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The New Nordic Diet

This HEART UK Nutrition Academy webpage has been funded by Novartis Pharmaceuticals UK Ltd who have had no input into the content or development of this material.
 

The New Nordic Diet emphasises locally-sourced foods including oily fish, whole grains and berries and has been proven to reduce cardiovascular disease risk. 

Take home messages

  • The New Nordic Diet addresses health, gastronomy, Nordic identity and environmental sustainability.
  • The result is a plant-based diet that has similarities with other cardiovascular protective dietary patterns such as DASH, the Portfolio diet and the Mediterranean diet.
  • Unique to the New Nordic Diet is the emphasis on locally sourced and culturally relevant foods such as Lingonberries, apples and pears, up to three servings of fish a week, whole grains comprised mainly of rye bread, oats and barley, and cruciferous vegetables such as broccoli, kale and cabbages.
  • Red and processed meat, as well as sugary foods and drinks, are actively discouraged.
  • Plant proteins such as legumes and nuts are encouraged over animal proteins.
  • The New Nordic Diet boasts a cardioprotective nutrient profile: higher in polyunsaturated fats including EPA and DHA, low in saturated fat, salt and sugars, high in fibre and antioxidants through whole grains, fruit and vegetables.
  • Randomised controlled trials have demonstrated that for those at risk of cardiovascular disease the New Nordic Diet:
    • lowers blood total, LDL and non-HDL cholesterol levels
    • reduces body weight, and weight gain is slower
    • reduces body fat, especially around the abdomen.
  • Larger cohort studies have also demonstrated that greater adherence to the New Nordic Diet potentially:
    • reduces risk of CVD by more than half
    • reduces MI risk by up to 45%.
  • Benefits are incremental, emphasising that gradually adopting the New Nordic Diet facilitates dietary change while still realising cardiovascular benefits.

The New Nordic Diet (NND) was developed to cater specifically for the Nordic population. The diet has been adopted by eight Nordic countries and regions: Norway, Denmark and the Faroe Islands, Sweden, Finland, Greenland and Iceland1.

The NND tackles emerging issues related to non-communicable diseases and environmental concerns, as well as being enjoyable. This has resulted in a plant-based dietary pattern sharing similarities with well-established cardiovascular-protective diets such as the Mediterranean, DASH and Portfolio diet. Despite being relatively new, the evidence supporting the benefits of the NND for lipid management and cardiovascular health is accumulating.

What is the New Nordic Diet?

The NND prioritises three core principles1,2:

  1. Health: it is aligned with the Nordic Nutritional Recommendations to prevent non-communicable diseases and promote mental health and social well-being.
  2. Gastronomic potential and Nordic identity: it is focused on palatability and cultural acceptance.
  3. Environmental sustainability: it promotes local, organic and wild foods to reduce transportation, biodiversity loss and use of pesticides and fertilisers.

The diet is made up of the following foods:

  • It is rich in vegetables, especially cruciferous such as cabbages, Brussels sprouts, kale, broccoli and carrots as well as salad vegetables and tubers.
  • It is rich in locally sourced fruits such as apples, pears, and specific local berries including blackberries and lingonberries.
  • Whole grains, especially rye, barley and oats.
  • Fish that are abundant in the region, especially oily fish – up to three servings a week. Seaweed is also recommended.
  • Low fat dairy, in moderation.
  • Fats, predominantly from rapeseed oil and spreads.
  • Legumes and nuts as key protein sources.
  • Small quantities of lean meat and wild meats like game and reindeer.
  • Limited red and processed meat.
  • Limited sugar sweetened beverages and snacks.

Many of the above foods are also common in the UK, thus, there is no reason why the NND, with a handful of adaptations, cannot be adopted in the UK.

The NND and cardiovascular risk factors

As the diet is similar to other plant-based, heart-healthy diets such as the Mediterranean, DASH, and Portfolio diets, it should not be surprising that it has been shown to have cardiovascular benefits1,3,4.

