{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:59:38Z","timestamp":1787029178142,"version":"build-2736575974"},"reference-count":36,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2021,10,27]],"date-time":"2021-10-27T00:00:00Z","timestamp":1635292800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Atherosclerotic cardiovascular disease (ACVD) is the leading cause of death worldwide. This study aimed to investigate the association between diet and lifestyle factors, beyond traditional risk factors, and the risk of incident ACVD. The Malm\u00f6 Diet and Cancer study included 30,446 middle-aged individuals. Baseline examinations including a dietary assessment, questionnaire and interviews, were performed between 1991\u20131996. After excluding individuals with prevalent cardiovascular disease and atrial fibrillation or flutter, 26,990 participants remained. In a previously developed diet quality index, adherence to recommended intake of saturated fat (SFA), polyunsaturated fat (PUFA), fish and shellfish, fiber, vegetables and fruit, and sucrose results in one point per dietary component, with a maximum diet score of six points. Diagnosis of incident ACVD was based on validated diagnoses of coronary artery disease, atherothrombotic ischemic stroke, carotid artery disease or peripheral artery disease. Multivariable Cox regression analysis adjusting for established risk factors was performed to assess hazard ratios (HR) with 95% confidence intervals (CI). After a median follow-up of 21.1 years, 5858 (21.7%) individuals diagnosed with ACVD unrelated to atrial fibrillation or flutter were identified. Higher diet score (HR 0.94\/point increase; 95% CI 0.91\u20130.97; p &lt; 0.001), intake of fish and shellfish (HR 0.95\/standard deviation (SD) increment, 95% CI 0.93\u20130.98), fiber (HR 0.93\/SD increment, 95% CI 0.89\u20130.98) and SFA (HR 0.96\/SD increment, 95% CI 0.92\u20130.99) consumption were associated with decreased risk for incident ACVD. High leisure-time physical activity (HR 0.82, 95% CI 0.74\u20130.91) was associated with reduced risk and obesity (HR 1.17, 95% CI 1.08\u20131.27) with increased risk of incident ACVD. The present study strengthens current recommendations of improving diet quality and increasing physical activity in preventing ACVD.<\/jats:p>","DOI":"10.3390\/nu13113822","type":"journal-article","created":{"date-parts":[[2021,10,27]],"date-time":"2021-10-27T23:24:42Z","timestamp":1635377082000},"page":"3822","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":45,"title":["Diet and Lifestyle Factors and Risk of Atherosclerotic Cardiovascular Disease\u2014A Prospective Cohort Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3225-0798","authenticated-orcid":false,"given":"Stefan","family":"Acosta","sequence":"first","affiliation":[{"name":"Department of Clinical Sciences, Lund University, 214 21 Malm\u00f6, Sweden"},{"name":"Vascular Center, Department of Cardiothoracic and Vascular Surgery, Sk\u00e5ne University Hospital, 205 01 Malm\u00f6, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3009-2431","authenticated-orcid":false,"given":"Anna","family":"Johansson","sequence":"additional","affiliation":[{"name":"Department of Clinical Sciences, Lund University, 214 21 Malm\u00f6, Sweden"},{"name":"\u00d6restadskliniken, 217 67 Malm\u00f6, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6500-6310","authenticated-orcid":false,"given":"Isabel","family":"Drake","sequence":"additional","affiliation":[{"name":"Department of Clinical Sciences, Lund University, 214 21 Malm\u00f6, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,10,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e254","DOI":"10.1161\/CIR.0000000000000950","article-title":"Heart disease and stroke statistics-2021 update: A report from the American Heart Association","volume":"143","author":"Virani","year":"2021","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1161\/CIRCULATIONAHA.115.016960","article-title":"Trends in Modifiable Risk Factors Are Associated with Declining Incidence of Hospitalized and Nonhospitalized Acute Coronary Heart Disease in a Population","volume":"133","author":"Mannsverk","year":"2016","journal-title":"Circulation"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2349","DOI":"10.1056\/NEJMoa1605086","article-title":"Genetic risk, adherence to a healthy life style, and coronary disease","volume":"375","author":"Khera","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Dimovski, K., Orho-Melander, M., and Drake, I. (2019). A favorable lifestyle lowers the risk of coronary artery disease consistently across strata of non-modifiable risk factors in a population-based cohort. BMC Public Health, 19.","DOI":"10.1186\/s12889-019-7948-x"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Hlebowicz, J., Drake, I., Gullberg, B., Sonestedt, E., Wallstr\u00f6m, P., Persson, M., Nilsson, J., Hedblad, B., and Wirf\u00e4lt, E. (2013). A high diet quality is associated with lower incidence of cardiovascular events in the Malm\u00f6 diet and cancer cohort. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0071095"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1177\/1358863X19867393","article-title":"Healthy diet and fiber intake are associated with decreased risk of incident symptomatic peripheral artery disease\u2013A prospective cohort study","volume":"24","author":"Kulezic","year":"2019","journal-title":"Vasc. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1159\/000510907","article-title":"Diet and lifestyle as risk factors for carotid artery disease: A prospective cohort study","volume":"49","author":"Johansson","year":"2020","journal-title":"Cereb. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Johansson, A., Drake, I., Engstr\u00f6m, G., and Acosta, S. (2021). Modifiable and non-modifiable risk factors for atherothrombotic ischemic stroke among subjects in the Malm\u00f6 Diet and Cancer Study. Nutrients, 13.","DOI":"10.3390\/nu13061952"},{"key":"ref_9","unstructured":"Malm\u00f6 Kost Cancer och Malm\u00f6 F\u00f6rebyggande Medicin (2021, October 01). Lund: Lund University; updated 11 November 2019; cited 18 May 2020. Available online: https:\/\/www.malmo-kohorter.lu.se\/malmo-kost-cancer-mkc."},{"key":"ref_10","unstructured":"Tetens, I., Pedersen, A.N., Schwab, U., Fogelholm, M., Thorsdottir, I., Gunnarsdottir, I., Anderssen, S., M\u00f6ltzer, H., Becker, W., and Hursti, U.-K. (2014). Nordic Nutrition Recommendations, Nordic Council of Ministers. Report."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1017\/S1368980010003848","article-title":"Development of a diet quality index assessing adherence to the Swedish nutrition recommendations and dietary guidelines in the Malmo Diet and Cancer cohort","volume":"14","author":"Drake","year":"2011","journal-title":"Public Health Nutr."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1016\/0021-9681(78)90058-9","article-title":"A questionnaire for the assessment of leisure time physical activities","volume":"31","author":"Taylor","year":"1978","journal-title":"J. Chron. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1867","DOI":"10.1001\/jama.292.15.1867","article-title":"Oral antiplatelet therapy in cerebrovascular disease, coronary artery disease and peripheral arterial disease","volume":"292","author":"Tran","year":"2004","journal-title":"JAMA"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"394","DOI":"10.1177\/2047487319869400","article-title":"Lifestyle factors and high-risk atherosclerosis: Pathways and mechanisms beyond traditional risk factors","volume":"27","author":"Lechner","year":"2020","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1038\/s41569-019-0206-1","article-title":"Dietary fats and cardiometabolic disease: Mechanisms and effects on risk factors and outcomes","volume":"16","author":"Wu","year":"2019","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e34","DOI":"10.1056\/NEJMoa1800389","article-title":"Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts","volume":"378","author":"Estruch","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"925","DOI":"10.2459\/JCM.0000000000000573","article-title":"Mediterranean diet impact on cardiovascular diseases: A narrative review","volume":"18","author":"Matttioli","year":"2017","journal-title":"J. Cardiovasc. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1017\/S0954422416000147","article-title":"Nutritional management of hyperapoB","volume":"29","author":"Lamantia","year":"2016","journal-title":"Nutr. Res. Rev."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1177\/2042018819890532","article-title":"The association between dietary intake, lifestyle and incident symptomatic peripheral arterial disease among individuals with diabetes mellitus: Insights from the Malm\u00f6 Diet and Cancer Study","volume":"10","author":"Lilja","year":"2019","journal-title":"Ther. Adv. Endocrinol. Metabol."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Look AHEAD Research Group, Wing, R.R., Bolin, P., Brancati, F.L., Bray, G.A., Clark, J.M., and Coday, M. (2013). Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N. Engl. J. Med., 369, 145\u2013154.","DOI":"10.1056\/NEJMoa1212914"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Soliman, G.A. (2019). Dietary fiber, atherosclerosis, and cardiovascular disease. Nutrients, 11.","DOI":"10.3390\/nu11051155"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.acvd.2015.09.005","article-title":"Dietary fibre intake and mortality from cardiovascular disease and all cancers: A meta-analysis of prospective cohort studies","volume":"109","author":"Kim","year":"2016","journal-title":"Arch. Cardiovasc. Dis."