Association of Meal and Snack Patterns With Mortality of All-Cause, Cardiovascular Disease, and Cancer: The US National Health and Nutrition Examination Survey, 2003 to 2014

Impact of health practice index and cardiovascular health metrics on incident cardiovascular disease according to glucose tolerance status

Aims

To evaluate and compare the association of incident cardiovascular disease (CVD) with the Health Practice Index (HPI) reflecting only lifestyle habits and Ideal Cardiovascular Health Metrics (ICVHMs) consisting of lifestyle habits and factors targeted for control in the same population according to glucose status.

Methods

This retrospective cohort study included 1,28,162 participants aged 18-72 years with no history of CVD followed for ≥ 3 years between 2008 and 2016. Participants were classified according to normal glucose tolerance (86,174), prediabetes (36,096), or diabetes (5892). HPI and ICVHMs scores were classified into three groups (high/medium/low). Multivariate Cox regression hazard analysis examined CVD risk.

Results

During a mean follow-up of 5.2 years, 1057 CVD events occurred. In prediabetes, CVD risk was significantly higher in groups with both medium and low HPI scores and ICVHMs scores compared to high scores for normal glucose tolerance (hazard ratios [HRs] for high/medium/low HPI scores were 0.95 [0.78-1.17], 1.56 [1.29-1.89], and 2.41 [1.74-3.34] and for ICVHMs scores were 0.74 [0.50-1.11], 1.58 [1.26-1.98], and 2.63 [2.10-3.31], respectively). Regarding diabetes, compared with high HPI/ICVHMs scores in the normal glucose tolerance group, a significantly increased CVD risk was observed in the high-score HPI group, but not in the high-score ICVHMs group (HPI high/medium/low HR, 1.63 [1.22-2.18], 2.19 [1.69-2.83], and 2.26 [1.34 -3.83]; ICVHMs high/medium/low HR, 1.14 [0.47-2.81], 2.38 [1.75-3.23], and 3.31 [2.50-4.38], respectively).

Conclusions

In diabetes, ideal lifestyle practices alone were insufficient for primary prevention of CVD but had a greater impact on primary prevention of CVD in prediabetes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-024-00708-7.

Relationship between circadian eating behavior (daily eating frequency and nighttime fasting duration) and cardiovascular mortality

BACKGROUND

Knowledge regarding the health impacts of daily eating frequency (DEF) and nighttime fasting duration (NFD) on mortality is very limited.

OBJECTIVE

This study aimed to examine whether DEF and NFD are associated with CVD and all-cause mortality.

METHODS

This was a prospective cohort study of a nationally representative sample from the United States, including 30,464 adults who participated in the National Health and Nutrition Examination Survey 2003-2014. Using 24-h dietary recall, DEF was assessed by the number of eating episodes, and NFD was calculated by the first and last eating time across a day. Death information was obtained from the National Death Index up to 2019. Weighted Cox proportional hazards regression models were used to assess survival relationships of DEF and NFD with mortality.

RESULTS

During 307,686 person-years of follow-up, 4560 deaths occurred, including 1824 CVD cases. After adjustment for confounders, compared to DEF at 4-6 times, participants whose DEF was less than 3 times had greater CVD [hazard-ratio (HR) = 1.33, 95% confidence-interval (CI): 1.06-1.67] and all-cause (HR = 1.16, 95% CI: 1.01-1.33) mortality risks. Furthermore, compared to NFD of 10 to 11 h, participants whose NFD was shorter than 10 h had HRs of 1.30 (95% CI: 1.08-1.55) for CVD mortality and 1.23 (95% CI: 1.08-1.39) for all-cause mortality. NFD longer than 14 h was also related to CVD mortality (HR = 1.37, 95% CI: 1.12-1.67) and all-cause mortality (HR = 1.36, 95% CI: 1.19-1.54). Similar results for the association of NFD and DEF with heart-specific and stroke-specific mortality were observed.

CONCLUSION

This study found that DEF less than 3 times and NFD shorter than 10 h or longer than 14 h were independently associated with greater cardiovascular and all-cause mortality.

