F AU : Pleasecheckandconfirmwhethertheeditstothearticletitlearecorrect : ood biodiversity and total and caus-specific mortality in 9 European countries : An analysis of a prospective cohort study

Background AU : Pleaseconfirmthatallheadinglevelsarerepresentedcorrectly: Food biodiversity, encomp ssing the vari ty of plants, animals, and other organisms consumed as food and drink, has intrinsic potential to underpin diverse, nutritious diets and improve Earth system resilience. Dietary species richness (DSR), which is recommended as a crosscutting measure of food biodiversity, has been positively associated with the micronutrient adequacy of diets in women and young children in lowand middle-income countries (LMICs). However, the relationships between DSR and major health outcomes have yet to be assessed in any population. Methods and findings We examined the associations between DSR and subsequent total and cause-specific mortality among 451,390 adults enrolled in the European Prospective Investigation into Cancer and Nutrition (EPIC) study (1992 to 2014, median follow-up: 17 years), free of cancer, diabetes, heart attack, or stroke at baseline. Usual dietary intakes were assessed at recruitment with country-specific dietary questionnaires (DQs). DSR of an individual’s yearly diet was calculated based on the absolute number of unique biological species in each (composite) food and drink. Associations were assessed by fitting multivariable-adjusted Cox proportional hazards regression models. In the EPIC cohort, 2 crops (common wheat and potato) and 2 animal species (cow and pig) accounted for approximately 45% of self-reported total dietary energy intake [median (P10–P90): 68 (40 to 83) species consumed per year]. Overall, higher DSR was inversely associated with all-cause mortality rate. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing total mortality in the sAU : PleasenotethatasperPLOSstyle; ordinalsshouldbespelledoutfirstthroughninth; andnumeralsshouldbeusedfor10thandup: econd, third, fourth, and fifth (highest) quintiles (Qs) of DSR to the first (lowest) Q indicate significant inverse associations, after stratification by sex, age, and study center and adjustment for smoking status, educational level, marital status, physical activity, alcohol intake, and total energy intake, Mediterranean diet score, red and processed meat intake, and fiber intake [HR (95% CI): 0.91 (0.88 to 0.94), 0.80 (0.76 to 0.83), 0.69 (0.66 to 0.72), and 0.63 (0.59 to 0.66), respectively; PWald < 0.001 for trend]. Absolute death rates among participants in the highest and lowest fifth of DSR were 65.4 and 69.3 cases/10,000 person-years, respectively. Significant inverse associations were also observed between DSR and deaths due to cancer, heart disease, digestive disease, and respiratory disease. An important study limitation is that our PLOS MEDICINE Food biodiversity and mortality in Europe PLOS Medicine | https://doi.org/10.1371/journal.pmed. 1003834 October 18, 2021 2 / 23 Funding: The coordination of EPIC is financially supported by the European Commission (DGSANCO) and IARC. The national cohorts are supported by Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l’Education Nationale, and Institut National de la Santé et de la Recherche Médicale (Inserm) (France); Deutsche Krebshilfe, Deutsches Krebsforschungszentrum, and Federal Ministry of Education and Research (Germany); the Hellenic Health Foundation (Greece); Associazione Italiana per la Ricerca sul Cancro-IARC-Italy and National Research Council (Italy); Dutch Ministry of Public Health, Welfare, and Sports (VWS), Netherlands Cancer Registry (NKR), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF), and Statistics Netherlands (the Netherlands); Health Research Fund (FIS), PI13/ 00061 to Granada, Regional Governments of Andalusı́a, Asturias, Basque Country, Murcia (no. 6236) and Navarra, and ISCIII RETIC (RD06/0020) (Spain); Swedish Cancer Society, Swedish Scientific Council and County Councils of Skåne and Västerbotten (Sweden); Cancer Research UK (14136 to EPIC-Norfolk; C570/A16491 and C8221/ A19170 to EPIC-Oxford) (United Kingdom). Funding for grant number IIG_FULL_2020_034 was obtained from Wereld Kanker Onderzoek Fonds (WKOF), as part of the World Cancer Research Fund International grant programme (PI: IH, Co-I: GH-C, MD-T, KM, EK-G, MT, PV, CL). Researchers were independent from the funders. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Abbreviations: AU : Themainabbreviationlisthasbeenupdated:Pleaseverifythatallentriesarecorr ct: BMI, body mass ind x; CHD, coronary heart disease; CI, confidence interval; CVD, cardiovascular disease; DQ, dietary questionnaire; DSR, dietary species richness; EPIC, European Prospective Investigation into Cancer and Nutrition; FFQ, food frequency questionnaire; HR, hazard ratio; ICD-10, 10th revision of the International Statistical Classification of Diseases, Injuries, and Causes of Death; LMIC, lowand middle-income country; Q, quintile; SDG, Sustainable Development Goal; STROBE, STrengthening the Reporting of OBservational Studies in Epidemiology; WCRF, World Cancer Research Fund. findings were based on an observational cohort using self-reported dietary data obtained through single baseline food frequency questionnaires (FFQs); thus, exposure misclassification and residual confounding cannot be ruled out.