ABSTRACT: 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 Malmö Diet and Cancer study included 30,446 middle-aged individuals. Baseline examinations including a dietary assessment, questionnaire and interviews, were performed between 1991-1996. 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 0.91-0.97; p < 0.001), intake of fish and shellfish (HR 0.95/standard deviation (SD) increment, 95% CI 0.93-0.98), fiber (HR 0.93/SD increment, 95% CI 0.89-0.98) and SFA (HR 0.96/SD increment, 95% CI 0.92-0.99) consumption were associated with decreased risk for incident ACVD. High leisure-time physical activity (HR 0.82, 95% CI 0.74-0.91) was associated with reduced risk and obesity (HR 1.17, 95% CI 1.08-1.27) with increased risk of incident ACVD. The present study strengthens current recommendations of improving diet quality and increasing physical activity in preventing ACVD.
