How many fruits and vegetables do you eat a day? And nuts? Are legumes and fish part of your plate several times a week, very occasionally or never? Do you consume whole dairy?
The answers to these questions can give you an individual score on your diet, taking as a reference a score (score) prepared based on a study that collected data from 245,000 people from 80 countries (including Argentina).
Led by researchers from Canada’s Population Health Research Institute (PHRI), the study concluded that a diet made up of higher amounts of the six food groups that make up the PURE Healthy Diet Score ( Healthy Diet Score) is associated with a lower risk of cardiovascular disease (CVD) and death globally.
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The authors of the work published in the European Heart Journal used previous observations of dietary habits and mortality derived from the Prospective Urban Rural Epidemiology (PURE) study, which included almost 148,000 adults from 21 countries (more than 7,300 from Argentina), to develop a diet score based on six “protective” components .
One point was awarded to intake levels above the median for each of them, resulting in a score of 0 to 6.
During a mean follow-up of just over 9 years, there were 15,707 deaths and more than 40,764 cardiovascular events.
Analyzing the data, the authors found that achieving the maximum score on the recommended intake of protective foods (5 or higher) was associated with a 30% lower risk of death, a 14% lower risk of heart attack, and a 19% lower risk of heart attack. of stroke and an 18% lower probability of CVD overall, compared with those who had achieved the minimum score (one point or less).
The results obtained were confirmed in five independent studies (ONTARGET, TRANSCEND, ORIGIN, INTERHEART, and INTERSTROKE) that included almost 97,000 patients with cardiovascular disease from 70 countries (4,500 from Argentina).
a diverse study
“This is by far the most diverse study of nutrition and health outcomes in the world,” said Andrew Mente, a PHRI investigator and lead author of the paper.
“Previous diet scores, including the EAT-Lancet planetary diet and the Mediterranean diet, tested the relationship between diet and cardiovascular disease and death primarily in Western countries. The PURE score included a good representation of high-income countries , mids, and lows,” said Salim Yusuf, lead author and PURE Principal Investigator.
What is included in the PURE Healthy Score
The PURE Healthy Diet Score recommends an average daily intake of two to three servings of fruit, two to three servings of vegetables, one serving of nuts, and two servings of full-fat dairy. And it also includes three to four servings a week of legumes and two to three of fish.
(Valid disclaimer: PURE is a prospective cohort study led by Yusuf that assesses the effect of macro and microeconomic factors on lifestyle and dietary risk factors for cardiovascular disease. Dozens of papers have already been published in journals with results arising from the follow-up -which continues to this day- of its 170,000 participants from 21 countries enrolled between 2003 and 2013).
“This particular paper is based on several previous ones, each one dedicated to a food component (there is one for meat, one for cereals, one for dairy products, one for carbohydrates, another for eggs, another for fish, another for fruit, vegetables, and legumes)”, explained to Clarín the cardiologist Fernando Botto, member of the executive committee of Latin American Clinical Studies (ECLA), which enrolled the Argentine participants.
“From each individual publication they were taking for this current paper of the PURE score the foods that were shown to have an impact on the reduction of mortality and cardiovascular diseases.”
The PURE score has several points of connection with the Mediterranean and DASH diets. Photo Shutterstock. PURE score, Mediterranean diet, DASH and flexitarian
The PURE score performed “slightly better” than the Mediterranean diet, the Healthy Eating Index (HEI), and the DASH diet. And “substantially better” than the flexitarian diet created by the EAT-Lancet Commission, the authors argued.
Does this imply that the results conflict with dietary patterns such as the Mediterranean, for example, which is promoted by the World Health Organization for its proven health benefits? According to the researchers, no.
The PURE score, they analyzed, is similar to the Mediterranean and DASH diets that emphasize increased fruits, vegetables, legumes, nuts, and fish, “with some differences in their focus on different types of fats and dairy or meat consumption.” red”.
“Our findings show that a similar dietary pattern, but one that also includes dairy (consumed primarily as full-fat dairy), may have the most favorable associations with health outcomes in a global population,” they noted.
