Adherence to the healthy Nordic food index and total and cause-specific mortality among Swedish women

Abstract

Several healthy dietary patterns have been linked to longevity. Recently, a Nordic dietary pattern was associated with a lower overall mortality. No study has, however, investigated this dietary pattern in relation to cause-specific mortality. The aim of the present study was to examine the association between adherence to a healthy Nordic food index (consisting of wholegrain bread, oatmeal, apples/pears, root vegetables, cabbages and fish/shellfish) and overall mortality, and death by cardiovascular disease, cancer, injuries/suicide and other causes. We conducted a prospective analysis in the Swedish Women’s Lifestyle and Health cohort, including 44,961 women, aged 29–49 years, who completed a food frequency questionnaire between 1991–1992, and have been followed up for mortality ever since, through Swedish registries. The median follow-up time is 21.3 years, and mortality rate ratios (MRR) were calculated using Cox Proportional Hazards Models. Compared to women with the lowest index score (0–1 points), those with the highest score (4–6 points) had an 18 % lower overall mortality (MRR 0.82; 0.71–0.93, p < 0.0004). A 1-point increment in the healthy Nordic food index was associated with a significantly lower risk of all-cause mortality: 6 % (3–9 %), cancer mortality: 5 % (1–9 %) and mortality from other causes: 16 % (8–22 %). When examining the diet components individually, only wholegrain bread and apples/pears were significantly inversely associated with all-cause mortality. We observed no effect-modification by smoking status, BMI or age at baseline. The present study encourages adherence to a healthy Nordic food index, and warrants further investigation of the strong association with non-cancer, non-cardiovascular and non-injury/suicide deaths.

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

References

  1. 1.

    Jacobs DR Jr, Gross MD, Tapsell LC. Food synergy: an operational concept for understanding nutrition. Am J Clin Nutr. 2009;89(5):1543S–8S. doi:10.3945/ajcn.2009.26736B.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  2. 2.

    Kiefte-de Jong JC, Mathers JC, Franco OH. Nutrition and healthy ageing: the key ingredients. Proc Nutr Soc. 2014;73(2):249–59. doi:10.1017/S0029665113003881.

    PubMed  Article  Google Scholar 

  3. 3.

    Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol. 2002;13(1):3–9.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92(5):1189–96.

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Bere E, Brug J. Towards health-promoting and environmentally friendly regional diets—a Nordic example. Public Health Nutr. 2009;12(1):91–6.

    PubMed  Article  Google Scholar 

  6. 6.

    Bere E, Brug J. Is the term ‘Mediterranean diet’ a misnomer? Public Health Nutr. 2010;13(12):2127–9.

    PubMed  Article  Google Scholar 

  7. 7.

    da Silva R, Bach-Faig A, Raido Quintana B, Buckland G, Vaz de Almeida MD, Serra-Majem L. Worldwide variation of adherence to the Mediterranean diet, in 1961–1965 and 2000–2003. Public Health Nutr. 2009;12(9A):1676–84.

    PubMed  Article  Google Scholar 

  8. 8.

    Astrup A. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359(20):2169–70 (author reply 2171–2162).

    CAS  PubMed  Article  Google Scholar 

  9. 9.

    Due A, Larsen TM, Mu H, Hermansen K, Stender S, Astrup A. Comparison of 3 ad libitum diets for weight-loss maintenance, risk of cardiovascular disease, and diabetes: a 6-mo randomized, controlled trial. Am J Clin Nutr. 2008;88(5):1232–41.

    CAS  PubMed  Google Scholar 

  10. 10.

    Olsen A, Egeberg R, Halkjaer J, Christensen J, Overvad K, Tjonneland A. Healthy aspects of the Nordic diet are related to lower total mortality. J Nutr. 2011;141(4):639–44.

    CAS  PubMed  Article  Google Scholar 

  11. 11.

    Uusitupa M, Hermansen K, Savolainen MJ, Schwab U, Kolehmainen M, Brader L, et al. Effects of an isocaloric healthy Nordic diet on insulin sensitivity, lipid profile and inflammation markers in metabolic syndrome—a randomized study (SYSDIET). J Intern Med. 2013;274:52–66.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  12. 12.

    Adamsson V, Reumark A, Cederholm T, Vessby B, Riserus U, Johansson G. What is a healthy Nordic diet? Foods and nutrients in the NORDIET study. Food Nutr Res. 2012;56. doi: 10.3402/fnr.v56i0.18189.

  13. 13.

    Mithril C, Dragsted LO, Meyer C, Tetens I, Biltoft-Jensen A, Astrup A. Dietary composition and nutrient content of the New Nordic Diet. Public Health Nutr. 2013;16(5):777–85.

  14. 14.

    Cho SS, Qi L, Fahey GC Jr, Klurfeld DM. Consumption of cereal fiber, mixtures of whole grains and bran, and whole grains and risk reduction in type 2 diabetes, obesity, and cardiovascular disease. Am J Clin Nutr. 2013;98(2):594–619. doi:10.3945/ajcn.113.067629.

