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Original research
Diet quality and risk and severity of COVID-19: a prospective cohort study
  1. Jordi Merino1,2,3,
  2. Amit D Joshi4,5,
  3. Long H Nguyen4,5,6,
  4. Emily R Leeming7,
  5. Mohsen Mazidi7,
  6. David A Drew4,5,
  7. Rachel Gibson8,
  8. Mark S Graham9,
  9. Chun-Han Lo4,5,
  10. Joan Capdevila10,
  11. Benjamin Murray9,
  12. Christina Hu10,
  13. Somesh Selvachandran10,
  14. Alexander Hammers9,11,
  15. Shilpa N Bhupathiraju3,12,
  16. Shreela V Sharma13,
  17. Carole Sudre9,
  18. Christina M Astley2,14,
  19. Jorge E Chavarro12,15,16,
  20. Sohee Kwon4,5,
  21. Wenjie Ma4,5,
  22. Cristina Menni7,
  23. Walter C Willett12,15,16,
  24. Sebastien Ourselin9,
  25. Claire J Steves7,
  26. Jonathan Wolf10,
  27. Paul W Franks12,17,
  28. Timothy D Spector8,
  29. Sarah Berry8,
  30. Andrew T Chan4,5,18
  1. 1Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
  2. 2Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA
  3. 3Department of Medicine, Harvard Medical School, Boston, MA, USA
  4. 4Clinical and Translational Epidemiological Unit, Massachusetts General Hospital, Boston, MA, USA
  5. 5Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
  6. 6Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
  7. 7Department of Twin Research, King's College London, London, UK
  8. 8Department of Nutritional Sciences, King’s College London, London, UK
  9. 9School of Biomedical Engineering & Imaging Sciences, King’s College London, London, UK
  10. 10Zoe Limited, London, UK
  11. 11King’s College London & Guy’s and St Thomas’ PET Centre, King’s College London, London, UK
  12. 12Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
  13. 13Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Houston, Texas, USA
  14. 14Division of Endocrinology & Computational Epidemiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
  15. 15Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
  16. 16Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
  17. 17Department of Clinical Sciences, Genetic and Molecular Epidemiology Unit, Lund University, Lund, Sweden
  18. 18Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
  1. Correspondence to Dr Andrew T Chan, Harvard Medical School, Boston, USA; achan{at}mgh.harvard.edu

Abstract

Objective Poor metabolic health and unhealthy lifestyle factors have been associated with risk and severity of COVID-19, but data for diet are lacking. We aimed to investigate the association of diet quality with risk and severity of COVID-19 and its interaction with socioeconomic deprivation.

Design We used data from 592 571 participants of the smartphone-based COVID-19 Symptom Study. Diet information was collected for the prepandemic period using a short food frequency questionnaire, and diet quality was assessed using a healthful Plant-Based Diet Score, which emphasises healthy plant foods such as fruits or vegetables. Multivariable Cox models were fitted to calculate HRs and 95% CIs for COVID-19 risk and severity defined using a validated symptom-based algorithm or hospitalisation with oxygen support, respectively.

Results Over 3 886 274 person-months of follow-up, 31 815 COVID-19 cases were documented. Compared with individuals in the lowest quartile of the diet score, high diet quality was associated with lower risk of COVID-19 (HR 0.91; 95% CI 0.88 to 0.94) and severe COVID-19 (HR 0.59; 95% CI 0.47 to 0.74). The joint association of low diet quality and increased deprivation on COVID-19 risk was higher than the sum of the risk associated with each factor alone (Pinteraction=0.005). The corresponding absolute excess rate per 10 000 person/months for lowest vs highest quartile of diet score was 22.5 (95% CI 18.8 to 26.3) among persons living in areas with low deprivation and 40.8 (95% CI 31.7 to 49.8) among persons living in areas with high deprivation.

Conclusions A diet characterised by healthy plant-based foods was associated with lower risk and severity of COVID-19. This association may be particularly evident among individuals living in areas with higher socioeconomic deprivation.

  • COVID-19
  • diet
  • dietary factors
  • infectious disease

Data availability statement

The diet quality data used for this study are held by the department of Twin Research at Kings’ College London. The data can be released to bona fide researchers using our normal procedures overseen by the Wellcome Trust and its guidelines as part of our core funding (https://web.www.healthdatagateway.org/dataset/fddcb382-3051-4394-8436-b92295f14259).

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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Data availability statement

The diet quality data used for this study are held by the department of Twin Research at Kings’ College London. The data can be released to bona fide researchers using our normal procedures overseen by the Wellcome Trust and its guidelines as part of our core funding (https://web.www.healthdatagateway.org/dataset/fddcb382-3051-4394-8436-b92295f14259).

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Footnotes

  • JM, ADJ and LHN are joint first authors.

  • TDS, SB and ATC are joint senior authors.

  • Twitter @Riudecanyenc, @EmilyLeemingRD, @DADrewPhD

  • Contributors JM, ADJ, LHN, ERL, TDS, SB and AC conceived the study design. JM, ADJ, ERL, MSG, JC, BM and SS contributed to the statistical analysis. All authors were involved in acquisition, analysis or interpretation of data. JM, LHN and DAD wrote the first draft of the manuscript. DAD, WW, SO, CJS, JW, PWF, TDS, SB and AC obtained funding. JM, ADJ and LHN provided administrative, technical or material support. TDS, SB and AC jointly supervised this work. All authors contributed to the critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. The corresponding authors attest that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. TDS, SB and AC are joint last authors.

  • Funding National Institutes of Health (K01DK110267, K01DK120742, K23DK120899, K23DK125838, P30DK046200, P30DK40561, U01HL145386, R24ES028521), National Institute for Health Research (MR/M016560/1), UK Medical Research Council/Engineering and Physical Sciences Research Council (T213038/Z/18/Z), Wellcome Trust (WT212904/Z/18/Z, WT203148/Z/16/Z, T213038/Z/18/Z), Massachusetts Consortium on Pathogen Readiness (MassCPR-003), American Gastroenterological Association (AGA2021-5102), American Diabetes Association (7-21-JDFM-005) and Alzheimer’s Society (AS-JF-17-011).

  • Disclaimer The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

  • Competing interests JW, CH, SS and JC are employees of Zoe Ltd. TDS, ERL and SB, area consultant to Zoe Ltd. DAD, JM and AC previously served as investigators on a clinical trial of diet and lifestyle using a separate mobile application that was supported by Zoe Ltd.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.