EAT-Lancet score and major health outcomes: the EPIC-Oxford study

In January, 2019, the EAT-Lancet Commission on healthy diets from the sustainable food systems report1Willett W Rockström J Loken B et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems.Lancet. 2019; 393: 447-492Summary Full Text Full Text PDF PubMed Scopus (3424) Google Scholar defined a universal reference diet to promote human and environmental health. To evaluate its association with the risk of major health outcomes, we used data from 46 069 participants enrolled throughout the UK in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford study. Using data from food frequency questionnaires collected between 1993 and 2001, we created an EAT-Lancet score based on the 14 key recommendations (appendix p 1). Participants were assigned a point for meeting each of the recommendations, resulting in possible scores of 0–14. We used multivariable-adjusted Cox proportional hazards models to assess associations between four divisions of the EAT-Lancet score (4–9, 10, 11, and 12–14) and risk of hospitalisation or death from ischaemic heart disease, stroke, and diabetes and total mortality, ascertained through health record linkage. We repeated analyses with each individual recommendation adjusted for the score (minus itself) to investigate whether one or more of the recommendations were responsible for associations.2Akbaraly TN Sabia S Shipley MJ Batty GD Kivimaki M Adherence to healthy dietary guidelines and future depressive symptoms: evidence for sex differentials in the Whitehall II study.Am J Clin Nutr. 2013; 97: 419-427Crossref PubMed Scopus (103) Google Scholar The EPIC-Oxford study protocol was approved by a Multicentre Research Ethics Committee (Scotland A Research Ethics Committee). All participants provided written informed consent. High adherence to the EAT-Lancet score was associated with lower risks of ischaemic heart disease (28%) and diabetes (59%) but was not associated with risk of stroke and not clearly associated with total mortality (results unadjusted for body-mass index [BMI]; figure). Cross-sectionally, high adherence to the EAT-Lancet score was associated with about 1·4 kg/m2 lower BMI and, in subsamples with measured data (appendix p 2), with about 0·5 mmol/L lower plasma non-HDL cholesterol and about 3·5 mm Hg lower systolic blood pressure compared with low adherence (p<0·001; appendix p 2), differences which could mediate the inverse association observed for ischaemic heart disease. No association was explained by one single recommendation, suggesting a cumulative effect; however, 41 810 (90·76%) participants achieved the recommendations for poultry, eggs, fish, legumes, and fats (appendix p 3), suggesting that only a subset of recommendations contributed to the protective association for the score. This consumption pattern might relate to the structure of our cohort, which includes a large proportion of vegetarians.3Davey GK Spencer EA Appleby PN Allen NE Knox KH Key TJ EPIC-Oxford: lifestyle characteristics and nutrient intakes in a cohort of 33 883 meat-eaters and 31 546 non meat-eaters in the UK.Public Health Nutr. 2007; 6: 259-268Crossref Scopus (382) Google Scholar Adherence to the EAT-Lancet score might be a marker for healthy lifestyle; therefore, residual confounding might operate. In this large prospective cohort of British adults, the EAT-Lancet reference diet shows beneficial associations for ischaemic heart disease and diabetes, but no association with stroke and no clear association with mortality. This work was supported by the Wellcome Trust, Our Planet Our Health (Livestock, Environment, and People), and the UK Medical Research Council. We declare no competing interests. Download .pdf (.14 MB) Help with pdf files Supplementary appendix Healthy diets and sustainable food systems – Authors' replyWe welcome this opportunity to engage with our colleagues' suggestions and concerns that have arisen since publishing the EAT-Lancet report on healthy diets from sustainable food systems.1 Full-Text PDF Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systemsFood systems have the potential to nurture human health and support environmental sustainability; however, they are currently threatening both. Providing a growing global population with healthy diets from sustainable food systems is an immediate challenge. Although global food production of calories has kept pace with population growth, more than 820 million people have insufficient food and many more consume low-quality diets that cause micronutrient deficiencies and contribute to a substantial rise in the incidence of diet-related obesity and diet-related non-communicable diseases, including coronary heart disease, stroke, and diabetes. Full-Text PDF Healthy diets and sustainable food systemsWe applaud the EAT-Lancet Commission1 by Walter Willett and colleagues but nonetheless take issue with their suggested ideal diet. We agree that preserving species diversity in the earth's biosphere benefits human health. We wish that the Commission had extended that assertion to the microbial species diversity in the human gut. Full-Text PDF Healthy diets and sustainable food systemsThe EAT-Lancet Commission1 aims to define healthy global diets that avoid environmental degradation. It adopts the planetary boundaries concept to define “a safe operating space for humanity”2,3 or more prosaically “global biophysical limits that humanity should operate within to ensure a stable and resilient Earth system”.1 However, the scientific analysis is obfuscated when two boundaries (climate change and nitrogen cycling) are relaxed to accommodate the pollution that seems unavoidable with a growing and more prosperous population: the “safe operating space”2,3 by definition is expanded to accommodate the diets that the report purports to scientifically test. Full-Text PDF Healthy diets and sustainable food systemsIn their report, Walter Willett and colleagues1 stated that their dietary recommendations were based on the best available science.1 Nevertheless, their prescriptions and proscriptions relied heavily upon dietary data that were found to be “meaningless”2 and a retracted study (PREDIMED).3 As such, the report contributes to the fictional discourse on diet–disease relations2,4 that began in the 1950s.4 Full-Text PDF This is not the EAT–Lancet Diet – Authors' replyWe thank Zoe Harcombe for her interest in our Correspondence.1 Harcombe voices thoughtful concern regarding the likeness of our EAT–Lancet score to the EAT–Lancet diet,2 and hence the score's ability to evaluate the diet's association with major health outcomes. Full-Text PDF This is not the EAT–Lancet DietIn their Correspondence on the EPIC-Oxford study of the EAT–Lancet diet, Anika Knuppel and colleagues1 claimed that “In this large prospective cohort of British adults, the EAT–Lancet reference diet shows beneficial associations for ischaemic heart disease and diabetes”. The EAT–Lancet diet was minutely specified (from 5 g lard to 13 g egg), and totalled 2500 calories per day.2 Each line item also had a so-called possible range (minimum to maximum). Full-Text PDF