BACKGROUND/OBJECTIVES: Unhealthy diet has been proposed as one of the main reasons for the high mortality in Central and Eastern Europe (CEE) and the former Soviet Union (FSU) but individual-level effects of dietary habits on health in the region are sparse. We examined the associations between the healthy diet indicator (HDI) and all-cause and cause-specific mortality in three CEE/FSU populations. SUBJECTS/METHODS: Dietary intakes of foods and nutrients, assessed by food frequency questionnaire in the Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) cohort study, were used to construct the HDI, which follows the WHO 2003 dietary recommendations. Among 18 559 eligible adult participants (age range: 45-69 years) without a history of major chronic diseases at baseline, 1209 deaths occurred over a mean follow-up of 7 years. The association between HDI and mortality was estimated by Cox regression. RESULTS: After adjusting for covariates, HDI was inversely and statistically significantly associated with cardiovascular disease (CVD) and coronary heart disease (CHD) mortality, but not with other cause-specific and all-cause mortality in the pooled sample. Hazard ratios per one standard deviation (s.d.) increase in HDI score were 0.95 (95% confidence interval=0.89-1.00, P=0.068), 0.90 (0.81-0.99, P=0.030) and 0.85 (0.74-0.97, P=0.018) for all-cause, CVD and CHD mortality, respectively. Population attributable risk fractions for low HDI were 2.9% for all-cause, 14.2% for CVD and 10.7% for CHD mortality. CONCLUSIONS: These findings support the hypothesis that unhealthy diet has had a role in the high CVD mortality in Eastern Europe.

Department of Epidemiology and Public Health University College London UK

Division of Human Nutrition Wageningen University

Institute of Internal and Preventive Medicine Siberian Branch of the Russian Academy of Medical Sciences Novosibirsk Russia

Jagiellonian University Krakow Poland

National Institute of Public Health Prague Czech Republic

Novosibirsk State Medical University Novosibirsk Russia

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Ginter E. Cardiovascular risk factors in the former communist countries. Analysis of 40 European MONICA populations. Eur J Epidemiol. 1995;11:199–205. PubMed

Bobak M, Marmot M. East-West mortality divide and its potential explanations: proposed research agenda. BMJ. 1996;312:421–425. PubMed PMC

Pomerleau J, McKee M, Lobstein T, Knai C. The burden of disease attributable to nutrition in Europe. Public Health Nutr. 2003;6:453–461. PubMed

Kesteloot H, Sans S, Kromhout D. Dynamics of cardiovascular and all-cause mortality in Western and Eastern Europe between 1970 and 2000. Eur Heart J. 2006;27:107–113. PubMed

Zatonski WA, HEM project team Epidemiological analysis of health situation development in Europe and its causes until 1990. Ann Agric Environ Med. 2011;18:194–202. PubMed

Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991. BMJ. 1998;316:1047–1051. PubMed PMC

Powles JW, Zatonski W, Vander Hoorn S, Ezzati M. The contribution of leading diseases and risk factors to excess losses of healthy life in Eastern Europe: burden of disease study. BMC public health. 2005;5:116. PubMed PMC

Frackiewicz J, Roszkowski W, Brzozowska A, Kaluza J. Diet quality and mortality in elderly people living in Warsaw Region. Przegl Epidemiol. 2010;64:119–125. PubMed

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

Kant AK. Dietary patterns and health outcomes. J Am Diet Assoc. 2004;104:615–635. PubMed

Waijers PM, Feskens EJ, Ocke MC. A critical review of predefined diet quality scores. Br J Nutr. 2007;97:219–231. PubMed

Fransen HP, Ocke MC. Indices of diet quality. Curr Opin Clin Nutr Metab Care. 2008;11:559–565. PubMed

Kourlaba G, Panagiotakos DB. Dietary quality indices and human health: a review. Maturitas. 2009;62:1–8. PubMed

World Health Organization . Diet, nutrition, and the prevention of chronic diseases. WHO; Geneva: 1990. (WHO Technical Report Series no. 797). PubMed

Huijbregts P, Feskens E, Rasanen L, Fidanza F, Nissinen A, Menotti A, et al. Dietary pattern and 20 year mortality in elderly men in Finland, Italy, and The Netherlands: longitudinal cohort study. BMJ. 1997;315:13–17. PubMed PMC

Knoops KT, Groot de LC, Fidanza F, Alberti-Fidanza A, Kromhout D, van Staveren WA. Comparison of three different dietary scores in relation to 10-year mortality in elderly European subjects: the HALE project. Eur J Clin Nutr. 2006;60:746–755. PubMed

Sjogren P, Becker W, Warensjo E, Olsson E, Byberg L, Gustafsson IB, et al. Mediterranean and carbohydrate-restricted diets and mortality among elderly men: a cohort study in Sweden. Am J Clin Nutr. 2010;92:967–974. PubMed

World Health Organization . Diet, nutrition and the prevention of chronic diseases. WHO; Geneva: 2003. (WHO Technical Report Series no. 916.). PubMed

Peasey A, Bobak M, Kubinova R, Malyutina S, Pajak A, Tamosiunas A, et al. Determinants of cardiovascular disease and other non-communicable diseases in Central and Eastern Europe: rationale and design of the HAPIEE study. BMC Public Health. 2006;6:255. PubMed PMC

Boylan S, Welch A, Pikhart H, Malyutina S, Pajak A, Kubinova R, et al. Dietary habits in three Central and Eastern European countries: the HAPIEE study. BMC Public Health. 2009;9:439. PubMed PMC

Willett WC, Sampson L, Stampfer MJ, Rosner B, Bain C, Witschi J, et al. Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol. 1985;122:51–65. PubMed

