Skip to main content

A prospective study of healthful and unhealthful plant-based diet and risk of overall and cause-specific mortality

Abstract

Purpose

Although emphasis has recently been placed on the importance of diet high in plant-based foods, the association between plant-based diet and long-term risk of overall and cause-specific mortality has been less studied. We aimed to investigate whether plant-based diet was associated with lower death risk.

Methods

This prospective cohort study used data from the US National Health and Nutrition Examination Survey. Diet was assessed using 24 h dietary recalls. We created three plant-based diet indices including an overall plant-based diet index (PDI), a healthful plant-based diet index (hPDI), and an unhealthful plant-based diet index (uPDI). Deaths from baseline until December 31, 2015, were identified. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression.

Results

We documented 4904 deaths among 40,074 participants after a median follow-up of 7.8 years. Greater adherence to PDI was associated with lower risk of overall (HR comparing extreme quintiles 0.80, 95% CI 0.73, 0.89, ptrend < 0.001) and cancer-specific (HR = 0.68, 95% CI 0.55, 0.85, ptrend < 0.001) mortality. These inverse associations remained for hPDI and overall mortality with a HR of 0.86 (95% CI 0.77, 0.95, ptrend = 0.001), but not for cancer or CVD mortality. Conversely, uPDI was associated with higher risk of total (HR = 1.33, 95% CI 1.19, 1.48, ptrend < 0.001) and CVD-specific (HR = 1.42, 95% CI 1.12, 1.79, ptrend = 0.015) mortality.

Conclusions

Increased intake of a plant-based diet rich in healthier plant foods is associated with lower mortality risk, whereas a plant-based diet that emphasizes less-healthy plant foods is associated with high mortality risk among US adults.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

Availability of data and material

Data described in the manuscript, codebook, and analytic code will be made publicly and freely available without restriction at [https://www.cdc.gov/nchs/nhanes/index.htm].

Code availability

SAS version 9.4.

References

  1. 1.

    Collaborators USBoD, Mokdad AH, Ballestros K, Echko M, Glenn S, Olsen HE, Mullany E, Lee A, Khan AR, Ahmadi A, Ferrari AJ, Kasaeian A, Werdecker A, Carter A, Zipkin B, Sartorius B, Serdar B, Sykes BL, Troeger C, Fitzmaurice C, Rehm CD, Santomauro D, Kim D, Colombara D, Schwebel DC, Tsoi D, Kolte D, Nsoesie E, Nichols E, Oren E, Charlson FJ, Patton GC, Roth GA, Hosgood HD, Whiteford HA, Kyu H, Erskine HE, Huang H, Martopullo I, Singh JA, Nachega JB, Sanabria JR, Abbas K, Ong K, Tabb K, Krohn KJ, Cornaby L, Degenhardt L, Moses M, Farvid M, Griswold M, Criqui M, Bell M, Nguyen M, Wallin M, Mirarefin M, Qorbani M, Younis M, Fullman N, Liu P, Briant P, Gona P, Havmoller R, Leung R, Kimokoti R, Bazargan-Hejazi S, Hay SI, Yadgir S, Biryukov S, Vollset SE, Alam T, Frank T, Farid T, Miller T, Vos T, Barnighausen T, Gebrehiwot TT, Yano Y, Al-Aly Z, Mehari A, Handal A, Kandel A, Anderson B, Biroscak B, Mozaffarian D, Dorsey ER, Ding EL, Park EK, Wagner G, Hu G, Chen H, Sunshine JE, Khubchandani J, Leasher J, Leung J, Salomon J, Unutzer J, Cahill L, Cooper L, Horino M, Brauer M, Breitborde N, Hotez P, Topor-Madry R, Soneji S, Stranges S, James S, Amrock S, Jayaraman S, Patel T, Akinyemiju T, Skirbekk V, Kinfu Y, Bhutta Z, Jonas JB, Murray CJL (2018) The State of US Health, 1990–2016: burden of diseases, injuries, and risk factors among US States. JAMA 319(14):1444–1472. https://doi.org/10.1001/jama.2018.0158

    Article  Google Scholar 

  2. 2.