Randomised trials have shown promise for the NND, demonstrating benefits for those at risk of cardiovascular diseases (CVD) in blood lipids and body fat.

The NND improves blood lipids

In a non-blinded randomised trial, the impact of the NND was compared with the Average Danish Diet (ADD), representing typical Western European eating patterns5. Over six months, 147 Danish participants with a high waist circumference and one other metabolic risk factor followed either the NND or ADD.

The NND group had significantly different dietary patterns compared to the ADD, with lower saturated fats and sugars and higher intake of fish, fruits, vegetables and whole grains. After six months, the NND group demonstrated notable reductions in:

  • Total cholesterol -0.24mmol/L, p=0.010
  • Very low density lipoprotein (VLDL) cholesterol -0.07mmol/L, p=0.05
  • Triglycerides (TGs) -0.17mmol/L p=0.004

In the Swedish NORDIET study, 88 mildly hypercholesterolaemic patients (LDL cholesterol ≥3.5mmol/L) were randomised to follow either the NND or a control diet (typical Swedish dietary pattern) for six weeks6.  Compared to the control diet group, the NND resulted in significant reduction in:

  • Total cholesterol -16%, p<0.001
  • LDL cholesterol -21%, p<0.01
  • HDL cholesterol -5%, p<0.01

The Nordic SYSTDIET study focused on 154 individuals with metabolic syndrome who were randomised to either the NND or their usual diet7.  After 18 weeks, the NND group, compared to the control group, had significant improvements in blood lipids:

  • LDL cholesterol -0.28mmol/L, p=0.012
  • Non-HDL cholesterol -0.29mmol/L, p=0.02
  • Total to HDL cholesterol ratio -0.31mmol/L, p=0.005

These findings aligned with an earlier publication by the same group8.

In a more recent 12-week intervention study, the NND was found to significantly lower blood total cholesterol and TGs compared to a control diet9.

In summary, the NND is notably lower in SFAs and higher in PUFA, particularly fish omega-3 fats. RCTs have consistently demonstrated that the NND significantly reduces blood lipids compared to a typical diet.

The NND, body weight and fat tissue

Excessive adipose tissue, particularly visceral fat, poses a risk for CVD and metabolic disorders, including type 2 diabetes5.

In the Danish study by Paulsen et al. in which participants had a high waist circumference, the NND group had greater reductions in body weight and adiposity compared to the control group5:

  • Weight loss: -3.22kg, p<0.001
  • Waist circumferences: -2.94 cm, p<0.001
  • Fat mass: -2.7kg, p<0.001
  • Sagittal diameter (abdominal fat measure): -0.83cm, p=0.003

Over a 52-week follow-up, NND adherence remained relatively high and despite both groups regaining weight, weight gain in the NND groups was significantly lower10. This follow up study also emphasised the role of physical activity in preventing weight gain, with physically active individuals regaining 3.4kg less than their inactive counterparts.

A systematic review and meta-analysis of seven randomised trials with 774 participants revealed that following the NND resulted in 1.83kg less weight gain than the control diets (p=0.001)11. A prospective Finnish study (DILGOM) with 3,735 participants found that higher NND adherence was associated with less weight gain3. And finally, a more recent 12-week intervention study from Sweden, found that those following the NND had a significantly lower BMI and waist circumference9.

In summary, the NND is linked to lower body weight, adiposity, and waist circumference compared to Western eating habits. It also reduces the rate of weight gain.

The NND and blood pressure

Hypertension is a key risk factor for CVD, and the Danish study by Poulsen et al. reported systolic blood pressure to be 5.1 mmHg lower in the NND group compared to the control group (p=0.041)5.

In a subgroup analysis of 37 participants with metabolic syndrome from the original SYSDIET study, the NND group, after 12 weeks, showed significantly lower diastolic blood pressure12:

  • Mean arterial pressure: -4.2 mmHg, p=0.006
  • Diastolic blood pressure: -4.4 mmHg, p=0.001

In summary, while the NND's impact on blood pressure is less explored, published RCTs  suggest it can effectively reduce it.

