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Community and primary care nursing
Nurses’ awareness of diverse healthy diets may increase patients’ adherence improving cardiovascular disease risk management
  1. Shaminder Singh1,
  2. Cathy A Eastwood2
  1. 1 Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  2. 2 Centre for Health Informatics, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Shaminder Singh, Community Health Sciences, University of Calgary, Calgary, AB T2N 4Z6, Canada; shasingh{at}

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Commentary on: Shan Z, Li Y, Baden MY, et al. Association between healthy eating patterns and risk of cardiovascular disease. JAMA Intern Med 2020; 180:1090–100. doi: 10.1001/jamainternmed.2020.2176

Implications for practice and research

  • Nurses should be aware and open to multiple healthy dietary patterns among diverse groups of people and how they might influence cardiovascular disease (CVD).

  • Further research is required to explore how to increase adherence to healthy diets for diverse population groups within their sociocultural and ecological contexts.


Historically, long-term risk management of CVD is composed of healthy dietary recommendations.1 2 A plethora of information about foods and nutrients occupy media and health research spaces,3 yet consumers often possess a suboptimal understanding of healthy dietary patterns.4 Information about isolated nutrients and foods is insufficient to manage CVD risks; instead, elevated public awareness of various recommended dietary patterns is required.4 Diverse healthy dietary patterns might increase adherence by accommodating people’s wide range of personal preferences, restrictions and ability to prepare food as well as the accessibility of the healthy diets in a variety of sociocultural contexts. Shan et al studied relationships between four healthy dietary patters with CVD risk using the data from three large prospective cohort studies spanning three decades of follow-up.5


A prospective cohort study design was employed to examine the relationship between risk of CVD and four distinct dietary patterns namely, Alternate Mediterranean Diet Score (AMED), Alternate Healthy Eating Index (AHEI), HEI-2015, Healthful Plant-Based Diet Index (HPDI). The data were derived from three multiethnic (white, black, Hispanic, minority group) studies: (1) Health Professionals Follow-up Study (HPFS; 1986–2012; 51 529 males aged 40–75), (2) Nurses’ Health Study (NHS; 1984–2016; 121 700 females aged 30–55) and (3) NHS II (1991–2017; 116 671 females aged 25–42). Every 2–4 years, more than 90% of participants responded on a validated Food-Frequency Questionnaire (FFQ) consisting of >110 items. Information was collected on covariates such as smoking, physical activity, use of aspirin and vitamin supplements, age, body weight and ethnicity. Medical records, WHO and National Survey of Stroke criteria were used to assess CVD. Statistical analyses such as ‘averaging the repeated measures’ and Cox proportional hazards models were employed to minimising within-person differences and to accentuate variations based on the dietary patterns.


A total of 74 930 women from NHS, 90 864 women from NHS II and 43 339 men from HPFS studies with a mean age (SD) of, respectively, 50.2 (7.2), 36.1 (4.7) and 53.2 (9.6) years were included in the final sample. Pooled multivariable-adjusted CVD HRs were calculated comparing the highest with the lowest quintiles ranged between 0.75 and 0.89 at 95% CI (trend p<0.001) for all four dietary patterns and their scores were significantly related to lower risk of CVD. A similar trend of the inverse relationship of dietary scores and CVD risk was found in stratified analyses by ethnicity and other lifestyle-related factors such as smoking and physical activity.


Shan et al analysed data collected from more than 200 000 participants (final sample; 20% males) in three prospective cohort studies (32 years follow-up) and examined associations of CVD risk factors with four distinct healthy dietary patters: AMED, AHEI, HEI-2015 and HPDI.5 Multivariate analyses showed a total of 10%–20% decreased risk of CVD in relation to a 25 percentile increase in the dietary scores on each dietary pattern in all the cohort studies. A similar inverse trend emerged in stratified analyses by ethnicity, revealing no statistical difference among the dietary patterns with CVD risks.

Despite limitations such as potential recall bias while responding to the FFQ, the study’s strength lies in its large sample size, gender considerations and follow-up period that spanned over three decades. The study establishes the effectiveness of all recommended diets if the adherence is high.5 But it raised an issue of suboptimal understanding of recommended diets at the population level.4 Nurses’ openness to and awareness of evidence-based recommendations for diverse healthy eating patterns might increase patients’ adherence to healthy diets to improve CVD risk management. More research on diverse dietary patterns and strategies to enhance adherence rates might promote precision recommendations to communities, increasing their adherence within their sociocultural and ecological contexts.



  • Twitter @ShaminderSingh, @Eastwoodcathy1

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.