Association Between Dietary Quality And Cardiovascular Disease Risk

Objective:Cardiovascular Disease（CVD）is the disease that causes the most deaths among chronic noninfectious diseases.The occurrence,development and prognosis of CVD are all affected by many factors.This study aims to explore the influence of dietary quality on CVD risk and the dose-response relationship,and establish a mediating effect model of the relationship between dietary quality and CVD risk with depressive symptoms,obesity,hypertension and diabetes as intermediate factors.To evaluate the mediating effect of depressive symptoms,obesity,hypertension,diabetes and other factors on the relationship between dietary quality and CVD risk and heart age.The results can provide scientific basis for exploring the mechanism and process of the influence of dietary quality on the risk of cardiovascular diseasesMethods:The study was based on the National Health and Nutrition Examination Survey,NHANES)four cycles of cross-sectional data（2011-2012,2013-2014,2015-2016 and2017-2018）and the Food Patterns Equivalents Database（FPED）dietary data.The Healthy Eating Index（HEI）was used to reflect the dietary quality of the population,and the cardiovascular risk prediction tool of the Framingham Heart Study（FHS）was used to evaluate the risk of CVD and heart age.In the NHANES data,the Patient Health Questionnaire（PHQ）self-rating scale was used to evaluate the depression level of the subjects.Obesity was defined based on the WHO BMI grading criteria and abdominal obesity criteria,and hypertension and diabetes were defined according to the standards of the American Heart Association and the Diabetes Association.With CVD risk and heart age as dependent variables,dietary quality of residents as independent variables,and depression,obesity,hypertension and diabetes as mediating variables,the Baron and Kenny step-by-step method was used to determine whether four cardiovascular disease-related risk factors had mediating effects between dietary quality,CVD risk and heart age.Generalized Structural Equation Model（GSEM）was used to test whether the mediating effect of four risk factors related to cardiovascular diseases was statistically significant,and the percentage of the mediating effect in the total effect was calculated.The dose-response relationship between HEI and CVD and heart age was analyzed by the restricted cubic spline model.The Weighted Quantile Sum（WQS）regression model evaluated the contribution of HEI dietary components to four cardiovascular disease-related risk factors,CVD risk,and heart age.Through principal component analysis,multiple dietary factors were reduced into a composite new variable"comprehensive HEI score"reflecting diet quality,and four cardiovascular disease-related risk factors were generated into a composite new variable"comprehensive risk".All models adjusted for covariates such as age,sex,poverty ratio,smoking,alcohol consumption,race,work activity,recreational activity,marital status,education level,and sampling period.Results:A total of 12644 subjects were included in this study,ranging in age from 30 to 74years old,with an average age of 51.46±12.61 years old,of which male and female accounted for 49.19%and 50.81%respectively.1.Association of dietary quality,depressive symptoms,obesity,hypertension,diabetes,and CVD risk（1）Compared with the lower diet quality group,the associations between higher and higher diet quality and higher CVD risk were statistically significant(P_all<0.05,OR _higher=0.669,95%CI:0.524～0.854;OR_high=0.636,95%CI:0.502～0.806).（2）Depressive symptoms,obesity,hypertension and diabetes were all associated with a statistically significant risk of CVD(P_all<0.05,OR_{depressive symptoms}=1.369,95%CI:1.036～1.808;OR_obesity=1.795,95%CI:1.486-2.168;OR_hypertension=4.754,95%CI:3.851-5.868;OR_diabetes=6.969,95%CI:5.880～8.259).（3）There was a dose-response relationship between dietary quality and CVD risk,and the risk of CVD decreased monotonically with the increase of dietary quality score(P_overall<0.05).2.Association of dietary quality,depressive symptoms,obesity,hypertension,diabetes and heart age（1）Compared with the lower diet quality group,the association between medium,high,and high diet quality and heart age was statistically significant(P_all<0.05,OR_medium=0.725,95%CI:0.609～0.864;OR_higher=0.674,95%CI:0.574～0.792;OR_high=0.563,95%CI:0.491～0.645).（2）After adjusting for all confounding factors,depressive symptoms,obesity,hypertension and diabetes were associated with a statistically significant risk of high heart age(P_all<0.05,OR_{depressive symptoms}=1.536,95%CI:1.266～1.865;OR_obesity=2.452,95%CI:2.144～2.805;OR_hypertension=8.259,95%CI:7.024～9.712;OR_diabetes=16.565,95%CI:12.398～22.132).（3）There was a dose-response relationship between dietary quality and heart age,and the risk of high heart age decreased monotonously with the increase of dietary quality fraction(P_overall<0.05).3.Association of dietary quality with depressive symptoms,obesity,hypertension,and diabetes（1）The association between higher and higher dietary quality groups and depressive symptoms was statistically significant compared with lower dietary quality groups(P_all<0.05,OR_higher=0.699,95%CI:0.530～1.129;OR_high=0.588,95%CI:0.446～0.776).（2）Compared with the lower diet quality group,the association between higher and higher diet quality groups and obesity was statistically significant(P_all<0.05,OR_higher=0.694,95%CI:0.585～0.824;OR_high=0.589,95%CI:0.492～0.706).（3）Compared with the lower diet quality group,the association between high diet quality and hypertension was statistically significant(OR_high=0.993,95%CI:0.989～0.997).