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Healthy diet indicator and mortality in Eastern European populations: prospective evidence from the HAPIEE cohort



Unhealthy diet has been proposed as one of the main reasons for the high mortality in Central and Eastern Europe (CEE) and the former Soviet Union (FSU) but individual-level effects of dietary habits on health in the region are sparse. We examined the associations between the healthy diet indicator (HDI) and all-cause and cause-specific mortality in three CEE/FSU populations.


Dietary intakes of foods and nutrients, assessed by food frequency questionnaire in the Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) cohort study, were used to construct the HDI, which follows the WHO 2003 dietary recommendations. Among 18 559 eligible adult participants (age range: 45–69 years) without a history of major chronic diseases at baseline, 1209 deaths occurred over a mean follow-up of 7 years. The association between HDI and mortality was estimated by Cox regression.


After adjusting for covariates, HDI was inversely and statistically significantly associated with cardiovascular disease (CVD) and coronary heart disease (CHD) mortality, but not with other cause-specific and all-cause mortality in the pooled sample. Hazard ratios per one standard deviation (s.d.) increase in HDI score were 0.95 (95% confidence interval=0.89–1.00, P=0.068), 0.90 (0.81–0.99, P=0.030) and 0.85 (0.74–0.97, P=0.018) for all-cause, CVD and CHD mortality, respectively. Population attributable risk fractions for low HDI were 2.9% for all-cause, 14.2% for CVD and 10.7% for CHD mortality.


These findings support the hypothesis that unhealthy diet has had a role in the high CVD mortality in Eastern Europe.

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We thank researchers, interviewers and participants in the HAPIEE study from Novosibirsk, Krakow, Kaunas, Havířov/Karviná, Jihlava, Ústí nad Labem, Liberec, Hradec Králové and Kromeříz. The HAPIEE study was funded by the Wellcome Trust (grant numbers 064947 and 81081), the US National Institute of Aging (grant number R01 AG23522) and the MacArthur Foundation Initiative on Social Upheaval and Health. DS was supported by the British Heart Foundation. NJ was supported by the European Community’s Seventh Framework Programme (FP7/2007–2013) under grant agreement no. HEALTH—F3-2010-242244.

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Correspondence to D Stefler.

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Stefler, D., Pikhart, H., Jankovic, N. et al. Healthy diet indicator and mortality in Eastern European populations: prospective evidence from the HAPIEE cohort. Eur J Clin Nutr 68, 1346–1352 (2014).

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