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The Baltic Sea Diet Pyramid (created by the Finnish Heart Association, the Finnish Diabetes Association and the University of Eastern Finland) 

The Baltic Sea Diet Pyramid (created by the Finnish Heart Association, the Finnish Diabetes Association and the University of Eastern Finland) 

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The health-related effects of the Nordic diet remain mostly unidentified. We created a Baltic Sea Diet Score (BSDS) for epidemiological research to indicate adherence to a healthy Nordic diet. We examined associations between the score and nutrient intakes that are considered important in promoting public health. We also examined the performance of...

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... Baltic Sea Diet Pyramid (Fig. 1) served as a template for the score. The pyramid contains ten food groups: (i) Nordic vegetables (tomato, cucumber, leafy vegetables, roots, cabbages, legumes); (ii) Nordic fruits (apples, pears, and berries); (iii) Nordic wholegrain cereals (rye, oats and barley); (iv) potatoes; (v) low-fat and fat-free milk products; (vi) Nordic fish ...

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... The applicability of these dietary patterns to northern European countries is limited by cultural values and preferences and the availability/costs of specific foods [22][23][24]. Nordic dietary patterns, known variably as the Nordic diet [25], New Nordic Diet [26], healthy Nordic diet [27,28] and Baltic Sea diet [29], include foods that are typically consumed as part of traditional Nordic diets and that are consistent with Nordic dietary guidelines [26,30]. These foods include whole-grain cereals (especially rye, oats and barley), berries, other temperate fruits (especially apples and pears), vegetables (especially root and cruciferous vegetables), legumes, fish/shellfish, nuts and canola oil/rapeseed oil (as primary fat sources) and low-fat dairy foods [26,27,29,31]. ...
... Nordic dietary patterns, known variably as the Nordic diet [25], New Nordic Diet [26], healthy Nordic diet [27,28] and Baltic Sea diet [29], include foods that are typically consumed as part of traditional Nordic diets and that are consistent with Nordic dietary guidelines [26,30]. These foods include whole-grain cereals (especially rye, oats and barley), berries, other temperate fruits (especially apples and pears), vegetables (especially root and cruciferous vegetables), legumes, fish/shellfish, nuts and canola oil/rapeseed oil (as primary fat sources) and low-fat dairy foods [26,27,29,31]. The benefits of Nordic dietary patterns have been recognised in major clinical practice guidelines on obesity [32], and diabetes [33][34][35][36]. ...
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Aims/hypothesis Nordic dietary patterns that are high in healthy traditional Nordic foods may have a role in the prevention and management of diabetes. To inform the update of the EASD clinical practice guidelines for nutrition therapy, we conducted a systematic review and meta-analysis of Nordic dietary patterns and cardiometabolic outcomes. Methods We searched MEDLINE, EMBASE and The Cochrane Library from inception to 9 March 2021. We included prospective cohort studies and RCTs with a follow-up of ≥1 year and ≥3 weeks, respectively. Two independent reviewers extracted relevant data and assessed the risk of bias (Newcastle–Ottawa Scale and Cochrane risk of bias tool). The primary outcome was total CVD incidence in the prospective cohort studies and LDL-cholesterol in the RCTs. Secondary outcomes in the prospective cohort studies were CVD mortality, CHD incidence and mortality, stroke incidence and mortality, and type 2 diabetes incidence; in the RCTs, secondary outcomes were other established lipid targets (non-HDL-cholesterol, apolipoprotein B, HDL-cholesterol, triglycerides), markers of glycaemic control (HbA 1c , fasting glucose, fasting insulin), adiposity (body weight, BMI, waist circumference) and inflammation (C-reactive protein), and blood pressure (systolic and diastolic blood pressure). