterol, and blood pressure. Based on cumulation of risk factors, a risk factor profile was determined for all participants and categorized as poor, intermediate, and ideal. Based on DNA sequence polymorphisms, we calculated a genetic risk score for AF, and categorized participants as having a low (quintile 1), intermediate (quintile 2-4) or high (quintile 5) genetic risk. Diagnoses of AF and/or atrial flutter were obtained from the Danish National Patient Register. We used weighted Cox proportional hazards regression to assess hazard ratios of AF. Results 3,094 AF cases occurred during a median follow-up of 12.9 years. Median age at baseline in the subcohort was 55 years (25th-75th percentile 52-60) and 2,092 (55%) were women. Participants at intermediate and high genetic risk had higher rates of AF compared with those at low genetic risk. Likewise, intermediate, and poor risk factor profiles were associated with higher rates of AF compared with those having ideal risk factor profiles. Weighted cumulative incidence proportions and hazard ratios of AF according to genetic risk and modifiable risk factors are shown in Figure 1. Within each category of genetic risk, incidence rates per 1,000 person-years were gradually higher with worse modifiable risk factor profiles. (Figure 2). For participants with high genetic risk, the incidence rates of AF per 1,000 person years were 5.0 (95% CI 3.4-7.3) for ideal, 6.6 (95% CI 5.4-8.1) for intermediate, and 10.4 (95% CI 9.2-11.8) for poor risk factor profiles. On an additive scale, there was a statistically significant interaction between genetic risk and modifiable risk factors (relative excess risk due to interaction=0.86 (95% 0.68-1.03, p&amp;lt;0.001). Conclusions A genetic risk score and modifiable risk factors were each associated with AF risk. The rates of AF increased gradually with cumulation of modifiable risk factors within each category of the genetic risk score, and we found an additive interaction between genetic risk and the modifiable risk factor profile. This underlines the importance of risk factor modification in primary AF prevention.Figure 1Figure 2

Organic food consumption and the incidence of type 2 diabetes mellitus in the Danish Diet, Cancer and Health cohort

AimTo investigate the association between organic food consumption and the incidence of type 2 diabetes mellitus. MethodsAmong 41,286 cohort participants, aged 50–65 years, organic food consumption of vegetables, fruits, dairy products, eggs, meat, and cereal products, was summarized into an organic food score evaluated as never, low, medium and high consumption and as continuous intake. During follow-up, 4,843 cases were identified in the National Diabetes Register. Organic food consumption was associated to the disease incidence in Cox regression models. ResultsOrganic food consumption was linearly associated with a lower incidence of type 2 diabetes mellitus (Women, HR: 0.94, 95% CI: 0.89–1.00, Men, HR: 0.95, 95% CI: 0.90–1.00). Organic food consumption frequency, compared to never consumption, showed HRs below 1.00 for both women (medium intake HR: 0.96, 95% CI: 0.84–1.10, high intake HR: 0.88, 95% CI: 0.74–1.05) and men (low intake, HR: 0.95, 95% CI: 0.85–1.05, medium intake, HR: 0.92, 95% CI: 0.83–1.03, high intake, HR: 0.89, 95% CI: 0.75–1.05) but were not statistically significant. Similar patterns were observed with consumption of the specific organic food groups for women, but not for men. ConclusionsOrganic food consumption was associated with a suggested lower incidence of type 2 diabetes mellitus.

11.D. Round table: Anti-inflammatory vs. sustainable dietary patterns throughout the life course