    Millen BE, Abrams S, Adams-Campbell L, Anderson CA, Brenna JT, Campbell WW, Clinton S, Hu F, Nelson M, Neuhouser ML, Perez-Escamilla R, Siega-Riz AM, Story M, Lichtenstein AH (2016) The 2015 dietary guidelines advisory committee scientific report: development and major conclusions. Adv Nutr 7(3):438–444. https://doi.org/10.3945/an.116.012120

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Nelson ME, Hamm MW, Hu FB, Abrams SA, Griffin TS (2016) Alignment of healthy dietary patterns and environmental sustainability: a systematic review. Adv Nutr 7(6):1005–1025. https://doi.org/10.3945/an.116.012567

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Kinlen LJ, Hermon C, Smith PG (1983) A proportionate study of cancer mortality among members of a vegetarian society. Br J Cancer 48(3):355–361. https://doi.org/10.1038/bjc.1983.200

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Chang-Claude J, Frentzel-Beyme R, Eilber U (1992) Mortality pattern of German vegetarians after 11 years of follow-up. Epidemiology 3(5):395–401. https://doi.org/10.1097/00001648-199209000-00003

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Key TJ, Thorogood M, Appleby PN, Burr ML (1996) Dietary habits and mortality in 11,000 vegetarians and health conscious people: results of a 17 year follow up. BMJ 313(7060):775–779. https://doi.org/10.1136/bmj.313.7060.775

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Key TJ, Appleby PN, Davey GK, Allen NE, Spencer EA, Travis RC (2003) Mortality in British vegetarians: review and preliminary results from EPIC-Oxford. Am J Clin Nutr 78(3 Suppl):533s–538s. https://doi.org/10.1093/ajcn/78.3.533S

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Orlich MJ, Singh PN, Sabate J, Jaceldo-Siegl K, Fan J, Knutsen S, Beeson WL, Fraser GE (2013) Vegetarian dietary patterns and mortality in Adventist Health Study 2. JAMA Intern Med 173(13):1230–1238. https://doi.org/10.1001/jamainternmed.2013.6473

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Appleby PN, Crowe FL, Bradbury KE, Travis RC, Key TJ (2016) Mortality in vegetarians and comparable nonvegetarians in the United Kingdom. Am J Clin Nutr 103(1):218–230. https://doi.org/10.3945/ajcn.115.119461

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Bao Y, Han J, Hu FB, Giovannucci EL, Stampfer MJ, Willett WC, Fuchs CS (2013) Association of nut consumption with total and cause-specific mortality. N Engl J Med 369(21):2001–2011. https://doi.org/10.1056/NEJMoa1307352

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Aune D, Keum N, Giovannucci E, Fadnes LT, Boffetta P, Greenwood DC, Tonstad S, Vatten LJ, Riboli E, Norat T (2016) Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies. BMJ 353:i2716. https://doi.org/10.1136/bmj.i2716

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Wang X, Ouyang Y, Liu J, Zhu M, Zhao G, Bao W, Hu FB (2014) Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ 349:g4490. https://doi.org/10.1136/bmj.g4490

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Muraki I, Rimm EB, Willett WC, Manson JE, Hu FB, Sun Q (2016) Potato consumption and risk of type 2 diabetes: results from three prospective cohort studies. Diabetes Care 39(3):376–384. https://doi.org/10.2337/dc15-0547

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB (2014) Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med 174(4):516–524. https://doi.org/10.1001/jamainternmed.2013.13563

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Veronese N, Stubbs B, Noale M, Solmi M, Vaona A, Demurtas J, Nicetto D, Crepaldi G, Schofield P, Koyanagi A, Maggi S, Fontana L (2017) Fried potato consumption is associated with elevated mortality: an 8 y longitudinal cohort study. Am J Clin Nutr 106(1):162–167. https://doi.org/10.3945/ajcn.117.154872

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Malik VS, Li Y, Pan A, De Koning L, Schernhammer E, Willett WC, Hu FB (2019) Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortality in US Adults. Circulation 139(18):2113–2125. https://doi.org/10.1161/CIRCULATIONAHA.118.037401