Mediterranean lifestyle index and 24-h systolic blood pressure and heart rate in community-dwelling older adults

Specific foods, nutrients, dietary patterns, and physical activity are associated with lower blood pressure (BP) and heart rate (HR), but little is known about the joint effect of lifestyle factors captured in a multidimensional score. We assessed the association of a validated Mediterranean-lifestyle (MEDLIFE) index with 24-h-ambulatory BP and HR in everyday life among community-living older adults. Data were taken from 2,184 individuals (51% females, mean age: 71.4 years) from the Seniors-ENRICA-2 cohort. The MEDLIFE index consisted of 29 items arranged in three blocks: 1) Food consumption; 2) Dietary habits; and 3) Physical activity, rest, and conviviality. A higher MEDLIFE score (0-29 points) represented a better Mediterranean lifestyle adherence. 24-h-ambulatory BP and HR were obtained with validated oscillometric devices. Analyses were performed with linear regression adjusted for the main confounders. The MEDLIFE-highest quintile (vs Q1) was associated with lower nighttime systolic BP (SBP) (-3.17 mmHg [95% CI: -5.25, -1.08]; p-trend = 0.011), greater nocturnal-SBP fall (1.67% [0.51, 2.83]; p-trend = 0.052), and lower HR (-2.04 bpm [daytime], -2.33 bpm [nighttime], and -1.93 bpm [24-h]; all p-trend < 0.001). Results were similar for each of the three blocks of MEDLIFE and by hypertension status (yes/no). Among older adults, higher adherence to MEDLIFE was associated with lower nighttime SBP, greater nocturnal-SBP fall, and lower HR in their everyday life. These results suggest a synergistic BP-related protection from the components of the Mediterranean lifestyle. Future studies should determine whether these results replicate in older adults from other Mediterranean and non-Mediterranean countries.

Snack quality and snack timing are associated with cardiometabolic blood markers: the ZOE PREDICT study

BACKGROUND

Snacking is a common diet behaviour which accounts for a large proportion of daily energy intake, making it a key determinant of diet quality. However, the relationship between snacking frequency, quality and timing with cardiometabolic health remains unclear.

DESIGN

Demography, diet, health (fasting and postprandial cardiometabolic blood and anthropometrics markers) and stool metagenomics data were assessed in the UK PREDICT 1 cohort (N = 1002) (NCT03479866). Snacks (foods or drinks consumed between main meals) were self-reported (weighed records) across 2-4 days. Average snacking frequency and quality [snack diet index (SDI)] were determined (N = 854 after exclusions). Associations between snacking frequency, quality and timing with cardiometabolic blood and anthropometric markers were assessed using regression models (adjusted for age, sex, BMI, education, physical activity level and main meal quality).

RESULTS

Participants were aged (mean, SD) 46.1 ± 11.9 years, had a mean BMI of 25.6 ± 4.88 kg/m2 and were predominantly female (73%). 95% of participants were snackers (≥ 1 snack/day; n = 813); mean daily snack intake was 2.28 snacks/day (24 ± 16% of daily calories; 203 ± 170 kcal); and 44% of participants were discordant for meal and snack quality. In snackers, overall snacking frequency and quantity of snack energy were not associated with cardiometabolic risk markers. However, lower snack quality (SDI range 1-11) was associated with higher blood markers, including elevated fasting triglycerides (TG (mmol/L) β; - 0.02, P = 0.02), postprandial TGs (6hiAUC (mmol/L.s); β; - 400, P = 0.01), fasting insulin (mIU/L) (β; - 0.15, P = 0.04), insulin resistance (HOMA-IR; β; - 0.04, P = 0.04) and hunger (scale 0-100) (β; - 0.52, P = 0.02) (P values non-significant after multiple testing adjustments). Late-evening snacking (≥ 9 pm; 31%) was associated with lower blood markers (HbA1c; 5.54 ± 0.42% vs 5.46 ± 0.28%, glucose 2hiAUC; 8212 ± 5559 vs 7321 ± 4928 mmol/L.s, P = 0.01 and TG 6hiAUC; 11,638 ± 8166 vs 9781 ± 6997 mmol/L.s, P = 0.01) compared to all other snacking times (HbA1c remained significant after multiple testing).

CONCLUSION

Snack quality and timing of consumption are simple diet features which may be targeted to improve diet quality, with potential health benefits.

CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE

NCT03479866, https://clinicaltrials.gov/ct2/show/NCT03479866?term=NCT03479866&draw=2&rank=1.