Abstract Diet is well known to affect the risk of several chronic diseases throughout the life course, potentially through modulation of the inflammatory response. Chronic inflammation, which increases with age, may contribute to the development of various chronic diseases, including cardiovascular disease, diabetes, and cancer. In parallel, the environmental impact of diet varies substantially depending on the choice of food products and the underlying production systems. Adopting sustainable diets produces co-benefits for population health, but also for the environment by limiting greenhouse gas emissions and land use. However, these patterns may be deficient in micronutrients, and are not consistently associated with lower risk of chronic conditions throughout the life course. In particular, among children and adolescents, nutritionally adequate and appealing sustainable diets are important to promote healthy growth and to develop sustainable dietary habits. Therefore, we developed this workshop with the aim to explore the overlap and synergies between sustainable and anti-inflammatory diets at different stages in life. As dietary patterns provide a more complete overview of usual diet intake, in this panel we will (1) briefly present different methods that can be used to estimate dietary patterns and as an example, we will present previous results from inflammatory dietary patterns and their association with cognitive decline. Regarding adherence to sustainable diets, we will present results from (2) studies in adults (Danish Diet, Cancer and Health study) and their association to stroke, type 2 diabetes and overall mortality and (3) studies in children (‘Children of the 90s’ ALSPAC cohort) regarding their growth curves. Regarding challenges in policy implementation, we will present (4) an example of a co-creation strategy with students and chefs to develop innovative and healthy plant-based foods for school canteens. In the discussion part of the round table, we will focus on how to combine anti-inflammatory and sustainable diets to promote health across the life course and the potential strategies for policy implementation of these dietary patterns. The objectives of this workshop are (1) to discuss within a multidisciplinary set of experts the potential synergies between two very popular “healthy” dietary patterns and (2) to evaluate what are the main challenges of implementing dietary strategies based on these diets in different generations: among children who could potentially not have their needs fulfilled and among adolescents who might not accept such dietary changes, plus potential strategies for middle-aged and older adults. The added value is to bring domain experts together in a discussion space, where new knowledge can be generated, research gaps in this field can be highlighted and future interdisciplinary collaborations be fostered. Key messages • Some dietary factors might have an impact on chronic conditions through inflammatory pathways. Yet the overlap and synergies between sustainable and anti-inflammatory patterns is still not explored. • Sustainable diets may produce health benefits throughout the life course. Implementation strategies can be challenging, however innovative strategies in schools may be successful. Speakers/Panelists Patricia Chocano-Bedoya Institute of Primary Health Care, Bern, Switzerland Christina Dahm Department of Public Health, Aarhus University, Aarhus, Denmark Jessica Laine Carmeli Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland Margarita Kokkorou European Commission Joint Research Centre, Ispra, Italy

The estimated health impact of sustainable diets in the Danish population: a risk-benefit assessment

Abstract Background To mitigate the climate emergency and support a growing world population, sustainable diets have become a popular topic. These plant-forward diets are promising in terms of health effects, but estimated population health impacts linked to changes in nutrition and exposure to food contaminants have yet to be quantified. We used a risk-benefit assessment (RBA) to quantify the net health impact of theoretical dietary changes. Methods We collected dietary consumption data from the Danish National Survey of Diet and Physical Activity, exposure data for selected chemical contaminants (cadmium, methyl mercury, lead, and inorganic arsenic) from Danish food monitoring, and dose-response data for various health outcomes from published epidemiological data. The average Danish diet was compared to multiple dietary scenarios: a Danish-adjusted EAT-Lancet diet and other alternative scenarios that looked at proportional decreases in animal-based foods with plant-based substitutions. Results Shifting to a Danish-adjusted EAT-Lancet diet would require increased consumption of legumes by 6,352%, nuts by 1,036%, bread and cereals by 100%, fruits and berries by 40%, and fish and shellfish by 39%. Red meat and dairy consumption would need decreases of 83% and 25%, respectively. With these changes, we estimated that a net of 22,900 DALYs would be averted in one year in the Danish population. The food groups contributing most to positive health impacts were nuts (-7,721 DALYs), bread and cereals (-6,244), decreased red meat (-5,681), legumes (-2,509), and fruits and berries (-1,396). These results are preliminary; all scenarios will be compared. Conclusions Our results support a beneficial impact on the health of the Danish population due to sustainable dietary transitions. Similar benefits are expected for other populations across Europe. We argue that RBAs are a powerful decision-support tool and can provide quantitative evidence for sustainable diets and future interventions. Key messages • Our comprehensive risk-benefit assessment concluded that transitioning towards a more sustainable diet leads to positive health impacts. • Our conclusions support policy and decision makers in implementing plant-forward dietary recommendations and agendas in the Danish population.

Urine antimony and risk of cardiovascular disease – A prospective case-cohort study in Danish Non-Smokers