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Steffen LM, Jacobs DR Jr, Stevens J, Shahar E, Carithers T, Folsom AR (2003) Associations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic stroke: the atherosclerosis risk in communities (ARIC) Study. Am J Clin Nutr 78(3):383–390. https://doi.org/10.1093/ajcn/78.3.383

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Satija A, Bhupathiraju SN, Rimm EB, Spiegelman D, Chiuve SE, Borgi L, Willett WC, Manson JE, Sun Q, Hu FB (2016) Plant-based dietary patterns and incidence of type 2 diabetes in us men and women: results from three prospective cohort studies. PLoS Med. https://doi.org/10.1371/journal.pmed.1002039

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Martinez-Gonzalez MA, Sanchez-Tainta A, Corella D, Salas-Salvado J, Ros E, Aros F, Gomez-Gracia E, Fiol M, Lamuela-Raventos RM, Schroder H, Lapetra J, Serra-Majem L, Pinto X, Ruiz-Gutierrez V, Estruch R, Group P (2014) A provegetarian food pattern and reduction in total mortality in the Prevencion con Dieta Mediterranea (PREDIMED) study. Am J Clin Nutr 100(Suppl 1):320S-328S. https://doi.org/10.3945/ajcn.113.071431

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Kim H, Caulfield LE, Garcia-Larsen V, Steffen LM, Coresh J, Rebholz CM (2019) Plant-based diets are associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all-cause mortality in a general population of middle-aged adults. J Am Heart Assoc. https://doi.org/10.1161/jaha.119.012865

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Kim H, Caulfield LE, Rebholz CM (2018) Healthy plant-based diets are associated with lower risk of all-cause mortality in US adults. J Nutr 148(4):624–631. https://doi.org/10.1093/jn/nxy019

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Baden MY, Liu G, Satija A, Li Y, Sun Q, Fung TT, Rimm EB, Willett WC, Hu FB, Bhupathiraju SN (2019) Changes in plant-based diet quality and total and cause-specific mortality. Circulation 140(12):979–991. https://doi.org/10.1161/circulationaha.119.041014

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Molina-Montes E, Salamanca-Fernández E, Garcia-Villanova B, Sánchez MJ (2020) The impact of plant-based dietary patterns on cancer-related outcomes: a rapid review and meta-analysis. Nutrients. https://doi.org/10.3390/nu12072010

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Kant AK, Graubard BI, Schatzkin A (2004) Dietary patterns predict mortality in a national cohort: the National Health Interview Surveys, 1987 and 1992. J Nutr 134(7):1793–1799. https://doi.org/10.1093/jn/134.7.1793

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Heidemann C, Schulze MB, Franco OH, van Dam RM, Mantzoros CS, Hu FB (2008) Dietary patterns and risk of mortality from cardiovascular disease, cancer, and all causes in a prospective cohort of women. Circulation 118(3):230–237. https://doi.org/10.1161/CIRCULATIONAHA.108.771881

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Stewart RA, Wallentin L, Benatar J, Danchin N, Hagstrom E, Held C, Husted S, Lonn E, Stebbins A, Chiswell K, Vedin O, Watson D, White HD, Investigators S (2016) Dietary patterns and the risk of major adverse cardiovascular events in a global study of high-risk patients with stable coronary heart disease. Eur Heart J 37(25):1993–2001. https://doi.org/10.1093/eurheartj/ehw125

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES) (2017) About the National Health and Nutrition Examination Survey. https://www.cdc.gov/nchs/nhanes/about_nhanes.htm. Accessed on 11 March 2021

  28. 28.