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of the evidence. Results We included 15 unique prospective cohort studies ( n =1,057,176, with 41,708 cardiovascular events and 13,121 diabetes cases) of people with diabetes for the assessment of cardiovascular outcomes or people without diabetes for the assessment of diabetes incidence, and six RCTs ( n =717) in people with one or more risk factor for diabetes. In the prospective cohort studies, higher adherence to Nordic dietary patterns was associated with ‘small important’ reductions in the primary outcome, total CVD incidence (RR for highest vs lowest adherence: 0.93 [95% CI 0.88, 0.99], p =0.01; substantial heterogeneity: I ² =88%, p Q <0.001), and similar or greater reductions in the secondary outcomes of CVD mortality and incidence of CHD, stroke and type 2 diabetes ( p <0.05). Inverse dose–response gradients were seen for total CVD incidence, CVD mortality and incidence of CHD, stroke and type 2 diabetes ( p< 0.05). No studies assessed CHD or stroke mortality. In the RCTs, there were small important reductions in LDL-cholesterol (mean difference [MD] −0.26 mmol/l [95% CI −0.52, −0.00], p MD =0.05; substantial heterogeneity: I ² =89%, p Q <0.01), and ‘small important’ or greater reductions in the secondary outcomes of non-HDL-cholesterol, apolipoprotein B, insulin, body weight, BMI and systolic blood pressure ( p< 0.05). For the other outcomes there were ‘trivial’ reductions or no effect. The certainty of the evidence was low for total CVD incidence and LDL-cholesterol; moderate to high for CVD mortality, established lipid targets, adiposity markers, glycaemic control, blood pressure and inflammation; and low for all other outcomes, with evidence being downgraded mainly because of imprecision and inconsistency. Conclusions/interpretation Adherence to Nordic dietary patterns is associated with generally small important reductions in the risk of major CVD outcomes and diabetes, which are supported by similar reductions in LDL-cholesterol and other intermediate cardiometabolic risk factors. The available evidence provides a generally good indication of the likely benefits of Nordic dietary patterns in people with or at risk for diabetes. Registration ClinicalTrials.gov NCT04094194. Funding Diabetes and Nutrition Study Group of the EASD Clinical Practice. Graphical abstract
... Dietary quality indices have been developed to assess adherence to desirable diets comprehensively. For example, the Baltic Sea Diet Score (BSDS) has been developed to illustrate a healthy dietary pattern in Nordic countries (10,11) . A higher BSDS has been associated with better periodontal health in adults (12,13) . ...
... Overall diet quality was assessed using BSDS, which is based on foods typically consumed by the general population in the Nordic countries (10) . BSDS was calculated by summing the scores of six components of food consumption and two components of nutrient intake in quartiles of the present population of children, as described earlier (23) . ...
... high-fibre grain products, milk and fish, which are considered protective for dental health (7,9,34,35) , and that diet including these foods tends to restrict the consumption of high-sugar products, such as sweets and ice cream (10) . Although BSDS does not include high-sugar products, a higher BSDS was associated with lower caries experience at baseline and with a decrease in caries experience over 2 years. ...
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We examined cross-sectional and longitudinal associations of dietary factors with caries experience in a population sample of 487 children aged 6–9 years at baseline examinations of the Physical Activity and Nutrition in Children (PANIC) Study. Altogether, 406 of these children attended 2-year follow-up examinations. Food consumption and eating frequency were assessed using 4-day food records, diet quality using the Baltic Sea Diet Score (BSDS), and eating behaviour using the Children’s Eating Behavior Questionnaire. Caries experience was examined clinically. The cross-sectional associations of dietary factors with caries experience at baseline were analysed using linear regression and the longitudinal associations of dietary factors with a change in caries experience over follow-up using generalised mixed-effects regression adjusted for other risk factors. Higher consumption of high-fibre grain products (standardised regression coefficient β = -0.16, p = 0.003), milk (β = -0.11, p = 0.025) and higher BSDS (β = -0.15, p = 0.007) were associated with lower caries experience, whereas higher consumption of potatoes (β = 0.11, p = 0.048) and emotional overeating (β = 0.12, p = 0.025) were associated with higher caries experience. Higher snacking frequency (fixed coefficient β = 0.07, p = 0.033), desire to drink (β = 0.10, p = 0.046), slowness in eating (β = 0.12, p = 0.027), and food fussiness (β = 0.12, p = 0.018) were associated with higher caries experience, whereas enjoyment of food (β = -0.12, p = 0.034) and higher BSDS (β = -0.02, p = 0.051) were associated with lower caries experience.
... The cumulative average of each participant's dietary intake was used to assess the relationship between the Nordic diet and the CVD incidents. The Nordic diet score was calculated using a formerly published method by Kanerva et al. (22). The Nordic diet comprises nine components, including fruit and berries, vegetables, cereals, low-fat milk, sh, meat products, alcohol, total fat, and fat ratio. ...