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Ye EQ, Chacko SA, Chou EL, Kugizaki M, Liu S. Greater whole-grain intake is associated with lower risk of type 2 diabetes, cardiovascular disease, and weight gain. J Nutr. 2012;142(7):1304–13. doi:10.3945/jn.111.155325.

    CAS  PubMed  Article  Google Scholar 

  16. 16.

    World Cancer Research Fund. Food, nutrition, physical activity, and the prevention of cancer, a global perspective. Washington: American Institute for Cancer Research; 2007.

    Google Scholar 

  17. 17.

    Mozaffarian D, Wu JH. Omega-3 fatty acids and cardiovascular disease: effects on risk factors, molecular pathways, and clinical events. J Am Coll Cardiol. 2011;58(20):2047–67. doi:10.1016/j.jacc.2011.06.063.

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Miller PE, Snyder DC. Phytochemicals and cancer risk: a review of the epidemiological evidence. Nutr Clin Pract. 2012;27(5):599–612. doi:10.1177/0884533612456043.

    PubMed  Article  Google Scholar 

  19. 19.

    Kris-Etherton PM, Hecker KD, Bonanome A, Coval SM, Binkoski AE, Hilpert KF, et al. Bioactive compounds in foods: their role in the prevention of cardiovascular disease and cancer. Am J Med. 2002;113(Suppl 9B):71S–88S.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Fiedor J, Burda K. Potential role of carotenoids as antioxidants in human health and disease. Nutrients. 2014;6(2):466–88. doi:10.3390/nu6020466.

    PubMed Central  PubMed  Article  Google Scholar 

  21. 21.

    Kumle M, Weiderpass E, Braaten T, Persson I, Adami HO, Lund E. Use of oral contraceptives and breast cancer risk: the Norwegian-Swedish Women’s Lifestyle and Health Cohort Study. Cancer Epidemiol Biomark Prev. 2002;11(11):1375–81.

    CAS  Google Scholar 

  22. 22.

    Wolk A, Bergstrom R, Hunter D, Willett W, Ljung H, Holmberg L, et al. A prospective study of association of monounsaturated fat and other types of fat with risk of breast cancer. Arch Intern Med. 1998;158(1):41–5.

    CAS  PubMed  Article  Google Scholar 

  23. 23.

    Khani BR, Ye W, Terry P, Wolk A. Reproducibility and validity of major dietary patterns among Swedish women assessed with a food-frequency questionnaire. J Nutr. 2004;134(6):1541–5.

    CAS  PubMed  Google Scholar 

  24. 24.

    Willett WC. Nutritional epidemiology. 2nd ed. New York: Oxford University Press; 1998.

    Book  Google Scholar 

  25. 25.

    Roswall N, Eriksson U, Sandin S, Löf M, Olsen A, Skeie G, et al. Adherence to the healthy Nordic food index, dietary composition and lifestyle among Swedish women. Food Nutr Res. 2015. doi: 10.3402/fnr.v59.26336.

  26. 26.

    Roswall N, Olsen A, Boll K, Christensen J, Halkjaer J, Sorensen T, et al. Consumption of predefined ‘Nordic’ dietary items in ten European countries—an investigation in the European prospective investigation into cancer and nutrition (EPIC) cohort. Public Health Nutr. 2014;17(12):2650–9. doi:10.1017/S1368980014000159.

    PubMed  Article  Google Scholar 

  27. 27.

    Engeset D, Hofoss D, Nilsson LM, Olsen A, Tjonneland A, Skeie G. Dietary patterns and whole grain cereals in the Scandinavian countries—differences and similarities. The HELGA project. Public Health Nutr. 2014;. doi:10.1017/S1368980014001104.

    Google Scholar 

  28. 28.

    Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, Gnardellis C, Lagiou P, Polychronopoulos E, et al. Diet and overall survival in elderly people. BMJ. 1995;311(7018):1457–60.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  29. 29.

    Kyro C, Skeie G, Loft S, Overvad K, Christensen J, Tjonneland A, et al. Adherence to a healthy Nordic food index is associated with a lower incidence of colorectal cancer in women: the diet, cancer and health cohort study. Br J Nutr. 2013;109(5):920–7.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Kanerva N, Rissanen H, Knekt P, Havulinna AS, Eriksson JG, Mannisto S. The healthy Nordic diet and incidence of type 2 diabetes—10-year follow-up. Diabet Res Clin Pract. 2014;. doi:10.1016/j.diabres.2014.08.016.

    Google Scholar 

  31. 31.

    Kanerva N, Kaartinen NE, Rissanen H, Knekt P, Eriksson JG, Saaksjarvi K, et al. Associations of the Baltic Sea diet with cardiometabolic risk factors—a meta-analysis of three Finnish studies. Br J Nutr. 2014;112(4):616–26. doi:10.1017/S0007114514001159.