（4）The association between HEI score and diabetes mellitus was statistically significant（P<0.05,OR=0.994,95%CI:0.989,0.999）.4.Mediating effect of depressive symptoms on the association between dietary quality and CVD risk and heart age（1）The mediating effect regression coefficient of depressive symptoms on the association between dietary quality score and CVD risk was-0.00005（95%CI:-0.00006～-0.00002,P=0.010）,accounting for 2.41%of the total effect.（2）The regression coefficient of the mediating effect of depressive symptoms on the association between dietary quality score and heart age was-0.00005（95%CI:-0.00008～-0.00002,P=0.002）,accounting for 1.66%of the total effect.5.Mediating effect of obesity on the association between dietary quality and CVD risk and heart age（1）The regression coefficient of mediating effect of obesity on the association between dietary quality score and CVD risk was-0.00012（95%CI:-0.00016～-0.00007,P<0.001）,accounting for 9.12%of the total effect.（2）The mediating effect regression coefficient of obesity on the association between dietary quality score and heart age was-0.00046（95%CI:-0.00057～-0.00034,P<0.001）,accounting for 14.92%of the total effect.6.Mediating effect of hypertension on the association between dietary quality and CVD risk and heart age（1）The mediating effect regression coefficient of hypertension on the association between dietary quality score and CVD risk was-0.00026（95%CI:-0.00036～-0.00016,P<0.001）,accounting for 20.24%of the total effect.（2）The mediating effect regression coefficient of hypertension on the association between dietary quality score and heart age was-0.00061（95%CI:-0.00084～-0.00037,P<0.001）,accounting for 19.86%of the total effect.7.Mediating effect of diabetes mellitus on the association between dietary quality and CVD risk and heart age（1）The regression coefficient of mediating effects of diabetes mellitus on the association between dietary quality score and cardiovascular disease risk was-0.00020（95%CI:-0.00035～-0.00005,P<0.001）,accounting for 15.43%of the total effect.（2）The regression coefficient of mediating effects of diabetes mellitus on the association between dietary quality score and heart age was-0.00025（95%CI:-0.00043～-0.00007,P<0.001）,accounting for 8.06%of the total effect.8.Multiple mediating effects of depressive symptoms,obesity,hypertension,and diabetes on the relationship between dietary quality and CVD risk（1）The mediating effect regression coefficient of depressive symptoms on the association between dietary quality score and CVD risk was-0.00002（95%CI:-0.00004～-0.000005,P=0.045）,accounting for 1.49%of the total effect.（2）The mediating effect of obesity on dietary quality score and CVD was not statistically significant（P>0.05）.（3）The regression coefficient of mediating effect of hypertension on dietary quality score and CVD risk was-0.00025（95%CI:-0.00037～-0.00014,P<0.001）,accounting for 19.41%of the total effect.（4）The regression coefficient of mediating effect of diabetes mellitus on dietary quality score and CVD risk was-0.00020（95%CI:-0.00028～-0.00011,P<0.001）,accounting for 15.07%of the total effect.（5）Three cardiovascular disease-related risk factors with significant mediating effects on dietary quality score and CVD risk accounted for the mediating effects of hypertension,diabetes and depression symptoms in descending order.9.Multiple mediating effects of depressive symptoms,obesity,hypertension and diabetes on the relationship between diet quality and heart age（1）The regression coefficient of mediating effect of depressive symptoms on the association between dietary quality score and heart age was-0.00004（95%CI:-0.00006～-0.00001,P=0.013）,accounting for 1.15%of the total effect.（2）The mediating effect regression coefficient of obesity on the association between dietary quality score and heart age was-0.00023（95%CI:-0.00031～-0.00015,P<0.001）,accounting for 8.39%of the total effect.（3）The mediating effect regression coefficient of hypertension on the relationship between dietary quality score and heart age was-0.00058（95%CI:-0.00084～-0.00031,P<0.001）,accounting for 18.98%of the total effect.（4）The regression coefficient of mediating effect of diabetes mellitus on the relationship between dietary quality score and heart age was-0.00022（95%CI:-0.00032～-0.00012,P<0.001）,7.22%of the total effect.（5）The mediating effects of four CVD risk factors on dietary quality score and CVD risk in descending order were hypertension,obesity,diabetes and depression.10.Analysis of the mediating effect of combined risk on the relationship between dietary quality and CVD risk and heart age（1）The mediating effect regression coefficient of"combined risk"on the association between dietary quality score and CVD risk was-0.00035（95%CI:-0.00044～-0.00025,P<0.001）,accounting for 26.56%of the total effect.（2）The mediating effect regression coefficient of"combined risk"on the association between dietary quality score and heart age was-0.00067（95%CI:-0.00084～-0.00049,P<0.001）.Conclusions:1.Dietary quality was negatively correlated with CVD risk and heart age.With the increase of dietary quality score,CVD risk and heart ageincreased monotonically.2.Dietary quality was negatively correlated with depressive symptoms,obesity,hypertension and diabetes;3.Depressive symptoms,obesity,hypertension and diabetes mediated the relationship between dietary quality and CVD,and all played partial mediating roles.4.Depressive symptoms,obesity,hypertension and diabetes mediated the relationship between dietary quality and heart age,all playing partial mediating roles.The results of this study suggest that better dietary quality may reduce the level of depressive symptoms,obesity,hypertension,and diabetes,thereby reducing the risk of CVD.Therefore,dietary intervention measures are recommended to guide the development of good eating habits and reduce the level of risk factors related to cardiovascular diseases,so as to control and reduce the occurrence of cardiovascular diseases.