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Background Although both observational and interventional studies have demonstrated the beneficial effects of the Nordic diet on cardiovascular disease (CVD) risk factors, the association between adherence to this diet and CVD incidents is unknown. Therefore, in the present study, we aimed to investigate the association between adherence to the Nordic diet and the risk of CVD events in non-Nordic adults. Methods In the present cohort study, 2918 participants from the third wave of the Tehran Lipid and Glucose Study (TLGS) were included. All the participants who were free of CVD at baseline were followed up for 10.6 years. The Nordic diet score was assessed by applying a validated food frequency questionnaire (FFQ). Patients’ medical records were used to evaluate cardiovascular events, including coronary heart disease (CHD), stroke, and CVD-related mortality. Results During a median follow-up of 10.6 years, 203 subjects experienced cardiovascular events. Participants in the third and fourth quartiles of the Nordic diet had a 46% (HR: 0.64; 95% CI: 0.44, 0.93) and 58% (HR: 0.48; 95% CI: 0.28 to 0.62) lower risk of CVD than those in the lowest quartile. Among components of the Nordic diet, each score increase in cereals was associated with a 24% (HR: 0.76; 95% CI: 0.67 to 0.87), low-fat milk with a 23% (HR: 0.77; 95% CI: 0.68 to 0.87), and fish with a 22% (HR: 0.78; 95% CI: 0.69 to 0.89) lower risk of CVD. Conclusion We found high adherence to the Nordic diet might be beneficial in the prevention of cardiovascular events in the non-Nordic community. The main components of the Nordic diet that indicated an inverse relationship with CVD were cereals, fish, and low-fat milk.
... The database does not have information on GLA or DGLA content in foods. Healthy Nordic diet score used in the analyses is based on the Baltic Sea diet score [20] but modified slightly to comply with the availability of the dietary data in the KIHD cohort [21]. The score ranges from 0 to 25. ...
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Purpose N-6 polyunsaturated fatty acids (PUFA), particularly linoleic acid (LA), have been associated with lower risk of coronary heart disease (CHD), but little is known about their antiarrhythmic properties. We investigated the association of the serum n-6 PUFAs with the risk of atrial fibrillation (AF), the most common type of cardiac arrhythmia. Methods The study included 2450 men from the Kuopio Ischaemic Heart Disease Risk Factor Study, aged 42–60 years at baseline. The total n-6 PUFA includes linoleic acid (LA), arachidonic acid (AA), γ-linolenic acid (GLA) and dihomo-γ-linolenic acid (DGLA). Cox proportional hazards regression was used to estimate hazard ratio (HR) of incident events. Results During the mean follow-up of 22.4 years, 486 AF cases occurred. The multivariable-adjusted HR in the highest versus the lowest quartile of total serum n-6 PUFA concentration was 0.79 (95% CI 0.58–1.08, P trend = 0.04). When evaluated individually, only serum LA concentration was inversely associated with AF risk (multivariable-adjusted extreme-quartile HR 0.69, 95% CI 0.51–0.94, P trend = 0.02). These associations were stronger among the men without history of CHD or congestive heart failure at baseline, compared to men with such disease history ( P for interaction = 0.05 for total n-6 PUFA and LA). Similar associations were observed with dietary LA and AA intakes. No significant associations were observed with serum AA, GLA or DGLA concentrations. Conclusions Higher circulating concentration and dietary intake of n-6 PUFA, mainly LA, are associated with lower risk of AF, especially among men without history of CHD or congestive heart failure.
... described as dietary patterns with emphasis on foods that have traditionally been used and cultivated in the Nordic region, such as fish, wholegrains like rye and oats, root vegetables, cabbages, fruits like apples and pears, rapeseed oil and, to a varying degree, including low-fat dairy products [1,2]. ...
... We have considered consumption of five traditional Nordic food groups as exposure of interest, selected to reflect components of a healthy Nordic diet [1,2]; Nordic fruits and vegetables (apples/pears, broccoli/cauliflower, cabbage, carrots, swede); fatty fish classified as fish with ≥ 4% fat in the meat (salmon, trout, herring, mackerel); lean fish containing < 4% fat in the meat (cod, haddock, plaice) excluding products like fish cakes, fish balls, fish spread and stew; wholegrain products (wholegrain bread and breakfast cereals); low-fat dairy products (skimmed-and semi-skimmed milk, and yoghurt). We analysed lean and fatty fish separately because they are specified in our dietary guidelines as sources of specific essential nutrients such as vitamin D and omega-3 fatty acids from fatty fish, and iodine from lean fish [21]. ...
