Plant-based diets and incident metabolic syndrome: Results from a South Korean prospective cohort study

Author summary Why was this study done? Plant-based diets have been associated with lower risk of cardiovascular risk factors and incident cardiovascular disease, but risks have differed by healthiness of plant-based diets. No data are available on how different types of plant-based diets are associated with risk of metabolic syndrome (MetS), which is strongly predictive of chronic diseases such as type 2 diabetes, cardiovascular disease, and shorter life span. Limited evidence is available in Asian populations, who have different dietary patterns than Western populations. What did the researchers do and find? We followed 5,646 South Korean middle-aged and older adults who provided data on their usual dietary intake, medical history, health behaviors, anthropometrics, blood samples for laboratory analyses, and diagnosis of health outcomes for 8 years (maximum of 14 years). South Korean adults who consumed diets high in less-healthy plant foods (refined grains, sugars, salty foods) and low in healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, tea and coffee) and animal foods (animal fat, dairy, eggs, fish/seafood, meat, miscellaneous animal foods) had 50% higher risk of developing MetS. Such less-healthy plant-based diets were associated with 4 out of 5 components of MetS, including abdominal obesity, hypertriglyceridemia, low high-density lipoprotein (HDL), and elevated blood pressure. What do these findings mean? Plant-based diets high in less-healthy plant foods and low in healthy plant foods have an adverse association with MetS. In an Asian population that has habitually consumed a diet rich in plant foods for a long period of time, it may be important to consider the quality of plant foods for prevention of MetS. Background Prior studies have shown that plant-based diets are associated with lower risk of cardiovascular risk factors and incident cardiovascular disease, but risks differed by quality of plant-based diets. No prospective studies have evaluated the associations between different types of plant-based diets and incident metabolic syndrome (MetS) and components of MetS. Furthermore, limited evidence exists in Asian populations who have habitually consumed a diet rich in plant foods for a long period of time. Methods and findings Analyses were based on a community-based cohort of 5,646 men and women (40-69 years of age at baseline) living in Ansan and Ansung, South Korea (2001-2016) without MetS and related chronic diseases at baseline. Dietary intake was assessed using a validated food frequency questionnaire. Using the responses in the questionnaire, we calculated 4 plant-based diet indices (overall plant-based diet index [PDI], healthful plant-based diet index [hPDI], unhealthful plant-based diet index [uPDI], and pro-vegetarian diet index). Higher PDI score represented greater consumption of all types of plant foods regardless of healthiness. Higher hPDI score represented greater consumption of healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, tea and coffee) and lower consumption of less-healthy plant foods (refined grains, potatoes, sugar-sweetened beverages, sweets, salty foods). Higher uPDI represented lower consumption of healthy plant foods and greater consumption of less-healthy plant foods. Similar to PDI, higher pro-vegetarian diet score represented greater consumption of plant foods but included only selected plant foods (grains, fruits, vegetables, nuts, legumes, potatoes). Higher scores in all plant-based diet indices represented lower consumption of animal foods (animal fat, dairy, eggs, fish/seafood, meat). Over a median follow-up of 8 years, 2,583 participants developed incident MetS. Individuals in the highest versus lowest quintile of uPDI had 50% higher risk of developing incident MetS, adjusting for demographic characteristics and lifestyle factors (hazard ratio [HR]: 1.50, 95% CI 1.31-1.71, P-trend < 0.001). When we further adjusted for body mass index (BMI), those in the highest quintile of uPDI had 24%-46% higher risk of 4 out of 5 individual components of MetS (abdominal obesity, hypertriglyceridemia, low high-density lipoprotein [HDL], and elevated blood pressure) (P-trend for all tests <= 0.001). Greater adherence to PDI was associated with lower risk of elevated fasting glucose (HR: 0.80, 95% CI 0.70-0.92, P-trend = 0.003). No consistent associations were observed for other plant-based diet indices and MetS. Limitations of the study may include potential measurement error in self-reported dietary intake, inability to classify a few plant foods as healthy and less-healthy, lack of data on vegetable oil intake, and possibility of residual confounding. Conclusions In this study, we observed that greater adherence to diets consisting of a high intake of refined carbohydrates, sugars, and salty foods in the framework of plant-based diets was associated with an elevated risk of MetS. These results suggest that considering the quality of plant foods is important for prevention of MetS in a population that habitually consumes plant foods.