AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Higher Healthy Eating Index Scores Are Associated with Lower Risk of Advanced CKM Stages: Findings from NHANES 2011 - 2016
By Zhang Y, Zhang M, Ghahramani N et al.
Background: Cardiovascular-kidney-metabolic (CKM) syndrome is a framework that characterizes the progression from no CKM risk factors to established cardiovascular disease. Nearly 90% of U.S. adults have CKM risk factors. Diet quality is a modifiable factor that may affect multiple components of CKM progression. Understanding whether and how better diet quality is associated with less advanced CKM stages may help inform CKM prevention, but these associations have not been well-characterized in U.S. adults. Research Questions: What is the association between diet quality, assessed using the Health Eating Index (HEI) - 2020, and CKM syndrome stages among U.S. adults? Methods: We included adults aged ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 2011-2016 who had complete dietary intake data and positive fasting subsample weights. Diet quality was assessed using the HEI-2020, calculated from 24-hour dietary recall data. The HEI-2020 includes 13 dietary components and ranges from 0 to 100, with higher scores indicating better diet quality. CKM stages were defined according to the American Heart Association framework: Stage 0, no CKM risk factors; Stage 1, excess or dysfunctional adiposity; Stage 2, metabolic risk factors or chronic kidney disease; Stage 3, subclinical cardiovascular disease; and Stage 4, clinical cardiovascular disease. We used survey-weighted multinomial logistic regression models to examine associations between HEI-2020 scores and CKM stages, with HEI-2020 modeled both per 10-point increment and by quartiles. Results were reported as relative risk ratios (RRRs) with 95% confidence intervals (CIs). Models were adjusted for sociodemographic and lifestyle factors. Results: Among 5,964 participants, the median age was 49 years (IQR, 34-63 years), 51.0% were female, and 8.3%, 21.4%, 52.8%, 6.8%, and 10.7% were classified as CKM Stages 0, 1, 2, 3, and 4, respectively. Each 10-point increment in HEI-2020 score was associated with a progressively lower relative risk of more advanced CKM stages: the RRRs were 0.91 (95% CI, 0.82-1.01) for Stage 1, 0.82 (95% CI, 0.73-0.93) for Stage 2, 0.80 (95% CI, 0.69-0.93) for Stage 3, and 0.77 (95% CI, 0.66-0.90) for Stage 4. Compared with adults in the lowest quartile of HEI-2020 scores, those in the highest quartile had lower RRRs for advanced CKM stages: 0.79 (95% CI, 0.57-1.10) for Stage 1, 0.57 (95% CI, 0.39-0.83) for Stage 2, 0.50 (95% CI, 0.28-0.90) for Stage 3, and 0.38 (95% CI, 0.22-0.66) for Stage 4 (P for trend = 0.174, 0.005, 0.035, and 0.002, respectively). (Table 1) Conclusions: In this nationally representative sample of U.S. adults, higher HEI-2020 scores were associated with lower risk of advanced CKM stages, particularly Stages 2-4. Improving overall diet quality may help prevent progression and reduce the population burden of CKM syndrome.