Eating behaviors and incident cardiovascular disease in Japanese people: The population-based Panasonic cohort study 14

Evidence on common eating behaviors to support the prevention of cardiovascular disease (CVD) in Japanese people is insufficient. This retrospective cohort study aimed to investigate the association of diet behaviors (e.g., skipping breakfast, eating speed, snack after dinner, and alcohol consumption) with incident CVD in Japanese individuals. Employees of Panasonic Corporation who underwent the annual health checkups and without a history of CVD at baseline were enrolled. The main outcome was incident 3-point major adverse cardiovascular events (MACE). The secondary outcomes were incident coronary artery disease (CAD) and stroke. To assess the effect of BMI, the subgroup analysis was conducted. In total, 132,795 participants were included. Overall, 3,115, 1,982, and 1,165 participants developed 3-point MACE, CAD, and stroke, respectively. Skipping breakfast (HR: 1.13, 95% CI: 1.03-1.23) and fast eating (HR: 1.23, 95% CI: 1.04-1.47) were associated with 3-point MACE in the participants overall. Skipping breakfast (HR: 1.23, 95% CI: 1.10-1.37) and fast eating (HR: 1.38, 95% CI: 1.12-1.71) were also associated with 3-point MACE in participants with BMI < 25 kg/m². In contrast, in participants with BMI ≥ 25 kg/m², these associations were not detectable (P value for the interaction between subgroups = 0.09 [skipping breakfast] and 0.03 [fast eating], respectively). The diet behavior is a potential risk factor of incident CVD in Japanese people, particularly in those with BMI < 25 kg/m².

Snack consumption patterns and their associations with risk of incident metabolic syndrome: Tehran lipid and glucose study

AIM

Few studies considered the association between snack patterns and metabolic abnormalities. Here we aimed to characterize the major snack patterns among Iranian adults and determine their association with the risk of metabolic syndrome (MetS).

METHODS

This study was conducted on 1713 MetS-free adults who participated in the third phase of the Tehran Lipid and Glucose Study (TLGS). At baseline, dietary intake of snack was assessed using a validated 168-items food frequency questionnaire, and snack patterns were obtained by principal component analysis (PCA). Adjusted Hazard Ratios (HRs) and 95% confidence intervals (CIs) were calculated for the association of incident MetS with the extracted snack patterns.

RESULTS

PCA identified five major snack patterns, defined as "healthy pattern", "low-fructose pattern", "high-trans pattern", "high-caffeine pattern" and "high-fructose pattern". Participants in the highest tertile of the "high-caffeine pattern" had lower risk of MetS (HR = 0.80, 95% CI = 0.65-0.99, P for trend = 0.032). Other snack patterns have not shown any significant association with MetS incidence.

CONCLUSIONS

Our findings suggest that consuming a snack pattern with high loads of caffeine, defined as "High-caffeine pattern" in the present study, could reduce the risk of MetS in healthy adults. Further prospective studies are needed to more fully determine the association between snack patterns and MetS incidence.

Snacking and anxiety during the coronavirus disease (COVID-19) pandemic: A prospective cohort study

Anxiety and snacking increased during the initial coronavirus disease 2019 (COVID-19) lockdowns, but it remains unknown whether this change in snacking persisted and if it related to anxiety levels. We used prospective data to examine changes in snacking frequency from t1 (eased restrictions in England in May-June 2020) to t2 (national lockdown in December 2020-March 2021), the association of anxiety (assessed by the Generalised Anxiety Disorder-7 questionnaire at t1) with the snacking change, and the mediating and moderating effects of disinhibition and flexible restraint (assessed by the Three Factor Eating Questionnaire in 2016-17). Analyses including 2128 adults (mean age 28.4 y) residing in England from the Avon Longitudinal Study of Parents and Children showed that snacking frequency increased over time (mean change 1.23 (95% CI 0.81, 1.65) snacks/wk). Linear regressions of snacking adjusted for sociodemographic covariates showed that having clinical levels of generalised anxiety at t1, versus not, was associated with 1.22 (95% CI 0.07, 2.37) more snacks/wk at t2. Disinhibition partially mediated the association between Generalised Anxiety Disorder and snacking (β_indirect = 0.15, 95% CI 0.01, 0.32), while there was no evidence that flexible restraint moderated the association (β = 0.05, 95% CI -0.57, 0.66). Our longitudinal findings highlight a detrimental anxiety-snacking association partly operating via disinhibition, suggesting future research could target mitigating anxiety and disinhibited eating behaviours to benefit diet-related outcomes following the pandemic.

