Online-only supplemental documents

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Online-only supplemental documents

eTable 1- 23 Food groups used for the plant-based diet index and examples of food items included in each of the food groups

12 Plant-based food groups

Fruits

Apple, banana, pear, orange, strawberry, grapes, other fruits

Vegetables

Cauliflower, broccoli, spinach, carrots, onion, lettuce, tomato, cabbage, cooked vegetables

Whole grains

Whole grain bread, dark bread, rye bread, whole grain breakfast oats, whole grain pasta, brown rice

Nuts

Peanuts, walnuts, other nuts, peanut butter

Legumes

Legumes, tofu, soybeans, other soy products

Vegetable oils

Olive oil, vegetable oils used for cooking, and all margarines

Tea and coffee

Black tea, green tea, herbal tea, coffee

Potatoes

Potatoes, fries

Refined grains

Cornflakes, white bread, croissants, raisin bread, white pasta, white rice

Sweets

Sugar, cookies, cake, chocolate, candy-bars, honey, sweets, chocolate toppings, other sweet toppings

Sugary beverages

Carbonated beverages with sugar, non-carbonated beverages with sugar, orange juice, fruit juice

Alcoholic beverages

Red wine, white wine, beer, liquor, Dutch-eggnog

11 Animal-based food groups

Low-fat milk

Skimmed milk, semi-skimmed milk, skimmed coffee creamer, semi-skimmed coffee creamer

Low-fat yoghurt

Skimmed yoghurt, semi-skimmed yoghurt, skimmed quark, buttermilk

Full-fat milk

Full-fat milk, cream, coffee-cream

Full-fat yoghurt

Full-fat yoghurt, semi-skimmed quark, full quark

Cheese

Full fat cheese, low fat cheese, cheese fondue, other cheese

Desserts and sugary dairy

Custard, cream, ice cream, mousse, cream, chocolate milk, fruit yoghurt, yoghurt drinks

Unprocessed lean meat

^Chicken

Fish

Salmon, tuna, trout, herring, mussels, other fish

Eggs

Boiled eggs, fried eggs

Animal fat

Butter on bread, butter used for cooking, lard

Processed and red meat

Beef, pork, meatballs, sate, bacon, liver, processed meats

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eTable 2- Intake of 23 food groups across quintiles of the plant-based diet index Plant-based diet index

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Score≤43 43<score≤47 47<score ≤50 50<score≤55 score˃55

Median=40 Median=46 Median=49 Median=53 Median=59

n=2212 n=1976 n=1639 n=2171 n=1635

Food intake (grams/day)^a

-Fruits 170.6 (91.2, 266.2) 195.0 (109.6, 299.5) 213.7 (122.4, 322.7) 220.4 (124.5, 329.2) 249.6 (150.6, 375.6)

-Vegetables 178.7 (127.4, 244.2) 196.4 (141.4, 268.3) 201.8 (146.7, 272.3) 210.7 (151.5, 283.9) 234.4 (178.1, 313)

-Whole grains 93.4 (56.0, 129.9) 102.4 (57.0, 142.3) 110.0 (70.0, 151.6) 116.1 (70.1, 162.5) 138.8 (80.9, 188.7)

-Legumes 0.0 (0.0, 7.8) 0.0 (0.0, 12.9) 0.0 (0.0, 15.8) 4.5 (0.0, 19.4) 10.7 (0.0, 31.0)

-Nuts 0.0 (0.0, 4.4) 1.1 (0.0, 8.1) 2.4 (0.0, 9.6) 4.3 (0.0, 12.8) 8.5 (2.2, 18.1)

-Vegetable oils 12.0 (3.0, 22.0) 18.0 (8.0, 27.4) 21.0 (11.5, 30.7) 24.5 (14.6, 34.1) 28.7 (19.6, 39.7)

-Tea and coffee 750.0 (500.0, 875.0) 750.0 (550.0, 1000.0) 754.5 (593.8, 1000.0) 825.0 (625.0, 1025.0) 933.1 (750.0, 1125.0)

-Refined grains 33.5 (14.1, 70.0) 42.3 (20.0, 86.2) 42.7 (20.4, 88.3) 52.2 (26.2, 104.9) 58.4 (30.0, 115.1)