Brunner E, Stallone D, Juneja M, Bingham S, Marmot M. Dietary assessment in Whitehall II: comparison of 7 d diet diary and food-frequency questionnaire and validity against biomarkers. Br J Nutr. 2001;86:405–414. PubMed

van Kappel AL, Steghens JP, Zeleniuch-Jacquotte A, Chajes V, Toniolo P, Riboli E. Serum carotenoids as biomarkers of fruit and vegetable consumption in the New York Women’s Health Study. Public Health Nutr. 2001;4:829–835. PubMed

Al-Delaimy WK, Slimani N, Ferrari P, Key T, Spencer E, Johansson I, et al. Plasma carotenoids as biomarkers of intake of fruits and vegetables: ecological-level correlations in the European Prospective Investigation into Cancer and Nutrition (EPIC) Eur J Clin Nutr. 2005;59:1397–1408. PubMed

Henriquez-Sanchez P, Sanchez-Villegas A, Doreste-Alonso J, Ortiz-Andrellucchi A, Pfrimer K, Serra-Majem L. Dietary assessment methods for micronutrient intake: a systematic review on vitamins. Br J Nutr. 2009;102(Suppl 1):S10–37. PubMed

Schofield WN. Predicting basal metabolic rate, new standards and review of previous work. Hum Nutr Clin Nutr. 1985;39(Suppl 1):5–41. PubMed

van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res. 2007;16:219–242. PubMed

Friedenreich C, Norat T, Steindorf K, Boutron-Ruault MC, Pischon T, Mazuir, et al. Physical activity and risk of colon and rectal cancers: the European prospective investigation into cancer and nutrition. Cancer Epidemiol Biomarkers Prev. 2006;15:2398–2407. PubMed

Cust AE, Smith BJ, Chau J, van der Ploeg HP, Friedenreich CM, Armstrong BK, et al. Validity and repeatability of the EPIC physical activity questionnaire: a validation study using accelerometers as an objective measure. Int J Behav Nutr Phys Act. 2008;5:33. PubMed PMC

Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR, Jr., Tudor-Locke C, et al. Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;2011;43:1575–1581. PubMed

Walter SD. The estimation and interpretation of attributable risk in health research. Biometrics. 1976;32:829–849. PubMed

Kartashov AI, Buzin VV, Glazunov IS, Abol’ian LV. Results of testing the basic questionnaire “SINDI” in the evaluation of prophylaxis program development. Sov Zdravookhr. 1991;3:45–49. PubMed

McKee M, Bobak M, Rose R, Shkolnikov V, Chenet L, Leon D. Patterns of smoking in Russia. Tob Control. 1998;7:22–26. PubMed PMC

World Health Organization [accessed: 16th July 2013];Global Health Observatory Data Repository. Cause-specific mortality and morbidity: Age-standardized mortality rate by cause by country. Internet: http://apps.who.int/gho/data/node.main.18?lang=en.

Bingham SA. Limitations of the various methods for collecting dietary intake data. Ann Nutr Metab. 1991;35:117–127. PubMed

Cade J, Thompson R, Burley V, Warm D. Development, validation and utilisation of food-frequency questionnaires - a review. Public Health Nutr. 2002;5:567–587. PubMed

World Health Organization Regional Office for Europe . Nutrition and Food Security Programme: Food based dietary guidelines in the WHO European Region. WHO Regional Office for Europe; Copenhagen: 2003.

Connor SL, Ojeda LS, Sexton G, Weidner G, Connor WE. Diets lower in folic acid and carotenoids are associated with the coronary disease epidemic in Central and Eastern Europe. J Am Diet Assoc. 2004;104:1793–1799. PubMed

Kristenson M, Ziedén B, Kucinskienë Z, Elinder LS, Bergdahl B, Elwing B, et al. Antioxidant state and mortality from coronary heart disease in Lithuanian and Swedish men: concomitant cross sectional study of men aged 50. BMJ. 1997;314:629–633. PubMed PMC

Bobak M, Brunner E, Miller NJ, Skodová Z, Marmot M. Could antioxidants play a role in high rates of coronary heart disease in the Czech Republic? Eur J Clin Nutr. 1998;52:632–636. PubMed

Pomerleau J, Lock K, Knai C, McKee M. Interventions designed to increase adult fruit and vegetable intake can be effective: a systematic review of the literature. J Nutr. 2005;135:2486–2495. PubMed

Rees K, Dyakova M, Wilson N, Ward K, Thorogood M, Brunner E. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2013;12:CD002128. PubMed PMC

The Southern European Atlantic diet and all-cause and cause-specific mortality: a European multicohort study

The Southern European Atlantic diet and depression risk: a European multicohort study

Longitudinal trajectories of blood lipid levels in an ageing population sample of Russian Western-Siberian urban population

Traditional Eastern European diet and mortality: prospective evidence from the HAPIEE study

Association between soft drink, fruit juice consumption and obesity in Eastern Europe: cross-sectional and longitudinal analysis of the HAPIEE study

Cardiovascular health among the Czech population at the beginning of the 21st century: a 12-year follow-up study

Psychosocial and socioeconomic determinants of cardiovascular mortality in Eastern Europe: A multicentre prospective cohort study

Mediterranean diet score and total and cardiovascular mortality in Eastern Europe: the HAPIEE study

Fruit and vegetable consumption and mortality in Eastern Europe: Longitudinal results from the Health, Alcohol and Psychosocial Factors in Eastern Europe study

Antioxidant vitamin intake and mortality in three Central and Eastern European urban populations: the HAPIEE study