Relationship Between Carbohydrate Intake (Quantity, Quality, and Time Eaten) and Mortality (Total, Cardiovascular, and Diabetes): Assessment of 2003-2014 National Health and Nutrition Examination Survey Participants

OBJECTIVE

In this study we investigated the association of the quantity, quality, and timing of carbohydrate intake with all-cause, cardiovascular disease (CVD), and diabetes mortality.

RESEARCH DESIGN AND METHODS

This secondary data analysis included use of National Health and Nutrition Examination Survey (2003-2014) and National Death Index data from adults (n = 27,623) for examination of the association of total daily and differences in carbohydrate intake with mortality. Participants were categorized into four carbohydrate intake patterns based on the median values of daily high- and low-quality carbohydrate intake. The differences (Δ) in carbohydrate intake between dinner and breakfast were calculated (Δ = dinner - breakfast). Cox regression models were used.

RESULTS

The participants who consumed more high-quality carbohydrates throughout the day had lower all-cause mortality risk (hazard ratio [HR] 0.88; 95% CI 0.79-0.99), whereas more daily intake of low-quality carbohydrates was related to greater all-cause mortality risk (HR 1.13; 95% CI: 1.01-1.26). Among participants whose daily high- and low-quality carbohydrate intake were both below the median, the participants who consumed more high-quality carbohydrates at dinner had lower CVD (HR 0.70; 95% CI 0.52-0.93) and all-cause mortality (HR 0.82; 95% CI 0.70-0.97) risk; an isocaloric substitution of 1 serving low-quality carbohydrates intake at dinner with high-quality reduced the CVD and all-cause mortality risks by 25% and 19%. There was greater diabetes mortality among the participants who consumed more low-quality carbohydrates at dinner (HR 1.78; 95% CI 1.02-3.11), although their daily high-quality carbohydrate intake was above the median.

CONCLUSIONS

Consuming more low-quality carbohydrates at dinner was associated with greater diabetes mortality, whereas consuming more high-quality carbohydrates at dinner was associated with lower all-cause and CVD mortality irrespective of the total daily quantity and quality of carbohydrates.

Mobile Digital Health Intervention to Promote Nutrition and Physical Activity Behaviors Among Long-term Unemployed in Rural Areas: Protocol for a Randomized Controlled Trial

Background

Long-term unemployed have poor nutritional and physical activity statuses, and, therefore, special health promotion needs. Particularly in rural areas, however, they often do not have access to health promotion service. Thus, new promising strategies to improve the health of long-term unemployed are needed. Hence, a digital health intervention to promote nutritional and physical health behaviors was conceived, and the effectiveness of the intervention in combination with face-to-face sessions will be evaluated in a randomized controlled trial.

Objective

The aim of this study is to elucidate the effectiveness of a mobile digital health intervention to promote the nutritional and physical activity behaviors of long-term unemployed in the rural areas of Germany.

Methods

The 9-week intervention aims to promote nutritional or physical activity behavior by improving drinking habits, increasing the consumption of fruits, vegetables, and whole grains, increasing daily step count, strengthening muscles, and improving endurance. The intervention design is based on the transtheoretical model and is implemented in a mobile app using the MobileCoach open-source platform. The effectiveness of the intervention will be elucidated by a 9-week, 2-armed, parallel-designed trial. Therefore, long-term unemployed will be recruited by employees of the German social sector institutions and randomized either to receive information brochures; the digital intervention in the form of a mobile app; and 3 face-to-face sessions regarding technical support, healthy eating, and physical activity (n=100) or to receive a control treatment consisting of solely the hand over of information brochures (n=100). The effectiveness of the intervention will be assessed using questionnaires at baseline, after 9 weeks in face-to-face appointments, and after a 3-month follow-up period by postal contact. The use of the mobile app will be monitored, and qualitative interviews or focus groups with the participants will be conducted. Incentives of €50 (US $49.7) will be paid to the participants and are tied to the completion of the questionnaires and not to the use of the mobile app or progress in the intervention.

Results

The effectiveness of the intervention in promoting the nutritional and physical activity behaviors of long-term unemployed participants will be elucidated. The adherence of the participants to and the acceptance and usability of the mobile device app will be evaluated. Recruitment started in March 2022, and the final publication of the results is expected in the first half of 2023.

