AJCN. First published ahead of print April 1, 2015 as doi: 10.3945/ajcn.115.110213.

Editorial

Dietary patterns: from nutritional epidemiologic analysis to national

13
guidelines
of the effects of the DASH diet with and without sodium and a corElizabeth M Cespedes and Frank B Hu
Identifying the optimal diet (or diets) for chronic disease prevention is a public health priority. Traditionally, nutrition research
has focused on single nutrients or specific foods, although individuals do not consume nutrients or foods in isolation. Thus, recent
nutritional epidemiologic studies have shifted to dietary pattern
analysis, which describes the overall diet; the foods, food groups,
and nutrients included; their combination and variety; and the frequency and quantity with which they are habitually consumed (1).
Among the most prominent methods to assess dietary patterns are a
priori numerical indexes, which measure adherence to a dietary
pattern that has been predefined on the basis of previous scientific
evidence. Often, multiple indexes describe variations of the same
dietary pattern (e.g., Mediterranean diet score) or use different
scoring and weighting schemes, such as population-specific in4
takes [e.g., Dietary Approaches to Stop Hypertension (DASH) ]
versus fixed cutoffs for recommended intakes (e.g., Alternate
Healthy Eating Index). Another approach is to empirically derive
common patterns of foods that tend to be consumed together by
using principal components analysis or that explain the largest
variation in intermediate outcomes such as biomarkers of diseases
by using a statistical approach called reduced rank regression (2).
Despite different approaches to deriving dietary patterns, com-mon
elementsnutrients and foodsemerge over and over and are
likely to be drivers of the observed effects. Yet, isolating these
foods and nutrients may not provide a realistic picture of what
people eat in combination and the impact on health: it is likely the
cumulative and interactive effects of multiple components of diet
that predict disease, and when one component of the diet changes,
it is typically substituted by another. Not only do dietary patterns
encompass the totality of a diet, they allow for multiple ways to
achieve a healthy diet. Thus, public health guidelines and recommendations may be most easily translated into eating behaviors
when described by the composite measure of diet quality encompassed in dietary patterns.
Although observational studies of dietary patterns and health out-comes
are often cost-effective and allow for wider exposure ranges and longer
follow-up in which clinical endpoints can be observed, testing the
efficacy of dietary patterns through randomized con-trolled trials of
intermediate endpoints provides a complementary evidence base. One
approach is controlled intervention trials, in which all food is provided
to participants over the course of weeks or months. These studies allow
more precise definition of the di-etary exposures tested. Prominent
examples include the evaluation

responding reduction in blood pressure (3, 4). The long-term benefit of such a dietary pattern is affirmed in large cohort studies
showing that adherence to the DASH-style pattern is associated
with decreased risk of cardiovascular disease (CVD) outcomes (5).
Long-term trials of dietary pattern interventions on hard end-points
are rare because of their prohibitive cost and lack of dietary
compliance in the long run. One exception is the PREDIMED
(Prevencion con Dieta Mediterranea) trial (6), which included

.7000 participants with CVD risk factors and which compared

advice to follow a low-fat diet (control) with advice to follow a
Mediterranean-style diet along with the provision of either olive
oil or nuts. Compared with the control group, both inter-vention
groups experienced an approximate 30% decrease in
cardiovascular events after 4 y of follow-up. The results from
this landmark trial, together with consistent observational evidence on higher Mediterranean diet scores and lower incidence
of CVD in large cohorts (7), provide convincing evidence to
support the health benefits of the Mediterranean diet in primary
prevention of CVD.
As methods to assess dietary patterns are refined and the ev-idence
base is strengthened, the advantages that dietary patterns offer as an
approach for informing public health recommenda-tions are
increasingly being recognized. For example, the 2015 Dietary
Guidelines Advisory Committee (DGAC) focused its ev-idence
review and recommendations on healthful dietary patterns instead
of individual nutrients or foods in its recently released scientific
report (8). The DGAC noted remarkable consistency in the findings
over a wide range of disease outcomes and across different dietary
pattern assessment methods. Overall, the report identified that a
healthy dietary pattern is higher in vegetables, fruits, whole grains,
low- or nonfat dairy, seafood, legumes, and nuts; moderate in
alcohol (among adults); lower in red and

From the Departments of Nutrition and Epidemiology, Harvard TH Chan

School of Public Health, Boston, MA.
Supported by NIH grants HL60712, P30 DK46200, and U54 CA155626.

Address correspondence to FB Hu, Department of Nutrition, Harvard TH

Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115.
E-mail: [email protected].
Abbreviations used: CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; DGAC, Dietary Guidelines Advisory Committee; PREDIMED, Prevencion con Dieta Mediterranea.
doi: 10.3945/ajcn.115.110213.

Am J Clin Nutr doi: 10.3945/ajcn.115.110213. Printed in USA. 2015 American Society for Nutrition

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Copyright (C) 2015 by the American Society for Nutrition