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Background The shape of the associations between intake of foods basic in a healthy Nordic diet and long-term health is not well known. Therefore, we have examined all-cause mortality in a large, prospective cohort of women in Norway in relation to intake of: Nordic fruits and vegetables, fatty fish, lean fish, wholegrain products, and low-fat dairy products. Methods A total of 83 669 women who completed a food frequency questionnaire between 1996 and 2004 were followed up for mortality until the end of 2018. Cox proportional hazards regression models were used to examine the associations between consumption of the Nordic food groups and all-cause mortality. The Nordic food groups were examined as categorical exposures, and all but wholegrain products also as continuous exposures in restricted cubic spline models. Results A total of 8 507 women died during the 20-year follow-up period. Nordic fruits and vegetables, fatty fish and low-fat dairy products were observed to be non-linearly associated with all-cause mortality, while higher intake of lean fish and wholegrain products reduced all-cause mortality. Intake levels and hazard ratios (HR) and 95% confidence intervals (CI) associated with lowest mortality were approximately 200 g/day of Nordic fruits and vegetables (HR 0.83 (95% CI: 0.77–0.91)), 10–20 g/day of fatty fish (10 g/day: HR 0.98 (95% CI: 0.94–1.02)) and 200 g/day of low-fat dairy products (HR 0.96 (95% CI: 0.81–1.01)) compared to no consumption. Consumption of fatty fish ≥ 60 g/day compared to no intake statistically significantly increased the mortality (60 g/day: HR 1.08 (95% CI: 1.01–1.16)), as did consumption of low-fat dairy products ≥ 800 g/day compared to no intake (800 g/day: HR 1.10 (95% CI: 1.02–1.20)). After stratification by smoking status, the observed association between Nordic fruits and vegetables and all-cause mortality was stronger in ever smokers. Conclusion The associations between intake of foods basic in healthy Nordic diets and all-cause mortality may be non-linear. Therefore, assumptions of linear associations between traditional Nordic food groups and health outcomes could lead to wrong conclusions in analyses of healthy Nordic diets.
... Overall diet quality was assessed by the mBSDS, an a priori diet score based on healthier food choices of ingredients typically grown and culturally adapted in the Nordic countries (41,42) . ...
... Diverging from the original Baltic Sea Diet Score (42) , total fat intake was excluded from the mBSDS score components as the fat ratio was considered a more important measure for a healthy diet, based on new food recommendations (9,41) . The mBSDS includes eight score components (fruits and berries, vegetables, cereals, low-fat milk, fish, red and processed meat, fat ratio, and alcohol) (Supplementary Table S1). ...
... The mBSDS includes eight score components (fruits and berries, vegetables, cereals, low-fat milk, fish, red and processed meat, fat ratio, and alcohol) (Supplementary Table S1). The component scoring, excluding alcohol, was established Accepted manuscript using sex-specific population consumption quartiles as cut-offs, and points were assigned based on components' perceived health effects (42) . The component points ranged from 0 to 3 according to the consumption quartiles. ...
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Added sugar intake has been associated with several health issues, but few studies have examined its association with overall diet quality. We aimed at examining the association between added sugar intake and overall diet quality in Finnish adults. Associations between added sugar intake and sociodemographic factors, lifestyle factors, and BMI were also explored. Our data comprised 5094 adults residing in Finland who participated in the National FinHealth 2017 Study. Dietary intake was assessed by a validated food frequency questionnaire. Food consumption and nutrient intakes were calculated using the Finnish national food composition database. Added sugar intake was estimated based on food categorization and identifying naturally occurring sugar sources. Overall diet quality was assessed by the modified Baltic Sea Diet Score. The average added sugar intake was 7.6E% in women and 8.3E% in men in this study population. Added sugar intake was inversely associated with education ( P =0.03 women; P =0.001 men), physical activity ( P <0.0001), and BMI in men ( P =0.003), and directly with smoking ( P =0.002 women; P <0.0001 men). Added sugar intake was inversely associated with overall diet quality in both sexes ( P <0.0001). No interactions were found except for men’s physical activity subgroups, the inverse association being stronger among active men than moderately active or inactive men ( P for interaction=0.005). Our findings suggest that high added sugar intake is associated with several unhealthy dietary and lifestyle habits, including poor-quality diets, smoking, and leisure-time inactivity in Finnish adults. Efforts to improve diet quality should consider added sugar intake equally in the whole population.
