Operational Differences in Plant-Based Diet Indices Affect the Ability to Detect Associations with Incident Hypertension in Middle-Aged US Adults

Hyunju Kim, Casey M. Rebholz, Vanessa Garcia-Larsen, Lyn M. Steffen, Josef Coresh, Laura E. Caulfield

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


BACKGROUND: Several distinct plant-based diet indices (PDIs) have been developed to characterize adherence to plant-based diets.

OBJECTIVE: We contrasted 5 PDIs in a community-based cohort by assessing characteristics of the diet and evaluating whether these PDIs are associated with risk of incident hypertension.

METHODS: Using FFQ data from adults (45-64 y, n = 8041) without hypertension at baseline in the Atherosclerosis Risk in Communities (ARIC) Study, we scored participants' diets using the overall PDI (oPDI), healthy PDI (hPDI), less healthy (unhealthy) PDI (uPDI), provegetarian diet index, and PDI from the Rotterdam Study (PDI-Rotterdam). For the oPDI, provegetarian diet, and PDI-Rotterdam, higher intakes of all or selected plant foods received higher scores. For the hPDI, higher intakes of plant foods identified as healthful received higher scores. For the uPDI, higher intakes of less healthy plant foods received higher scores. All indices scored higher intakes of animal foods lower. We examined agreement between indices, and whether scores on these indices were associated with risk of hypertension using Cox proportional hazard models.

RESULTS: The PDIs were moderately-to-strongly correlated and largely ranked subjects consistently, except for the uPDI. Over a median follow-up of 13 y, 6044 incident hypertension cases occurred. When adjusted for sociodemographic characteristics, other dietary factors, and health behaviors, the highest compared with the lowest quintile for adherence to the oPDI, hPDI, and provegetarian diet was associated with a 12-16% lower risk of hypertension (all P-trend <0.05). Highest adherence to the uPDI was associated with a 13% higher risk of hypertension, when clinical factors were further adjusted for (P-trend = 0.03). No significant association was observed with the PDI-Rotterdam. The oPDI, hPDI, and provegetarian diet moderately improved the prediction of hypertension.

CONCLUSIONS: In middle-aged US adults, despite moderate agreement in ranking subjects across PDIs, operational differences can affect the ability to detect diet-disease associations, such as hypertension.

Original languageEnglish (US)
Pages (from-to)842-850
Number of pages9
JournalJournal of Nutrition
Issue number4
StatePublished - Apr 1 2020

Bibliographical note

Funding Information:
The Atherosclerosis Risk in Communities Study was supported by National Heart, Lung, and Blood Institute (NHLBI), NIH, Department of Health and Human Services awards HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700004I, and HHSN268201700005I (to JC). HK was supported by the Department of International Health Tuition Scholarship, Bacon Chow Endowed Award, Harry D Kruse Fellowship, Harry J Prebluda Fellowship, and the Richard and Barbara Hall Student Award from the Program in Human Nutrition in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. CMR was supported by National Institute of Diabetes and Digestive and Kidney Diseases Mentored Research Scientist Development Award K01 DK107782 and NHLBI grant R21 HL143089. Author disclosures: The authors report no conflicts of interest. The funding agencies had no role in study design, data collection, analysis, drafting of the manuscript, and the decision to submit this manuscript for publication. Supplemental Tables 1–5 and Supplemental Figures 1–3 are available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/jn/. In the Supplementary data, oPDI is labeled PDI. Address correspondence to LEC (e-mail: lcaulfi1@jhu.edu). Abbreviations used: ARIC, Atherosclerosis Risk in Communities; DASH, Dietary Approaches to Stop Hypertension; hPDI, healthy plant-based diet index; oPDI, overall plant-based diet index; PDI, plant-based diet index; PDI-Rotterdam, plant-based diet index from the Rotterdam Study; SSB, sugar-sweetened beverage; uPDI, less healthy (unhealthy) plant-based diet index.

Publisher Copyright:
Copyright © The Author(s) 2019.


  • Adults
  • Comparison
  • Diet indices
  • Hypertension
  • Plant-based diets
  • United States
  • Humans
  • Middle Aged
  • Hypertension/epidemiology
  • Male
  • Diet, Vegetarian
  • Food Analysis
  • Female
  • Nutritional Status
  • Cohort Studies

PubMed: MeSH publication types

  • Research Support, Non-U.S. Gov't
  • Journal Article
  • Research Support, N.I.H., Extramural


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