From dietary guidelines to cardiovascular impacts: a national target trial emulation with an equity lens
1
Food, Nutrition and Health Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, Canada
2
Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
Popul. Med. 2026;8(Supplement Supplement 1):A2947
ABSTRACT
BACKGROUND:
Dietary guidelines translate nutrition science into practical recommendations to prevent chronic diseases[1,2], yet policymakers lack causal, population-level evidence on whether improving diets in line with guidelines yields measurable cardiovascular benefits, especially for people facing socioeconomic disadvantage. We estimated the causal effects of improving alignment with Canada’s Food Guide[3,4] on incident cardiovascular disease (CVD) using universal, equity-targeted, and food-component strategies.
METHODS:
We analyzed 12325 adults aged 20 years and older from the nationally representative Canadian Community Health Survey-Nutrition 2004[5], linked to hospitalization and mortality records through 2017[6,7]. Food Guide alignment was assessed using the Healthy Eating Food Index-2019 [8]. Using a target trial emulation framework[9,10], we fit weighted pooled logistic regression models with stabilized inverse-probability weights to estimate 5- and 13-year CVD risk under counterfactual scenarios: (1) universal population-wide improvements to prespecified alignment levels; (2) equity-targeted improvements among socioeconomically disadvantaged groups (low income, food insecurity, low education, high neighborhood deprivation), evaluated among adults aged 45–80 years; and (3) food-component changes (fruit and vegetables, sodium, plant-based protein).
RESULTS:
In counterfactual analyses, neither universal strategies to improve overall alignment nor equity-targeted strategies produced statistically significant reductions in CVD risk at 5 or 13 years, despite dose–response patterns in cumulative incidence curves. In contrast, increasing fruit and vegetable intake from ~25% to 38% of total foods consumed (equal to two extra daily reference amounts) was associated with a 48% lower 13-year CVD risk in the total population (relative risk 0.52; 95% confidence interval 0.31–0.88), even though remained below the guideline benchmark of 50%. No risk reduction was observed under sodium reduction and improved plant-based protein strategies.
CONCLUSIONS:
Universal and equity-targeted strategies to improve alignment with Canada’s Food Guide were not associated with statistically detectable population-level CVD reductions. However, realistic increases in fruit and vegetable intake showed substantial benefits without reaching full guideline targets.
Dietary guidelines translate nutrition science into practical recommendations to prevent chronic diseases[1,2], yet policymakers lack causal, population-level evidence on whether improving diets in line with guidelines yields measurable cardiovascular benefits, especially for people facing socioeconomic disadvantage. We estimated the causal effects of improving alignment with Canada’s Food Guide[3,4] on incident cardiovascular disease (CVD) using universal, equity-targeted, and food-component strategies.
METHODS:
We analyzed 12325 adults aged 20 years and older from the nationally representative Canadian Community Health Survey-Nutrition 2004[5], linked to hospitalization and mortality records through 2017[6,7]. Food Guide alignment was assessed using the Healthy Eating Food Index-2019 [8]. Using a target trial emulation framework[9,10], we fit weighted pooled logistic regression models with stabilized inverse-probability weights to estimate 5- and 13-year CVD risk under counterfactual scenarios: (1) universal population-wide improvements to prespecified alignment levels; (2) equity-targeted improvements among socioeconomically disadvantaged groups (low income, food insecurity, low education, high neighborhood deprivation), evaluated among adults aged 45–80 years; and (3) food-component changes (fruit and vegetables, sodium, plant-based protein).
RESULTS:
In counterfactual analyses, neither universal strategies to improve overall alignment nor equity-targeted strategies produced statistically significant reductions in CVD risk at 5 or 13 years, despite dose–response patterns in cumulative incidence curves. In contrast, increasing fruit and vegetable intake from ~25% to 38% of total foods consumed (equal to two extra daily reference amounts) was associated with a 48% lower 13-year CVD risk in the total population (relative risk 0.52; 95% confidence interval 0.31–0.88), even though remained below the guideline benchmark of 50%. No risk reduction was observed under sodium reduction and improved plant-based protein strategies.
CONCLUSIONS:
Universal and equity-targeted strategies to improve alignment with Canada’s Food Guide were not associated with statistically detectable population-level CVD reductions. However, realistic increases in fruit and vegetable intake showed substantial benefits without reaching full guideline targets.
| eISSN: | 2654-1459 |
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