},{"key":"ref_23","first-page":"CD011472","article-title":"Dietary fibre for the primary prevention of cardiovascular disease","volume":"1","author":"Hartley","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Wallstr\u00f6m, P., Sonestedt, E., Hlebowicz, J., Ericson, U., Drake, I., Persson, M., Gullberg, B., Hedblad, B., and Wirf\u00e4lt, E. (2012). Dietary fiber and saturated fat intake associations with cardiovascular disease differ by sex in the Malm\u00f6 Diet and Cancer cohort: A prospective study. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0031637"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"397","DOI":"10.3945\/ajcn.112.037770","article-title":"Dietary intake of saturated fat by food source and incident cardiovascular disease: The multi-ethnic study of atherosclerosis","volume":"96","author":"Mozaffarian","year":"2012","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1079\/PHN2003474","article-title":"Dietary fat intake\u2014Food sources and dietary correlates in the Malm\u00f6 Diet and Cancer cohort","volume":"6","author":"Mattisson","year":"2003","journal-title":"Public Heal. Nutr."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1017\/S000711451400124X","article-title":"Association between total, processed, red and white meat consumption and all-cause, CVD and IHD mortality: A meta-analysis of cohort studies","volume":"112","author":"Abete","year":"2014","journal-title":"Br. J. Nutr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2271","DOI":"10.1161\/CIRCULATIONAHA.109.924977","article-title":"Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: A systematic review and meta-analysis","volume":"121","author":"Micha","year":"2010","journal-title":"Circulation"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1017\/S1368980015002062","article-title":"Red and processed meat consumption and mortality: Dose\u2013response meta-analysis of prospective cohort studies","volume":"19","author":"Wang","year":"2015","journal-title":"Public Health Nutr."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1007\/s11883-012-0282-8","article-title":"Unprocessed red and processed meats and risk of coronary artery disease and type 2 diabetes\u2013an updated review of the evidence","volume":"14","author":"Micha","year":"2012","journal-title":"Curr. Atheroscler. Rep."},{"key":"ref_31","unstructured":"Mensink, R.P. (2016). Effects of Saturated Fatty Acids on Serum Lipids and Lipoporoteins: A Systematic Review and Regression Analysis, WHO."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1094","DOI":"10.1016\/j.jacc.2018.01.011","article-title":"Sustained physical activity, not weight loss, associated with improved survival in coronary heart disease","volume":"71","author":"Moholdt","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1371","DOI":"10.1136\/bjsports-2018-099093","article-title":"Dose-response associations of cardiorespiratory fitness with all-cause mortality and incidence and mortality of cancer and cardiovascular and respiratory diseases: The UK Biobank cohort study","volume":"53","author":"Steell","year":"2019","journal-title":"Br. J. Sports Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2315","DOI":"10.1093\/eurheartj\/ehw106","article-title":"2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)","volume":"37","author":"Piepoli","year":"2016","journal-title":"Eur. Heart J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1097\/00008469-200112000-00003","article-title":"The Malm\u00f6 Diet and cancer Study: Representativity, cancer incidence and mortality in participants and non-participants","volume":"10","author":"Manjer","year":"2001","journal-title":"Eur. J. Cancer Prev."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1007\/s10654-009-9404-1","article-title":"Atrial fibrillation in the Malm\u00f6 Diet and Cancer study: A study of occurrence, risk factors and diagnostic validity","volume":"25","author":"Smith","year":"2010","journal-title":"Eur. J. Epidemiol."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/13\/11\/3822\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:21:11Z","timestamp":1760167271000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/13\/11\/3822"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,10,27]]},"references-count":36,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["nu13113822"],"URL":"https:\/\/doi.org\/10.3390\/nu13113822","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,10,27]]}}}