Conclusions

Positive health-related changes made by the intervention would display the potency of digital health interventions to promote nutritional and physical activity behaviors among long-term unemployed in the rural areas of Germany, which would also contribute to an improved health status of the German population in general.

Trial Registration

German Clinical Trials Register DRKS00024805; https://www.drks.de/DRKS00024805

International Registered Report Identifier (IRRID)

PRR1-10.2196/40321

A Clustering Approach to Meal-Based Analysis of Dietary Intakes Applied to Population and Individual Data

BACKGROUND

Examination of meal intakes can elucidate the role of individual meals or meal patterns in health not evident by examining nutrient and food intakes. To date, meal-based research has been limited to focus on population rather than individual intakes, without considering portions or nutrient content when characterizing meals.

OBJECTIVES

We aimed to characterize meals commonly consumed, incorporating portions and nutritional content, and to determine the accuracy of nutrient intake estimates using these meals at both population and individual levels.

METHODS

The 2008-2010 Irish National Adult Nutrition Survey (NANS) data were used. A total of 1500 participants, with a mean ± SD age of 44.5 ± 17.0 y and BMI of 27.1 ± 5.0 kg/m2, recorded their intake using a 4-d weighed food diary. Food groups were identified using k-means clustering. Partitioning around the medoids clustering was used to categorize similar meals into groups (generic meals) based on their Nutrient Rich Foods Index (NRF9.3) score and the food groups that they contained. The nutrient content for each generic meal was defined as the mean content of the grouped meals. Seven standard portion sizes were defined for each generic meal. Mean daily nutrient intakes were estimated using the original and the generic data.

RESULTS

The 27,336 meals consumed were aggregated to 63 generic meals. Effect sizes from the comparisons of mean daily nutrient intakes (from the original compared with generic meals) were negligible or small, with P values ranging from <0.001 to 0.941. When participants were classified according to nutrient-based guidelines (high, adequate, or low), the proportion of individuals who were classified into the same category ranged from 55.3% to 91.5%.

CONCLUSIONS

A generic meal-based method can estimate nutrient intakes based on meal rather than food intake at the sample population and individual levels. Future work will focus on incorporating this concept into a meal-based dietary intake assessment tool.

Associations between the timing of different foods’ consumption with cardiovascular disease and all-cause mortality among adults with sleep disorders

Introduction

People with sleep disorders are under disrupted biological rhythms. Whether changing the timing of specific food consumption contributes to decreasing cardiovascular and all-cause risk is unknown.

Methods

A total of 8,005 participants with sleep disorders were selected from the U.S. National Health and Nutrition Examination Survey (NHANES) from 2005 to 2014. Cox proportional hazards regression models were used to analyze the relationship between the consumption time of foods and cardiovascular disease (CVD) and all-cause death. Moreover, equivalent food substitution models were carried out to evaluate the alterations in the risk of CVD mortality for the changed food intake time.

Results

After adjusting for multiple confounders, participants who consume red and orange vegetables, starchy vegetables, and fermented dairy in the morning (hazard ratio (HR)_{red and orange vegetables} = 0.45, 95% CI: 0.26–0.81; HR_{starchy vegetables} = 0.47, 95% CI: 0.25–0.88; HR_{fermented dairy} = 0.57, 95% CI: 0.36–0.89) and milk and eggs in the evening contribute to reducing the likelihood of death from CVD (HR_milk = 0.65, 95% CI: 0.43–0.96; HR_eggs = 0.72, 95% CI: 0.53–0.98). Iso-calorically switching 0.1 serving of starchy vegetable and fermented dairy and milk intake from one period to another does significantly reduce the mortality risk of CVD.

Conclusion

Higher intake of red and orange vegetables, starchy vegetables, and fermented dairy in the morning and milk and eggs in the evening confers a lower risk of CVD among individuals with sleep disorders.

The Association of Consumption Time for Food With Cardiovascular Disease and All-Cause Mortality Among Diabetic Patients

AIMS

This study aims to investigate whether food intake time across 3 meals is associated with long-term survival among the people with diabetes.

MATERIALS AND METHODS

This study included 4642 diabetic patients participating in the National Health and Nutrition Examination Survey from 2003 to 2014. Food consumed across a day including the forenoon, afternoon, and evening was divided into quantiles based on their distribution. Cox proportional hazards regression models were used to analyze the survival relationship between food intakes time and mortality.