-Potatoes 85.5 (56.6, 128.2) 96.4 (64.1, 142.5) 106.9 (71.2, 149.6) 114.3 (73.3, 170.0) 128.2 (87.3, 178.1)

-Sweets 48.3 (26.1, 81.3) 57.1 (31.8, 89.1) 63.9 (39.0, 96.7) 71.2 (42.3, 105.8) 82.9 (53.6, 118.3)

-Sugary beverages 9.2 (0.0, 79.8) 26.8 (0.0, 139.3) 50.0 (0.0, 139.6) 53.8 (0.0, 142.5) 87.3 (15.0, 174.5)

-Alcoholic beverages 21.4 (0.3, 106.3) 37.5 (1.6, 134.9) 42.7 (3.3, 147.0) 56.9 (4.3, 149.6) 71.4 (10.8, 176.4)

-Low-fat yoghurt 74.8 (0.0, 192.9) 60.2 (0.0, 166.1) 64.1 (0.0, 164.6) 53.6 (0.0, 158.6) 21.4 (0.0, 149.6)

-Full-fat yoghurt 0.0 (0.0, 37.4) 0.0 (0.0, 9.9) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)

-Low-fat milk 107.1 (1.6, 278.6) 100.2 (2.2, 264.4) 94.6 (0.0, 231.7) 79.0 (0.0, 224.4) 42.9 (0.0, 196.5)

-Full-fat milk 0.0 (0.0, 23.5) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)

-Cheese 33.4 (21.4, 48.1) 32.4 (20.4, 48.4) 30.8 (20.0; 46.6) 29.6 (19.9, 45.5) 29.3 (18.6, 46.2)

-Fish 18.7 (5.9, 32.1) 15.9 (3.3, 31.5) 13.7 (2.1, 28.5) 12.8 (1.0, 28.5) 8.9 (0.0, 23.9)

-Eggs 14.3 (8.6, 21.4) 14.3 (7.1, 21.4) 14.3 (7.1, 17.8) 14.3 (7.1, 17.1) 10.1 (7.1, 16.6)

-Animal fat 0.7 (0.0, 14.7) 0.0 (0.0, 3.0) 0.0 (0.0, 0.3) 0.0 (0.0, 0.0) 0.0 (0.0, 0.0)

-Desserts/dairy with sugars 20.5 (0.0, 63.9) 17.1 (0.0, 61.6) 13.8 (0.0, 52.3) 10.3 (0.0, 51.7) 5.4 (0.0, 41.0)

-Unprocessed lean meat 14.3 (5.4, 21.4) 12.4 (5.4, 21.4) 10.7 (3.9, 17.9) 10.0 (3.7, 16.4) 7.1 (0.0, 14.9)

-Processed meat / red meat 92.5 (65.5, 126.5) 88.7 (64.6, 118.3) 88.3 (62.0, 120.4) 85.7 (60.1, 116.6) 81.6 (55.0, 114.8)

aValues are median (25th percentile–75th percentile) for continuous variables with a skew distribution.

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eTable 3 –Repeated measurements of BMI, waist circumference, fat mass index, and body fat percentage

Time^a (years)

BMI n=9620

Waist circumference

n=9474

Time^b (years)

Fat mass index n=6153

Body fat percentage

n=6153

Mean (SD) Mean(SD)