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EDITORIAL

processed meat; and low in sugarsweetened foods and drinks and

refined grains. The healthy
dietary pattern described by the
DGAC is similar to current
dietary recommendations in other
countries, including the United
Kingdom (9).
In this issue of the Journal,
Reidlinger et al. (10) conducted a
randomized trial to test the
efficacy of the current United
Kingdom dietary guidelines on
biomarkers of CVD risk. The
authors report clinically
significant benefits on blood
pressure and ratio of total to HDL
cholesterol of a 12-wk dietary
inter-vention when compared
with a traditional British dietary
pattern. Smaller beneficial effects
on high-sensitivity C-reactive
protein and body weight were
also observed. The
recommendations for intervention
participants included reductions
in sodium, sat-urated fat, and
added sugars and increased
consumption of oily fish, fruit and
vegetables, and whole grains.
Targets were achieved through
dietitian advice and provision of
low-saturated/trans-fat margarine,
high-oleic-acid cooking oil, and
other incentive foods such as
brown rice, nuts, tinned fish, and
whole-grain breakfast cereal.
Adherence was assessed through
diet records and bio-markers of
intake.
In this study, control participants
were also provided with supplemental foods such as a butterbased spread, palm oilderived
cooking oil, cookies, and refined
breakfast cereal. Thus, control
participants consumed new and
additional sources of refined
carbohydrate and trans and
saturated fat characteristic of a traditional British diet. This difference
in quality of fat and carbo-hydrate
may have accounted, in part, for the
primary benefits of the intervention
diet on blood pressure and ratio of
total to HDL cholesterol observed
in this study. However, as the

authors note, the greater

consumption of saturated fats was
the main differ-ence from baseline
in the control group. By contrast, in
addition to improving the quality of
dietary fat, at follow-up the intervention group also achieved higher
protein and dietary fiber intakes,
slightly higher potassium intake,
and lower added sugar and sodium
intakes. Although this was a shortterm trial, the overall improvement
in diet quality in the intervention
group is likely to confer long-term
benefits on CVD risk.

Given the similarities between the

United Kingdom dietary
guidelines and the
recommendations from other
countries, the results of this study
provide relevant evidence to
policy makers and health
professionals both within and
beyond the United Kingdom. The
study represents an important step
for-ward in dietary pattern
research because few randomized
trials have tested the effect of
adherence to a diet consistent
with na-tional guidelines on CVD
risk in a healthy population. In
par-allel, concerted efforts have
been made to standardize dietary
patterning methodology across
various population-based cohorts, which have the advantage
of examining long-term health
outcomes (11). Establishing a
robust evidence base for the dietary patterns described by
national guidelines is essential to
test the public health relevance of
these guidelines. Not only do
dietary guidelines provide
science-based advice to promote
health and reduce chronic
diseases that are highly visible to
the public but they also serve as
an anchor point for national food
and nutrition policies.
The authors responsibilities were as
followsEMC: developed the first draft
of the manuscript; and FBH: contributed
to the development of the final draft of
the manuscript and approved the
manuscript. EMC had no conflicts of
interest to disclose. FBH has received
research support from the Califor-nia

Walnut Commission and Metagenics.

REFERENCES
Hu FB. Dietary pattern analysis: a new
direction in nutritional epidemi-ology.
Curr Opin Lipidol 2002;13:39.
Hoffmann K, Schulze MB,
Schienkiewitz A, Nothlings U, Boeing
H. Application of a new statistical
method to derive dietary patterns in
nutritional epidemiology. Am J
Epidemiol 2004;159:93544.
Appel LJ, Moore TJ, Obarzanek E,
Vollmer WM, Svetkey LP, Sacks FM,
Bray GA, Vogt TM, Cutler JA,
Windhauser MM, et al; DASH
Collaborative Research Group. A
clinical trial of the effects of dietary
patterns on blood pressure. N Engl J
Med 1997;336:111724.
Sacks FM, Svetkey LP, Vollmer WM,
Appel LJ, Bray GA, Harsha D,
Obarzanek E, Conlin PR, Miller ER III,
Simons-Morton DG, et al; DASHSodium Collaborative Research Group.
Effects on blood pres-sure of reduced
dietary sodium and the Dietary
Approaches to Stop Hypertension
(DASH) diet. N Engl J Med
2001;344:310.
Salehi-Abargouei A, Maghsoudi Z,
Shirani F, Azadbakht L. Effects of
Dietary Approaches to Stop
Hypertension (DASH)-style diet on fatal
or nonfatal cardiovascular diseases
incidence: a systematic review and
meta-analysis on observational
prospective studies. Nutrition 2013;29:
6118.

Estruch R, Ros E, Salas-Salvado J,

Covas MI, Corella D, Aros F, GomezGracia E, Ruiz-Gutierrez V, Fiol M,
Lapetra J, et al. Primary prevention of
cardiovascular disease with a
Mediterranean diet. N Engl J Med
2013;368:127990.
Martinez-Gonzalez MA, Bes-Rastrollo
M. Dietary patterns, Mediterra-nean
diet, and cardiovascular disease. Curr
Opin Lipidol 2014;25:206.
USDA. Scientific report of the 2015
Dietary Guidelines Advisory
Committee. February 2015. [cited 2015
Mar 13]. Available from:
http://www.health.gov/dietaryguidelines
/2015-scientific-report/PDFs/
Scientific-Report-of-the-2015-DietaryGuidelines-Advisory-Committee. pdf.
Department of Health; Committee on
Medical Aspects of Food Policy.
Nutritional aspects of cardiovascular
disease. London: Her Majestys
Stationery Office; 1994. Report on
Health and Social Subjects No. 46.
Reidlinger DP, Darzi J, Hall WL, Seed PT,
Chowienczyk PJ, Sanders TAB;
Cardiovascular disease risk REduction
Study (CRESSIDA) Study Investigators.
How effective are current dietary
guidelines for cardiovas-cular disease
prevention in healthy middle-aged and
older men and

women? A randomized controlled trial.

Am J Clin Nutr 2015;101:
.
Liese AD, Krebs-Smith SM, Subar AF,
George SM, Harmon BE, Neuhouser
ML, Boushey CJ, Schap TE, Reedy J.
The Dietary Patterns Methods Project:
synthesis of findings across cohorts and
relevance to dietary guidance. J Nutr
2015;145:393402.