... Mediterranean diet (MedDiet) [14] Rich in fruits, vegetables, whole grains, olive oil, nuts, legumes; moderate intake of fish and other meat, dairy products and red wine; and low intakes of eggs and sweets Dietary Approach to Stop Hypertension (DASH) [17] Rich in fruits, vegetables, fish, whole grains, nuts and legumes, low-fat dairy products; limited in fats, saturated fat, cholesterol, red and processed meats, sweets and sugar-containing beverages Mediterranean-DASH diet Intervention for Neurodegenerative Delay (MIND) [18] Consists of 10 brain-healthy food groups (green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, seafood, poultry, olive oil, and wine) and 5 unhealthy food groups (red meats, butter and stick margarine, cheese, pastries and sweets, and fried/fast foods) Baltic Sea diet [19] High intakes of total fruits (mostly apples and pears) and berries, vegetables, cereal (rye, oats and barley), fish, low-fat milk, and a high polyunsaturated fatty acid: saturated fatty acid ratio; limit processed meat products, percent energy from fat, and alcohol intake Healthy Eating Index (HEI) [12] Conforms to the serving recommendations of the USDA Food Guide Pyramid for five major food groups: grains, vegetables, fruits, milk, and meat; overall intake of fat, saturated fat, cholesterol, and sodium; and amount of variety in an individual's diet. ...
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Extending healthspan is a major public health challenge. Diet is one of the modifiable factors for preventing age-related diseases and preserving overall good health status during aging. Optimizing individuals’ intrinsic capacity, including domains in cognition, psychological, sensory function, vitality, and locomotion, has been proposed as a model of healthy aging by the World Health Organization. To better understand the relationships between a healthy diet and healthy aging, this review summarizes the recent epidemiologic and clinical data for dietary patterns that have been shown to play a role in (domains of) healthy aging. Regardless of priori or posteriori dietary patterns, it appears that dietary patterns centered on plant-based foods have a beneficial role in (domains of) healthy aging. Our review identified a knowledge gap in dietary patterns and multidimensional concepts of healthy aging. More epidemiological studies should consider intrinsic capacity as an outcome measure to further our understanding of a healthy diet and multidimensional concepts of healthy aging. When a sufficient number of epidemiological studies is available, evidence can be synthesized and clinical trials can be designed to evaluate a healthy diet as a strategy for healthy aging to further our progress in translating evidence to practice and promoting healthy aging.
... The data were entered and processed at the National Institute for Health and Welfare with use of the National Food Consumption Database FINELI (National Institute for Health and Welfare, Helsinki, Finland) [21]. BSDS consists of eight components [22]. For Nordic fruits (apples, pears, and berries), Nordic vegetables (tomatoes, cucumbers, leafy vegetables, roots, cabbages, and peas), Nordic cereals (rye, oat, and barley), Nordic fish (salmon and freshwater fishes), low-fat and fat-free milk, ratio of polyunsaturated fatty acids to saturated fatty acids (SFA) and trans-fatty acids, intake above the sex-specific quartiles served as cut-offs. ...
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A healthy diet reduces risk for high blood pressure. A small body size at birth increases risk for high blood pressure. Our aim was to study whether birth weight modifies the association between a healthy Nordic diet, characterized by high intake of Nordic vegetables, fruits, and berries, whole-grain rye, oat, and barley, and rapeseed oil, and blood pressure. Finnish men and women (n = 960) born in 1934-1944 attended clinical visits including clinical measurements, and questionnaires in 2001-2004 and 2011-2013. Linear regression was applied to investigate the interactions between birth weight and Nordic diet (measured by the Baltic sea diet score (BSDS)) on blood pressure change during the 10-year follow-up. Baseline Nordic diet and birth weight showed a significant interaction on systolic blood pressure (SBP) (p = 0.02), and pulse pressure (PP) (p < 0.01) over a 10-year follow-up. In the lowest birth weight category (women < 2951 g, men < 3061 g), predicted SBP decreased across BSDS thirds (lowest (T1): 155 mmHg, highest (T3): 145 mmHg, p for linearity = 0.01) as did predicted PP (T1: 71 mmHg, T3: 63 mmHg, p < 0.01). In the middle birth weight category, predicted SBP increased across BSDS thirds (T1: 151 mmHg, T3: 155 mmHg, p = 0.02) as did predicted PP (T1: 67 mmHg, T3: 71 mmHg, p < 0.01). In the highest birth weight category, no associations were found. Higher adherence to a healthy Nordic diet was associated with lower SBP and PP in individuals with low birth weight but with higher SBP and PP in those with average birth weight.