RS-I n=5416

RS-I-1 (1989-93) 0.0 (0.0) 5397 5083 NA NA NA

RS-I-2 (1993-95) 2.0 (0.6) 4483 NA NA NA NA

RS-I-3 (1997-99) 6.5 (0.4) 3512 3517 NA NA NA

RS-I-4 (2002-04) 11.0 (0.5) 2540 2652 11.6 (0.5) 2329 2329

RS-I-5 (2009-11) 17.6 (0.5) 1477 1473 17.2 (0.5) 1297 1297

RS-I-6 (2014-15) 22.5 (0.7) 741 741 22.1 (0.3) 698 698

RS-II n=1624

RS-II-1 (2000-01) 0.0 (0.0) 1620 1623 NA NA NA

RS-II-2 (2004-05) 4.0 (0.5) 1319 1339 4.0 (0.4) 659 659

RS-II-3 (2011-12) 10.6 (0.4) 1033 1035 10.8 (0.3) 993 993

RS-II-4 (2015-16) 15.0 (0.2) 797 820 15.0 (0.2) 797 797

RS-III n=2581

RS-III-1 (2006-08) 0.0 (0.0) 2561 2481 0.0 (0.0) 2079 2079

RS-III-2 (2012-14) 5.6 (0.4) 2142 2139 5.8 (0.4) 2059 2059

At baseline and follow-up in RS-I, RS-II, and RS-III, 9620 participants had at least one time measurement of BMI; 9474 participants had at least one time measurement of waist circumference; 6153 participants had at least one time measurement of fat mass index, and body fat percentage.

aTime variable is calculated as time scale for each measurement of BMI and waist circumference by subtracting baseline date from date of each measurement of BMI and waist circumference at follow-up period.

bTime variable is calculated as time scale for each measurement of fat mass index and body fat percentage by subtracting baseline date from date of each measurement of fat mass index and body fat percentage at follow-up period.

Abbreviations: BMI, body mass index; RS, Rotterdam Study; NA, not available

eTable 4- Missing values

^a

Physical activity Education level Smoking status RS-I n=5426 NA=1551 (28.6%) NA=26 (0.48%) NA=32 (0.59%) RS-II n=1624 NA=11 (0.68%) NA=23 (1.4%) NA=8 (0.49%) RS-III n=2583 NA=238 (9.2%) NA=7 (0.27%) NA=6 (0.23%) Total n=9633 NA=1800 (18.7%) NA=56 (0.58%) NA=46 (0.47%)

aIn our main analyses, only three variables: physical activity, education level, and smoking status were with missing values.

Abbreviations: NA, not available, (numbers of participants with missing values); RS, Rotterdam Study

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eTable 5- Interactions between plant-based diet score and baseline age, or sex for longitudinal BMI, waist circumference, fat mass index, and body fat percentage (additional analyses)

BMI (kg/m

²

)

Waist circumference (cm)

Fat mass index (kg/m

²

)

Body fat percentage

n=9620 n=9474 n=6153 n=6153

β (95% CI), p value β (95% CI), p value β (95% CI), p value β (95% CI), p value

Plant-based diet score × baseline age

0.01 (-0.01, 0.02), p=0.32 0.03 (-0.01, 0.07), p=0.11 0.02 (-0.01, 0.05), p=0.22 0.03 (-0.03, 0.10), p=0.31

Plant-based diet score × sex

-0.13 (-0.46, 0.20), P=0.45 -0.32 (-0.92, 0.27), p=0.29 -0.21 (-0.57, 0.15), p=0.35 -0.09 (-0.51, 0.34), p=0.69 Values are regression coefficients and 95%CIs for interactions between plant-based diet score and baseline age or sex for body adiposity outcomes.

Models include plant-based diet score, age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, -II, or -III), time of repeated measurements of BMI, waist circumference, fat mass index, and body fat percentage education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task -hours/week), and food supplement use (yes or no), and interaction between plant-based diet score and baseline age or sex.

Abbreviations: BMI, body mass index; RS, Rotterdam Study

eTable 6- Associations of plant-based diet score with BMI, waist circumference, fat mass index, and body fat percentage by excluding alcoholic beverages (sensitivity analyses)

BMI (kg/m

²

)

Fat mass index

(kg/m

²

) Body fat percentage

n=9620 n=9474 n=6153 n=6153

Plant-based diet score

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

Excluding alcoholic beverages -0.63 (-0.74, -0.51) -1.8 (-2.1, -1.5) -0.53 (-0.64, -0.42) -0.94 (-1.2, -0.72)

Values are regression coefficients and 95%CIs based on linear mixed models, and reflect differences in BMI, waist circumference, fat mass index, and body fat percentage averaged across the median follow-up of 7.1 years per 10 points higher score on the plant-based diet score without alcoholic beverages.

Models are adjusted for baseline age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, -II, or -III), time of repeated measurements of BMI, waist circumference, fat mass index, and body fat percentage education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task -hours/week), and food supplement use (yes or no).