Another difference with the Mediterranean diet is that it includes whole grains (whole grains, bread, pasta). “In our study, whole grains did not contribute to the utility of the diet score in predicting CVD risk or death. Therefore, including a moderate amount of whole grains is optional for a healthy diet,” the authors note. . The same goes for unprocessed meat.
What does it mean? That the health benefits obtained by increasing the consumption of the 6 foods considered protective are not altered by the moderate intake of grains and meats, as long as they are unrefined whole grains and unprocessed meats (see table).
Although in this work there was no specific recommendation on the consumption of eggs, a previous PURE study endorsed the intake of up to one per day, recalled Botto, head of Clinical Research at ICBA.
Full-fat dairy products were included among the foods considered protective. Photo Shutterstock. Whole dairy, the main difference
“The good thing about the PURE score is that it validates what is already known, but adds some strong points to the discussion. The first – and I think the most important – is that of full-fat dairy,” Botto said.
“Most of the previous recommendations suggested the intake of skimmed milk, skimmed yogurt, to reduce this issue of fat, however, PURE is very solid and forceful in favor of adding whole dairy, which would represent a change compared to Mediterranean diets. and DASH, for example.”
“The priority should be to increase protective foods such as nuts (often avoided because they are too energy-dense), fish and dairy, rather than restricting them (especially whole) to very low amounts,” she stressed. Mind.
According to the results obtained, “up to two daily servings of dairy products, mainly full-fat, can be included in a healthy diet. This is in line with modern nutrition science which shows that dairy products, particularly full-fat whole, they may protect against high blood pressure and metabolic syndrome,” he said.
And it concluded that a moderate increase in its consumption, especially in low- and middle-income countries, is likely to be beneficial.
It is that, at the population level, the lowest scores were obtained in participants from South Asia, China and Africa).
“These findings raise the idea that low intake of key natural foods (and possibly malnutrition) rather than high intake or overnutrition may be the leading dietary problem in relation to mortality and CVD globally. This challenges current beliefs,” the authors stated.
Can the PURE Diet score be modified for each region?
“Given the consistency of the PURE score results in different settings, it can be used as the basis for recommendations on what a healthy diet should look like globally and then modified for each region based on the specific types of food available and affordable in each of them,” cardiologist Rafael Díaz, director of ECLA, coordinator of the study in Argentina and one of the authors of the study, told Clarín.
“My position normally has a broad epidemiological bias, this means that I will always prioritize the overall results of the study over the results of the small subgroup in Argentina (despite the fact that our country contributed many patients),” he clarified.
In this sense, he highlighted that “the general results are much more important than the individual results for each country”, so the final conclusions try to “adapt them for their application in Argentina”.
One of the local characteristics is that here we have a higher consumption of red meat and chicken. “The reasons are probably simple: high availability, it can be approached by a large proportion of the population, and its excellent quality. This has to be reconciled with the final concept and message of the new PURE food index,” he said.
“The ideal diet for each population is likely to be one of variety and moderation, characteristics of the PURE diet,” he said, in line with his colleagues.
Is it necessary to get the maximum score to get benefits?
No. “A 20% improvement in diet quality in populations is probably achievable and would be associated with an 8% reduction in mortality and a 6% reduction in CVD,” the authors write.
And they noted that “even a modest improvement” is expected to have a large impact on the health of populations, especially in poorer countries.
In fact, the greatest gains in health were seen when reaching 4 points, with no major difference between that score and the maximum of 6.
Getting to four points can be achieved in a variety of ways that suit personal or cultural preferences and do not necessarily require including or excluding animal foods from the diet, the researchers noted.
Díaz exemplified: “Vegetarians can reach 4 by consuming lots of fruits, vegetables, legumes, nuts, whole grains and, in case they are lacto-ovo vegetarians, dairy. While non-vegetarians can achieve the same score by consuming lots of fruits, vegetables and legumes along with dairy or fish, or even moderate amounts of red meat or poultry.”
“The important thing is that they understand that they have to try a certain quantity and variety of these foods,” Botto responded when asked how he would transmit the results of the work to his patients.
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