    CAS  PubMed  Article  Google Scholar 

  32. 32.

    Jobs E, Adamsson V, Larsson A, Jobs M, Nerpin E, Ingelsson E, et al. Influence of a prudent diet on circulating cathepsin S in humans. Nutr J. 2014;13:84. doi:10.1186/1475-2891-13-84.

    PubMed Central  PubMed  Article  Google Scholar 

  33. 33.

    Adamsson V, Reumark A, Fredriksson IB, Hammarstrom E, Vessby B, Johansson G, et al. Effects of a healthy Nordic diet on cardiovascular risk factors in hypercholesterolaemic subjects: a randomized controlled trial (NORDIET). J Intern Med. 2011;269(2):150–9.

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Brader L, Uusitupa M, Dragsted LO, Hermansen K. Effects of an isocaloric healthy Nordic diet on ambulatory blood pressure in metabolic syndrome: a randomized SYSDIET sub-study. Eur J Clin Nutr. 2014;68(1):57–63.

    CAS  PubMed  Article  Google Scholar 

  35. 35.

    Poulsen SK, Due A, Jordy AB, Kiens B, Stark KD, Stender S, et al. Health effect of the New Nordic Diet in adults with increased waist circumference: a 6-mo randomized controlled trial. Am J Clin Nutr. 2014;99(1):35–45.

    CAS  PubMed  Article  Google Scholar 

  36. 36.

    Adamsson V, Reumark A, Marklund M, Larsson A, Riserus U. Role of a prudent breakfast in improving cardiometabolic risk factors in subjects with hypercholesterolemia: a randomized controlled trial. Clin Nutr. 2014;34(1):20–6. doi:10.1016/j.clnu.2014.04.009.

    PubMed  Article  Google Scholar 

  37. 37.

    Poulsen SK, Crone C, Astrup A, Larsen TM. Long-term adherence to the New Nordic Diet and the effects on body weight, anthropometry and blood pressure: a 12-month follow-up study. Eur J Nutr. 2014;. doi:10.1007/s00394-014-0686-z.

    Google Scholar 

  38. 38.

    Hu FB, Willett WC. Optimal diets for prevention of coronary heart disease. JAMA. 2002;288(20):2569–78.

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Boyer J, Liu RH. Apple phytochemicals and their health benefits. Nutr J. 2004;3:5.

    PubMed Central  PubMed  Article  Google Scholar 

  40. 40.

    Mozaffarian D, Rimm EB. Fish intake, contaminants, and human health: evaluating the risks and the benefits. JAMA. 2006;296(15):1885–99.

    CAS  PubMed  Article  Google Scholar 

  41. 41.

    Yashodhara BM, Umakanth S, Pappachan JM, Bhat SK, Kamath R, Choo BH. Omega-3 fatty acids: a comprehensive review of their role in health and disease. Postgrad Med J. 2009;85(1000):84–90.

    CAS  PubMed  Article  Google Scholar 

  42. 42.

    Jacobs DR Jr, Andersen LF, Blomhoff R. Whole-grain consumption is associated with a reduced risk of noncardiovascular, noncancer death attributed to inflammatory diseases in the Iowa Women’s Health Study. Am J Clin Nutr. 2007;85(6):1606–14.

    CAS  PubMed  Google Scholar 

  43. 43.

    Milner A, Spittal MJ, Pirkis J, LaMontagne AD. Suicide by occupation: systematic review and meta-analysis. Br J Psychiatry. 2013;203(6):409–16. doi:10.1192/bjp.bp.113.128405.

    PubMed  Article  Google Scholar 

  44. 44.

    Cubbin C, Smith GS. Socioeconomic inequalities in injury: critical issues in design and analysis. Annu Rev Public Health. 2002;23:349–75. doi:10.1146/annurev.publhealth.23.100901.140548.

    PubMed  Article  Google Scholar 

  45. 45.

    Lagiou P, Trichopoulos D, Sandin S, Lagiou A, Mucci L, Wolk A, et al. Mediterranean dietary pattern and mortality among young women: a cohort study in Sweden. Br J Nutr. 2006;96(2):384–92.

    CAS  PubMed  Article  Google Scholar 

Download references

Acknowledgments

The authors wish to thank data manager Pouran Almstedt for database administration. The present study was supported by a grant from the Swedish Research Council. Grant No. 521-2011-2955.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the regional Ethical Committee at Uppsala University, and the Ethical Committee at Karolinska Institutet, Stockholm.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Nina Roswall.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 15 kb)

Supplementary material 2 (DOCX 14 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Roswall, N., Sandin, S., Löf, M. et al. Adherence to the healthy Nordic food index and total and cause-specific mortality among Swedish women. Eur J Epidemiol 30, 509–517 (2015). https://doi.org/10.1007/s10654-015-0021-x

Download citation

Keywords

  • Nordic Diet
  • Mortality
  • Cancer
  • Cardiovascular disease
  • Cohort study