Development of the Nordic Nutrition Recommendations 2023 food-based diet score and its association with all-cause mortality in two Swedish cohorts

The 2023 Nordic Nutrition Recommendations (NNR23) emphasize both planetary health and disease prevention through food-based guidelines (1) . While previous planetary health diets may not guarantee sufficient micronutrient intake (2) , these dietary patterns focusing on human and planetary health have shown positive associations between higher adherence and lower mortality (3) . However, the health effects of adhering to the NNR2023 have not been investigated. This study aims to construct a diet score to investigate adherence to NNR2023, micronutrient adherence, and the association with mortality. We constructed a diet score based on NNR2023 with 15 food components [1]. Points were given proportionally between 0 and 1 points, reflecting the level of compliance with each food component, with a maximum possible score of 15 points. We then followed men aged 45-79 from the Cohort of Swedish Men (n=48,850) (COSM) and women aged 48–83 years from the Swedish Mammography Cohort (n=39,984) (SMC), with extensive information collected on diet and lifestyle in 1997, 2009 and 2019 (4) . Cases were retrieved through the Swedish Patient Register using the Swedish Personal Identification Number and The Death Register (4) . Participants were followed until death or administrative end of follow-up on 31 st of December 2019. Micronutrient intake was derived from reported food intake and dichotomized at the recommended intake for vitamins and adequate mineral intake. Multi-variable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) with 95 % confidence intervals (CIs) using age as the underlying timescale. Participants with the highest adherence to NNR2023 (>10 points, median (10 points), HR 0.77, 95% CI 0.74-0.80) exhibited a lower risk of all-cause mortality compared to those with the lowest adherence (<8 points, median (7.6 points)). Age- and sex-specific micronutrient recommendations for calcium, folate, and magnesium were more likely to be met for those with the highest adherence. However, vitamin D intake was lower in women, and calcium was lower in men under the age of 70. When analyzed as a restricted cubic spline, results indicate lower mortality risk with increasing adherence. High adherence to NNR2023 is beneficial for achieving adequate micronutrient intake and reducing overall mortality.