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To examine the associations of animal and plant protein intake with all-cause, cardiovascular and cancer mortality risk in middle-aged Italian men and women with substantially lower animal protein intake than North Americans. Food consumption was assessed by validated Epic semiquantitative FFQs. Multivariable Cox models stratified by center, age, and sex, and adjusted for confounders, estimated associations of animal and plant protein consumption with mortality for all causes, cardiovascular disease, and cancer. After a median follow-up of 15.2 years, 2,449 deaths were identified in 45,009 participants. No significant association between intake of total, animal or plant protein and mortality was found in the fully adjusted models. Substitution of plant protein for animal protein was inversely associated with cardiovascular mortality (HR, 0.47; 95% CI, 0.24–0.92) only in people with at least 1 unhealthy lifestyle risk factor and poor adherence to a Mediterranean diet. Participants in the highest quintile group of animal protein intake had higher glucose, total and LDL cholesterol levels than those in the lowest quintile. In contrast, higher plant protein intake was negatively associated with fasting insulin and cholesterol, despite higher BMI, physical inactivity and starch consumption. Replacing plant protein for animal protein was associated with lower cardiovascular mortality among individuals with unhealthy lifestyle risk factors. High animal but not plant protein intake is associated with impaired fasting glucose and hypercholesterolemia, despite lower calorie and carbohydrate intake, suggesting that protein source plays crucial roles in modulating cardiometabolic health independently of body weight.

Fatty acid levels in plasma phospholipids were related to food intake over the previous year as estimated by semiquantitative food frequency questionnaires compiled by 280 men and 246 women from the EPIC centers of Varese, Turin, Florence and Ragusa (Italy). Fatty acid content was determined by gas chromatography and analyzed in relation to age, sex and center. The most important finding was that plasma monounsaturated fatty acid levels, mainly oleic acid, were associated with olive oil consumption (r = 0.28 men, r = 0.19 women, both P <0.01). To our knowledge, this is the first time that these nonessential plasma fatty acids have been related to their dietary source in a population eating a varied and freely chosen diet. We confirmed that long-chain n-3 fatty acids in plasma phospholipids are associated with fish consumption and that odd chain 15: 0 and 17: 0 fatty acid levels are associated with dairy products and pizza-with-mozzarella consumption. N-6 polyunsaturated fatty acid levels reflected dietary intake of seed oils, mayonnaise and biscuits. Alcohol intake was positively associated with palmitic and palmitoleic acid and negatively associated with linoleic acid. These associations suggest indirect relations between alcohol consumption and other features of diet, and also that ethanol has an effect on fat metabolism. We found numerous indirect relationships (ie, not due to dietary consumption of food sources of the fatty acids) between plasma fatty acids and diet, which we propose as due to the influence of complex life-style factors.

ObjectiveTo determine if the Food Standards Agency nutrient profiling system (FSAm-NPS), which grades the nutritional quality of food products and is used to derive the Nutri-Score front-of-packet label to guide consumers towards healthier food choices, is associated with mortality.DesignPopulation based cohort study.SettingEuropean Prospective Investigation into Cancer and Nutrition (EPIC) cohort from 23 centres in 10 European countries.Participants521 324 adults; at recruitment, country specific and validated dietary questionnaires were used to assess their usual dietary intakes. A FSAm-NPS score was calculated for each food item per 100 g content of energy, sugars, saturated fatty acids, sodium, fibre, and protein, and of fruit, vegetables, legumes, and nuts. The FSAm-NPS dietary index was calculated for each participant as an energy weighted mean of the FSAm-NPS score of all foods consumed. The higher the score the lower the overall nutritional quality of the diet.Main outcome measureAssociations between the FSAm-NPS dietary index score and mortality, assessed using multivariable adjusted Cox proportional hazards regression models.ResultsAfter exclusions, 501 594 adults (median follow-up 17.2 years, 8 162 730 person years) were included in the analyses. Those with a higher FSAm-NPS dietary index score (highest versus lowest fifth) showed an increased risk of all cause mortality (n=53 112 events from non-external causes; hazard ratio 1.07, 95% confidence interval 1.03 to 1.10, P<0.001 for trend) and mortality from cancer (1.08, 1.03 to 1.13, P<0.001 for trend) and diseases of the circulatory (1.04, 0.98 to 1.11, P=0.06 for trend), respiratory (1.39, 1.22 to 1.59, P<0.001), and digestive (1.22, 1.02 to 1.45, P=0.03 for trend) systems. The age standardised absolute rates for all cause mortality per 10 000 persons over 10 years were 760 (men=1237; women=563) for those in the highest fifth of the FSAm-NPS dietary index score and 661 (men=1008; women=518) for those in the lowest fifth.ConclusionsIn this large multinational European cohort, consuming foods with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher mortality for all causes and for cancer and diseases of the circulatory, respiratory, and digestive systems, supporting the relevance of FSAm-NPS to characterise healthier food choices in the context of public health policies (eg, the Nutri-Score) for European populations. This is important considering ongoing discussions about the potential implementation of a unique nutrition labelling system at the European Union level.