... The Mediterranean diet is one example of the diets that have been associated with lower T2D risk [5] but due to cultural and geographical factors adherence to it is relatively poor in Nordic countries [6]. For example, in Finland, Baltic Sea Diet Score was developed to characterize a healthy Nordic diet based on typical Finnish foods and is characterized by high consumption of berries and fruits, whole grains, vegetables, rapeseed oil, fish, low-fat dairy, and low consumption of processed meat and alcohol [7]. ...
... The original Baltic Sea Diet Score consists of nine components, of which six are food groups and three represent nutrients [7]. The food items have been selected based on the traditional food culture in Finland. ...
... Funding Open access funding provided by University of Eastern Finland (UEF) including Kuopio University Hospital. The current study was funded by a personal Grant from Juho Vainio Foundation to H-M Original Baltic Sea Diet Score [7] Score used in the current study Healthy Nordic food index [34] Berries, apples, pears All fruits, berries Fish Tomato, cucumber, cabbage, roots, peas, lettuce Roots, pulses, vegetables Cabbages Rye, oats, barley Whole grains a Whole-grain rye (rye bread) Fat-free milk and milk < 2% fat Fat-free milk and milk < 2% fat Whole-grain oats (oatmeal) Salmon, freshwater fish Salmon, freshwater fish Apples and pears Beef, pork, processed meat products, sausages Processed and unprocessed meat Root vegetables Total fat as a percentage of total energy intake Total fat as a percentage of total energy intake Ratio of PUFA b to SFA c + trans-fatty acids Ratio of PUFA to SFA + trans-fatty acids Ethanol Ethanol ...
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Purpose To investigate the association between healthy Nordic diet and risk of type 2 diabetes (T2D) in middle-aged and older men from eastern Finland. Methods A total of 2332 men aged 42–60 years and free of T2D at baseline in 1984–1989 were included. Diet was assessed with 4-day food records at baseline and the healthy Nordic diet score was calculated based on a modified Baltic Sea Diet Score. T2D diagnosis was based on self-administered questionnaires, fasting and 2-h oral glucose tolerance test blood glucose measurements, or by record linkage to national health registries. Cox proportional hazards regression and analysis of covariance were used for analyses. Results During the mean follow-up of 19.3 years, 432 men (18.5%) were diagnosed with T2D. The multivariable-adjusted hazard ratio for T2D in the lowest vs. the highest quartile of the healthy Nordic diet score was 1.35 (95% CI 1.03–1.76) (P trend across quartiles 0.028). Lower adherence to healthy Nordic diet was also associated with higher plasma glucose and insulin concentrations. Conclusions In this prospective population-based cohort study among middle-aged and older men from eastern Finland, lower adherence to healthy Nordic diet was associated with higher risk of T2D and higher plasma glucose and serum insulin concentrations.
... All the indices were slightly modified from the original ones to be more in line with the current Nordic dietary recommendations 25 . The NDI, consisting of nine dietary components, was originally developed and validated by Kanerva et al. 26 . These components included fruits; vegetables; whole-grain products; low-fat milk; fish; red and processed meat; total fat intake (E%); a ratio of polyunsaturated fatty acids to saturated fatty acids and trans-fatty acids; and alcohol. ...
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There is limited evidence for any dietary factor, except alcohol, in breast cancer (BC) risk. Therefore, studies on a whole diet, using diet quality indices, can broaden our insight. We examined associations of the Nordic Diet (mNDI), Mediterranean diet (mMEDI) and Alternative Healthy Eating Index (mAHEI) with postmenopausal BC risk. Five Finnish cohorts were combined including 6374 postmenopausal women with dietary information. In all, 8–9 dietary components were aggregated in each index, higher total score indicating higher adherence to a healthy diet. Cox proportional hazards regression was used to estimate the combined hazard ratio (HR) and 95% confidence interval (CI) for BC risk. During an average 10-year follow-up period, 274 incident postmenopausal BC cases were diagnosed. In multivariable models, the HR for highest vs. lowest quintile of index was 0.67 (95 %CI 0.48–1.01) for mNDI, 0.88 (0.59–1.30) for mMEDI and 0.89 (0.60–1.32) for mAHEI. In this combined dataset, a borderline preventive finding of high adherence to mNDI on postmenopausal BC risk was found. Of the indices, mNDI was more based on the local food culture than the others. Although a healthy diet has beneficially been related to several chronic diseases, the link with the etiology of postmenopausal BC does not seem to be that obvious.