RESULTS

In the forenoon, compared to the participants in the lowest quantile of potato and starchy vegetable, participants in the highest quantile had lower mortality risk of cardiovascular disease (CVD) [hazard ratio (HR)potato = 0.46, 95% CI 0.24-0.89; HRstarchy-vegetable = 0.32, 95% CI 0.15-0.72]. In the afternoon, participants who consumed whole grain had lower mortality of CVD (HRwhole grain = 0.67, 95% CI 0.48-0.95). In the evening, the highest quantile of dark vegetable and milk intake is related to lower mortality risk of CVD (HRdark vegetable = 0.55, 95% CI 0.35-0.87; HRmilk = 0.56, 95% CI 0.36-0.88) and all-cause mortality (HRmilk = 0.71, 95% CI 0.54-0.92), whereas participants in the highest quantile of intakes of processed meat are more likely to die due to CVD (HRprocessed-meat = 1.74, 95% CI 1.07-2.82). Isocalorically switching 0.1 serving potato or starchy vegetable consumed in the afternoon or evening to the forenoon, 0.1 serving dark vegetable consumed in the afternoon to the evening, and 0.1 serving whole grain consumed in the forenoon to the afternoon reduced the risk of CVD mortality.

CONCLUSIONS

Higher intake of potato or starchy vegetable in forenoon, whole grain in the afternoon, and dark vegetable and milk in the evening and lower intake of processed meat in the evening was associated with better long-term survival in people with diabetes.

Association of Meal and Snack Patterns With Mortality of All-Cause, Cardiovascular Disease, and Cancer: The US National Health and Nutrition Examination Survey, 2003 to 2014

Background

Although accumulating evidence has demonstrated that consumption time of energy and macronutrients plays an important role in maintaining health, the association between consumption time of different foods and cardiovascular disease, cancer, and all‐cause mortalities is still largely unknown.

Methods and Results

A noninstitutionalized household population of the US 21 503 participants from National Health and Nutrition Examination Survey was included. Meal patterns and snack patterns throughout a whole day were measured using 24‐hour dietary recall. Principal component analysis was performed to establish dietary patterns. Cox proportional hazards models were used to evaluate the association between dietary patterns across meals and cardiovascular disease (CVD), cancer, and all‐cause mortalities. During the 149 875 person‐years of follow‐up, 2192 deaths including 676 deaths because of CVD and 476 because of cancer were documented. After adjusting for potential confounders, participants consuming fruit‐lunch had lower mortality risks of all‐cause (hazard ratio [HR], 0.82; 95% CI, 0.72–0.92) and CVD (HR, 0.66; 95% CI, 0.49–0.87); whereas participants who consumed Western‐lunch were more likely to die because of CVD (HR, 1.44; 95% CI, 1.10–1.89). Participants who consumed vegetable‐dinner had lower mortality risks of all‐cause, CVD, and cancer (HR_all‐cause, 0.69; 95% CI, 0.60–0.78; HR_CVD, 0.77; 95% CI, 0.61–0.95; HR_cancer, 0.63; 95% CI, 0.48–0.83). For the snack patterns, participants who consumed fruit‐snack after breakfast had lower mortality risks of all‐cause and cancer (HR_all‐cause, 0.78; 95% CI, 0.66–0.93; HR_cancer, 0.55; 95% CI, 0.39–0.78), and participants who consumed dairy‐snack after dinner had lower risks of all‐cause and CVD mortalities (HR_all‐cause, 0.82; 95% CI, 0.72–0.94; HR_CVD, 0.67; 95% CI, 0.52–0.87). Participants who consumed a starchy‐snack after main meals had greater mortality risks of all‐cause (HR_{after‐breakfast}, 1.50; 95% CI, 1.24–1.82; HR_{after‐lunch}, 1.52; 95% CI, 1.27–1.81; HR_{after‐dinner}, 1.50; 95% CI, 1.25–1.80) and CVD (HR_{after‐breakfast}, 1.55; 95% CI, 1.08–2.24; HR_{after‐lunch}, 1.44; 95% CI, 1.03–2.02; HR_{after‐dinner}, 1.57; 95% CI, 1.10–2.23).

Conclusions

Fruit‐snack after breakfast, fruit‐lunch, vegetable‐dinner, and dairy‐snack after dinner was associated with lower mortality risks of CVD, cancer, and all‐cause; whereas Western‐lunch and starchy‐snack after main meals had greater CVD and all‐cause mortalities.