    Ahluwalia N, Dwyer J, Terry A, Moshfegh A, Johnson C (2016) Update on NHANES dietary data: focus on collection, release, analytical considerations, and uses to inform public policy. Adv Nutr 7(1):121–134. https://doi.org/10.3945/an.115.009258

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Tooze JA, Midthune D, Dodd KW, Freedman LS, Krebs-Smith SM, Subar AF, Guenther PM, Carroll RJ, Kipnis V (2006) A new statistical method for estimating the usual intake of episodically consumed foods with application to their distribution. J Am Diet Assoc 106(10):1575–1587. https://doi.org/10.1016/j.jada.2006.07.003

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Satija A, Bhupathiraju SN, Spiegelman D, Chiuve SE, Manson JE, Willett W, Rexrode KM, Rimm EB, Hu FB (2017) Healthful and unhealthful plant based diets and the risk of coronary heart disease in U. S. Adults. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2017.05.047

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Guasch-Ferre M, Hu FB (2019) Are fruit juices just as unhealthy as sugar-sweetened beverages? JAMA Netw Open 2(5):e193109. https://doi.org/10.1001/jamanetworkopen.2019.3109

    Article  PubMed  Google Scholar 

  32. 32.

    Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES) (2021) NHANES Laboratory Data. https://wwwn.cdc.gov/nchs/nhanes/search/datapage.aspx?Component=Laboratory. Accessed on 11 March 2021

  33. 33.

    Schwingshackl L, Schwedhelm C, Hoffmann G, Lampousi AM, Knuppel S, Iqbal K, Bechthold A, Schlesinger S, Boeing H (2017) Food groups and risk of all-cause mortality: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr 105(6):1462–1473. https://doi.org/10.3945/ajcn.117.153148

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Ruby MB (2012) Vegetarianism A blossoming field of study. Appetite 58(1):141–150. https://doi.org/10.1016/j.appet.2011.09.019

    Article  PubMed  Google Scholar 

  35. 35.

    Liese AD, Krebs-Smith SM, Subar AF, George SM, Harmon BE, Neuhouser ML, Boushey CJ, Schap TE, Reedy J (2015) The dietary patterns methods project: synthesis of findings across cohorts and relevance to dietary guidance. J Nutr 145(3):393–402. https://doi.org/10.3945/jn.114.205336

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Gardener H, Rundek T, Wright CB, Elkind MS, Sacco RL (2013) Coffee and tea consumption are inversely associated with mortality in a multiethnic urban population. J Nutr 143(8):1299–1308. https://doi.org/10.3945/jn.112.173807

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Ding M, Satija A, Bhupathiraju SN, Hu Y, Sun Q, Han J, Lopez-Garcia E, Willett W, van Dam RM, Hu FB (2015) Association of coffee consumption with total and cause-specific mortality in 3 large prospective cohorts. Circulation 132(24):2305–2315. https://doi.org/10.1161/circulationaha.115.017341

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  38. 38.

    Ma Y, Hebert JR, Li W, Bertone-Johnson ER, Olendzki B, Pagoto SL, Tinker L, Rosal MC, Ockene IS, Ockene JK, Griffith JA, Liu S (2008) Association between dietary fiber and markers of systemic inflammation in the Women’s Health Initiative Observational Study. Nutrition 24(10):941–949. https://doi.org/10.1016/j.nut.2008.04.005

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Cassidy A, Rogers G, Peterson JJ, Dwyer JT, Lin H, Jacques PF (2015) Higher dietary anthocyanin and flavonol intakes are associated with anti-inflammatory effects in a population of US adults. Am J Clin Nutr 102(1):172–181. https://doi.org/10.3945/ajcn.115.108555

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Ishikawa T, Suzukawa M, Ito T, Yoshida H, Ayaori M, Nishiwaki M, Yonemura A, Hara Y, Nakamura H (1997) Effect of tea flavonoid supplementation on the susceptibility of low-density lipoprotein to oxidative modification. Am J Clin Nutr 66(2):261–266. https://doi.org/10.1093/ajcn/66.2.261

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Mozaffarian D, Wu JH (2011) Omega-3 fatty acids and cardiovascular disease: effects on risk factors, molecular pathways, and clinical events. J Am Coll Cardiol 58(20):2047–2067. https://doi.org/10.1016/j.jacc.2011.06.063

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    van Dam RM, Hu FB (2005) Coffee consumption and risk of type 2 diabetes: a systematic review. JAMA 294(1):97–104. https://doi.org/10.1001/jama.294.1.97

    Article  PubMed  Google Scholar 

  43. 43.

