Abstract 25: Adolescent Diet Quality and Primordial Prevention of Cardiovascular Disease in the Nurses’ Health Study II
Authors: Dahm Christina C , Chomistek Andrea K , Jakobsen Marianne U , Mukamal Kenneth J , Eliassen Heather , Overvad Kim , Willett Walter C , Rimm Eric B , Chiuve Stephanie E 
Published: July 2021

Background:
Current clinical practice focuses on primary prevention of CVD through modification of clinical risk factors, such as high cholesterol, hypertension and diabetes. The absence of established risk factors at mid-life is associated with a low long-term risk of CVD. Previously, a healthy lifestyle in young adulthood was associated with a low CVD risk profile at mid-life. Whether a high quality diet in adolescence can prevent development of CVD risk factors in adulthood is unknown.

Methods:
As part of the Nurses’ Health Study II, which included women aged 25-42 at recruitment in 1989, women completed a validated high school food frequency questionnaire, reflecting intake in grades 9-12, in 1998. Diet quality was defined by a modified Alternative Healthy Eating Index (AHEI-hs), where high scores reflect a diet high in fruits, vegetables, whole grains and unsaturated fats and low in red/processed meat, sugar sweetened beverages and trans fat. Physician-diagnosed clinical risk factors (hypertension, high cholesterol, diabetes) were assessed every 2 years. We assessed the relation between the AHEI-hs and time-to-first-development of any risk factor in 28,284 women who were free of diagnosed clinical risk factors in 1998 (mean age 43). We also explored the AHEI-hs in relation to risk of CVD (CHD or ischemic stroke) in 43,721 women who were free from CVD, but not necessarily risk factors, in 1998 (mean age 44). Cox proportional hazards models were adjusted for potential confounders in high school (BMI, energy, smoking, physical activity) and adulthood (smoking, physical activity, oral contraceptives, postmenopausal hormones, aspirin use, energy, alcohol, family history of disease).

Results:
From 1998 through 2011, 11,328 risk factors and 520 CVD events were documented. After adjustment for high school and adult confounders, higher AHEI-hs scores were associated with a lower rate of diagnosed risk factors (HR comparing quartile 4 to 1: 0.84, 95% CI 0.80,0.89, p trend <0.001). Further adjustment for adult diet quality did not alter results appreciably. A higher AHEI-hs was also associated with lower risk of CVD (HR comparing quartile 4 to 1: 0.77, 95% CI 0.60, 0.99, p trend = 0.03), but not after adjustment for adult confounders and adult diet quality (HR 0.98, 95% CI 0.75, 1.27, p trend = 0.85). Compared to women in the lowest tertiles of AHEI scores in high school and adulthood, women in the highest tertiles at both time points had a lower risk of developing a CVD risk factor (HR 0.78, 95% CI 0.73, 0.84) and of CVD (HR: 0.70, 95% CI 0.50, 0.97).

Conclusions:
A high quality diet during adolescence was associated with lower risk of developing clinical CVD risk factors in adulthood, and maintenance of good dietary habits throughout early adulthood was most strongly associated with lower risk of CVD. For ideal cardiovascular health, healthy diet habits should begin in early life and continue through adulthood.