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eTable 7- Associations of plant-based diet score with BMI, waist circumference, fat mass index, and body fat percentage by additionally adjusting for baseline diet quality reflecting dietary guidelines or for dietary intake at RS-I-5 and RS-II-3 (sensitivity analyses)

BMI (kg/m

²

)

Fat mass index

(kg/m

²

) Body fat percentage Plant-based diet score

n=9620 n=9474 n=6153 n=6153

Adjusting for diet quality reflecting adherence

to dietary guidelines^a β (95% CI) β (95% CI) β (95% CI) β (95% CI)

-0.67 (-0.78, -0.55) -1.8 (-2.2, -1.5) -0.59 (-0.70, -0.48) -1.0 (-1.2, -0.79)

n=2178 n=2178 n=2133 n=2133

Adjusting for dietary intake at RS-I-5 and RS- II-3^b

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

-0.57 (-0.79,-0.34) -1.5 (-2.2, -0.92) -0.42 (-0.61, -0.24) -0.75 (-1.1, -0.40) Values are regression coefficients and 95%CIs based on linear mixed models, and reflect differences in BMI, waist circumference, fat mass index, and body fat percentage averaged across the median follow-up of 7.1 years per 10 points higher score on the plant-based diet score without alcoholic beverages or with additional adjustment for diet quality score reflecting adherence to dietary guidelines.

aModels are adjusted for baseline age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, -II, or -III), time of repeated measurements of BMI, waist circumference, fat mass index, and body fat percentage education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task-hours/week), food supplement use (yes or no) and diet quality reflecting adherence to dietary guidelines.

bAnalyses are performed with adjustment for baseline age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, or -II), time of repeated measurements of longitudinal BMI, waist circumference, fat mass index, and body fat percentage, education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task -hours/week) at baseline and at RS-I-5 and RS-II-3, food supplement use (yes or no), and plant-based diet score at RS-I-5 and RS-II-3.

eTable 8- Associations of plant-based diet score with BMI, waist circumference, fat mass index, and body fat percentage by excluding less healthy plant-based foods or healthy plant-based foods (sensitivity analyses)

BMI (kg/m

²

)

Fat mass index

(kg/m

²

n=9620 n=9474 n=6153 n=6153

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

Excluding less healthy plant-based foods -0.68 (-0.80, -0.56) -1.9 (-2.2, -1.6) -0.64 (-0.74, -0.53) -1.4 (-2.3, -0.60)

Excluding healthy plant-based foods -0.42 (-0.56, -0.28) -1.1 (-1.5, -0.71) -0.40 (-0.54, -0.26) -0.64 (-0.92, -0.36)

Values are regression coefficients and 95%CIs based on linear mixed models, and reflect differences in BMI, waist circumference, fat mass index, and body fat percentage averaged across the median follow-up of 7.1 years per 10 points higher score on the plant-based diet index without less healthy plant-based foods or healthy plant-based foods.

Models are adjusted for baseline age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, -II, or -III), time of repeated measurements of BMI, waist circumference, fat mass index, and body fat percentage education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task -hours/week), and food supplement use (yes or no).

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eTable 9– Associations of plant-based diet score with BMI, waist circumference, fat mass index, and body fat percentage after adding positive scores from fish, eggs, low-fat milk, and low-fat yoghurt

BMI (kg/m

²

)

²

)

Body fat percentage

n=9620 n=9474 n=6153 n=6153

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

-0.54 (-0.76, -0.32) -1.4 (-1.9, -0.93) -0.46 (-0.68, -0.18) -0.71 (-0.90, -0.52) Values are regression coefficients and 95%CIs based on linear mixed models, and reflect differences in BMI, waist circumference, fat mass index, and body fat percentage averaged across the median follow-up of 16.1 years in participants from RS-I and RS-II with available data per 10 points higher score.

Analyses are performed for associations of modification of plant-based dietby scoring fish, egg, low-fat milk, and low-fat yoghurt positive scores with adjustment for baseline age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, -II or -III,), time of repeated measurements of longitudinal BMI, waist circumference, fat mass index, and body fat percentage education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task -hours/week), and food supplement use (yes or no).