    Kroenke CH, Kwan ML, Sweeney C, Castillo A, Caan BJ (2013) High- and low-fat dairy intake, recurrence, and mortality after breast cancer diagnosis. J Natl Cancer Inst 105(9):616–623. https://doi.org/10.1093/jnci/djt027

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Lu W, Chen H, Niu Y, Wu H, Xia D, Wu Y (2016) Dairy products intake and cancer mortality risk: a meta-analysis of 11 population-based cohort studies. Nutr J 15(1):91. https://doi.org/10.1186/s12937-016-0210-9

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Huang J, Liao LM, Weinstein SJ, Sinha R, Graubard BI, Albanes D (2020) Association between plant and animal protein intake and overall and cause-specific mortality. JAMA Intern Med 180(9):1173–1184. https://doi.org/10.1001/jamainternmed.2020.2790

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Holmes MD, Pollak MN, Willett WC, Hankinson SE (2002) Dietary correlates of plasma insulin-like growth factor I and insulin-like growth factor binding protein 3 concentrations. Cancer Epidemiol Biomarkers Prev 11(9):852–861

    CAS  PubMed  Google Scholar 

  47. 47.

    Allen NE, Appleby PN, Davey GK, Kaaks R, Rinaldi S, Key TJ (2002) The associations of diet with serum insulin-like growth factor I and its main binding proteins in 292 women meat-eaters, vegetarians, and vegans. Cancer Epidemiol Biomarkers Prev 11(11):1441–1448. https://doi.org/10.1001/jamainternmed.2013.6473

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Smith CJ, Scott SM, Wagner BM (1998) The necessary role of the autopsy in cardiovascular epidemiology. Hum Pathol 29(12):1469–1479. https://doi.org/10.1016/s0046-8177(98)90018-1

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Pagidipati NJ, Gaziano TA (2013) Estimating deaths from cardiovascular disease: a review of global methodologies of mortality measurement. Circulation 127(6):749–756. https://doi.org/10.1161/CIRCULATIONAHA.112.128413

    Article  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Jurek AM, Greenland S, Maldonado G, Church TR (2005) Proper interpretation of non-differential misclassification effects: expectations vs observations. Int J Epidemiol 34(3):680–687. https://doi.org/10.1093/ije/dyi060

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Drs Li and Yang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Yang and Li. Acquisition, analysis, or interpretation of data: all authors. Drafting of the manuscript: Li and Yang. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: Li and Zhu. Obtained funding: Yang. Administrative, technical, or material support: Yang. Study supervision: Yang.

Funding

This work was supported by the National Natural Science Foundation of China (82073651), Anhui Provincial Natural Science Foundation (2008085MH262), and a grant of the Scientific Research of BSKY from Anhui Medical University (XJ201935).

Author information

Affiliations

Authors

Contributions

Hairong Li and Wanshui Yang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Wanshui Yang and Hairong Li Acquisition, analysis, or interpretation of data: all authors. Drafting of the manuscript: Hairong Li and Wanshui Yang. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: Hairong Li and Yu Zhu. Obtained funding: Wanshui Yang. Administrative, technical, or material support: Wanshui Yang. Study supervision: Wanshui Yang.

Corresponding author

Correspondence to Wanshui Yang.

Ethics declarations

Conflict of interest

The authors declared that they have no conflict of interest.

Ethical approval

The National Centers for Health Statistics approved the NHANES study protocol. The Institutional Review Board at our institute determined that this analysis used a public dataset, so human subjects’ approval was waived.

Consent to participate

All participants provided the written informed consent.

Consent for publication

All of the authors have read and approved the final version of this manuscript.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 490 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Li, H., Zeng, X., Wang, Y. et al. A prospective study of healthful and unhealthful plant-based diet and risk of overall and cause-specific mortality. Eur J Nutr (2021). https://doi.org/10.1007/s00394-021-02660-7

Download citation

Keywords

  • Plant-based diet
  • Cancer
  • Mortality
  • Cardiovascular disease
  • Cohort study