BackgroundLimited evidence suggests that antimony induces vascular inflammation and oxidative stress and may play a role in cardiovascular disease (CVD) risk. However, few studies have examined whether environmental antimony from sources other than tobacco smoking is related with CVD risk. The general population may be exposed through air, drinking water, and food that contains antimony from natural and anthropogenic sources, such as mining, coal combustion, and manufacturing. ObjectivesTo examine the association of urine antimony with incident acute myocardial infarction (AMI), heart failure, and stroke among people who never smoked tobacco. MethodsBetween 1993 and 1997, the Danish Diet, Cancer and Health (DCH) cohort enrolled participants (ages 50–64 years), including n = 19,394 participants who reported never smoking at baseline. Among these never smokers, we identified incident cases of AMI (N = 809), heart failure (N = 958), and stroke (N = 534) using the Danish National Patient Registry. We also randomly selected a subcohort of 600 men and 600 women. We quantified urine antimony concentrations in samples provided at enrollment. We used modified Cox proportional hazards models to estimate adjusted hazard ratios (HR) for each incident CVD outcome in relation to urine antimony, statistically adjusted for creatinine. We used a separate prospective cohort, the San Luis Valley Diabetes Study (SLVDS), to replicate these results. ResultsIn the DCH cohort, urine antimony concentrations were positively associated with rates of AMI and heart failure (HR = 1.52; 95%CI = 1.12, 2.08 and HR = 1.58; 95% CI = 1.15, 2.18, respectively, comparing participants in the highest (>0.09 µg/L) with the lowest quartile (<0.02 µg/L) of antimony). In the SLVDS cohort, urinary antimony was positively associated with AMI, but not heart failure. DiscussionAmong this sample of Danish people who never smoked, we found that low levels of urine antimony are associated with incident CVD. These results were partially confirmed in a smaller US cohort.

Higher Habitual Dietary Intakes of Flavanols and Anthocyanins Differentially Associate with Lower Incidence of Ischemic Stroke Subtypes—A Follow-Up Analysis

BackgroundWe previously reported that habitual consumption of dietary flavanol oligomers + polymers and anthocyanins is associated with a lower risk of ischemic stroke. However, no studies have investigated their relationship with ischemic stroke subtypes. ObjectivesIn this follow-up analysis, we aimed to examine the association of flavanol oligomers + polymers and anthocyanin intake with ischemic stroke subtypes, including the following: 1) large-artery atherosclerosis, 2) cardioembolism, 3) small-vessel occlusion, 4) other determined etiology, and 5) undetermined etiology. MethodsParticipants (n = 55,094) from the Danish Diet, Cancer, and Health Study were followed up for <16 y for first-time ischemic stroke events, which were classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Intakes of flavanol oligomers + polymers and anthocyanins were calculated from food frequency questionnaires using the Phenol-Explorer database, and their relationships with ischemic stroke subtypes were investigated using restricted cubic splines within Cox proportional hazards models. After multivariable adjustment, higher habitual intakes (quintile 5 compared with quintile 1) of flavanol oligomers + polymers and anthocyanins were associated with a lower risk of specific ischemic stroke subtypes, including large-artery atherosclerosis [flavanol oligomers + polymers, hazard ratio {HR} (95% confidence interval {CI}): 0.64 (0.47, 0.87)], cardioembolism [anthocyanins, HR (95% CI): 0.45 (0.25, 0.82)], and small-vessel occlusion [flavanol oligomers + polymers, HR (95% CI): 0.65 (0.54, 0.80); anthocyanins, HR (95% CI): 0.79 (0.64, 0.97)], but not stroke of other determined or undetermined etiology. ConclusionsHigher habitual intakes of flavanols and anthocyanins are differentially associated with a lower risk of ischemic stroke from atherosclerosis and/or cardioembolism but not with other subtypes.

Five-year changes in weight and risk of atrial fibrillation in the Danish Diet, Cancer, and Health Cohort.

Obesity is a major risk factor for atrial fibrillation (AF). Compared with stable weight, gaining weight was associated with a higher risk of incident AF in observational studies. The results, however, are conflicting regarding weight loss and risk of AF. This study aimed to assess the association between 5-year weight changes and risk of incident AF. The study was based on participants from the Danish Diet, Cancer, and Health Cohort. Body mass index (BMI) was assessed at a baseline examination and at a second examination 5 years later. Diagnoses of AF and co-morbidities were retrieved from the Danish National Patient Registry. In total, 43 758 participants without prior AF were included. The median age was 61 years and 54% were female. During a median follow-up of 15.7 years, 5312 individuals had incident AF (incidence rate 8.6/1000 person-years). Compared with stable weight, weight gain between 2.5 and 5 BMI units (kg/m2) was associated with a higher risk of AF [hazard ratio (HR) 1.24, 95% confidence interval (CI) 1.09-1.41]. Weight gain of 5 or more BMI units (kg/m2) was associated with a HR of 1.95 (95% CI 1.48-2.56) of incident AF. However, there was no statistically significant association between weight loss and risk of AF. Five-year weight gain was associated with greater risk of AF compared with stable weight in the Danish Diet, Cancer, and Health Cohort. There was no statistically significant association between weight loss and risk of AF.