Abbreviations: BMI, body mass index;RS, Rotterdam Study

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eTable 10- Associations of the plant-based diet score with BMI, waist circumference, fat mass index, and body fat percentage by additionally adjusting for baseline health condition or excluding participants with obesity, diabetes, coronary heart disease, cancers at baseline and censoring body composition data collected after onset of diabetes, coronary heart disease, and cancers at follow-up

Values are regression coefficients and 95%CIs based on linear mixed models, and reflect differences in BMI, waist circumference, fat mass index, and body fat percentage averaged across the follow-up period per 10 points higher score on the plant-based diet index.

aAnalyses are performed with adjustment for baseline age (years), sex, total energy (kcal/day), RS sub-cohort (RS-I, -II, or -III), time of repeated measurements of longitudinal BMI, waist circumference, fat mass index, or body fat percentage, education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of MET-hours/week), food supplement use (yes or no), baseline diabetes (yes or no), baseline obesity (yes or no), baseline coronary heart disease (yes or no), and baseline cancers (yes or no).

bAnalyses are performed based on body composition data collected before onset of diabetes, coronary heart disease, and cancers at follow-up in participants without obesity, diabetes, coronary heart disease, or cancers at baseline and adjusted for baseline age (years), sex, total energy (kcal), RS sub-cohort (RS-I, -II, or -III), time of repeated measurements of BMI, waist circumference, fat mass index, or body fat percentage, education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task- hours/week), and food supplement use (yes or no).

BMI (kg/m

²

)

²

)

Body fat percentage Plant-based diet score

n=9620 n=9474 n=6153 n=6153

Additionally adjusting for baseline health condition^a β (95% CI) β (95% CI) β (95% CI) β (95% CI)

-0.67 (-0.82, -0.51) -1.9 (-2.1, -1.7) -0.63 (-0.75, -0.50) -1.0 (-1.2, -0.87)

n=6364 n=6080 n=2741 n=2741

Excluding participants with chronic diseases at baseline and censoring data measured after onset of diabetes, coronary heart disease , and cancers^b

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

-0.63 (-0.76, -0.49) -1.5 (-1.9, -1.1) -0.48 (-0.62, -0.34) -0.72 (-0.96, -0.46)

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eTable 11- Associations of plant-based diet score with BMI, waist circumference, fat mass index, and body fat percentage in the three sub- cohorts

BMI (kg/m

²

)

Fat mass index

(kg/m

²

β (95% CI) β (95% CI) β (95% CI) β (95% CI)

RS-I^a -0.62 (-0.78, -0.46) -1.6 (-2.1, -1.2) -0.44 (-0.62, -0.26) -0.85 (-1.2, -0.50)

RS-II^b -0.63 (-0.97, -0.29) -2.2 (-3.0, -1.5) -0.76 (-1.0, -0.51) -1.3 (-1.8, -0.87)

RS-III^c -0.88 (-1.2, -0.61) -2.6 (-3.3, -1.9) -0.68 (-0.88, -0.48) -1.2 (-1.6, -0.81)

Values are regression coefficients and 95%CIs based on linear mixed models, and reflect differences in BMI, waist circumference, fat mass index, and body fat percentage averaged across the follow-up period per 10 points higher score on the plant-based diet index in three sub-cohorts, respectively. Analyses were performed with adjustment for baseline age (years), sex, total energy (kcal/day), time of repeated measurements of BMI, waist circumference, fat mass index, or body fat percentage, education level (primary, lower/intermediate, intermediate, or higher), smoking status (never, ever, current), physical activity (z-score of metabolic equivalent of task -hours/week), and food supplement use (yes or no).

aIn RS-I, 5416 participants with BMI measurements; 5281 participants with waist circumference measurements; 2477 participants with fat mass index, and body fat percentage measurements.

bIn RS-II, 1624 participants with BMI measurements; 1624 participants with waist circumference measurements; 1189 participants with waist circumference measurements, and body fat percentage measurements.

cIn RS-III, 2580 participants with BMI measurements; 2569 participants with waist circumference measurements; 2487 participants with fat mass index, and body fat percentage measurements.