Long-term cardiovascular benefits

Most studies published to date have used datasets from cohort studies, examining the extent of adherence to the NND and its correlation with cardiovascular or metabolic outcomes. Cohort studies have looked at the association between the degree of adherence to the NND over a longer period, and the impact on CVD outcomes.

NND scoring systems

Two validated scoring systems are commonly used to assess adherence to the NND3,13. Both provide a score range, with lower scores indicating poor adherence and higher scores reflecting better adherence.

Baltic Sea Diet Score (BSDS)3: 0-25

The BSDS, the most comprehensive score, assesses six food groups with a positive and three with a negative nutrient profile.  The nine foods are categorised into quartiles based on consumption levels. Scores range from 0 to 3, with the first quartile scoring 0 and the fourth quartile scoring 3 for health-beneficial foods. Conversely, for foods with negative health associations, the score allocation is reversed. The BSDS also considers meal patterns.

Heathy Nordic Food Index (HNFI)13: 0-6

The HNFI provides a simplified score range, focusing on the consumption of six positive food recommendations from the NND. Median intakes of these six food groups are typically identified using food frequency questionnaires (FFQ). A score of 0 is assigned to intakes below the median, while a score of 1 is given to intakes meeting or surpassing the median.

 

The HNFI has been criticised for its simplicity, potentially underestimating the impact of NND on CVD outcomes. Unlike BSDS, HNFI does not consider the ratio of polyunsaturated fatty acids (PUFA) to saturated fatty acids (SFA), a crucial dietary factor influencing LDL cholesterol and the subsequent risk of CVD14–16.

The evidence from cohort studies

  • In a 2015 study using 10-year follow-up data from the 1991/2 Swedish Women's Lifestyle and Health Cohort, the HNFI score was used to assess 43,000 FFQs for adherence to the NND. Notably, there was no observed correlation between the HNFI score and CVD17. The accompanying editorial highlighted the omission of considering the fat quality in the diet as a potential reason for this absence of correlation14.
  • Subsequently, the HNFI scoring system was used to evaluate adherence to the NND, using FFQ data from 57,053 individuals aged 50-64 years taking part in the Danish Diet, Cancer, and Health Cohort study13. The findings revealed a 23% and 45% lower risk of myocardial infarction (MI) in men and women, respectively, with HNFI scores of 5-6 (indicating high adherence) compared to those with the lowest adherence (score of 0). Another analysis within the same dataset also demonstrated a 14% reduction in strokes for the highest adherence group compared to the lowest18.
  • In 2020, the BSDS was used to evaluate NND adherence using four-day food records from the Finnish Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) involving 1,547 men aged 42-6019. Compared to the highest quartile for adherence, the lowest quartile had a 39% increased risk of CVD death (p=0.049) and a 27% increased risk of all-cause mortality (p<0.001) after a 23.6-year follow-up20.
  • A more recent study, explored adherence to the NND in a non-Nordic population group from the Tehran Lipid and Glucose Study21. Using FFQs from 2,918 adult men and women (mean age 39 years), a modified BSDS score (ranged 0-24, excluding alcohol) was applied. Quartile analysis revealed a 36% reduced risk of CVD for the third quartile and a 52% reduced risk for the fourth quartile compared to the first quartile (lowest adherence). Higher intakes of whole grains, low-fat dairy and fish contributed significantly to the positive effect.

In summary, cohort studies demonstrate the cardiovascular benefits of following the NND.

The NND and type 2 diabetes

The impact of the NND on type 2 diabetes has also been investigated as it is one of the primary non-communicable diseases and a significant risk factor for CVD.

Studies on the correlation between the NND and type 2 diabetes risk show mixed results. While data from the Helsinki Birth Cohort Study and the Health 2000 Survey22, along with a study involving 2,285 older men from the KIHD study23, found no link between BSDS and type 2 diabetes risk, a contradictory result emerged from a publication using data from the Danish Diet, Cancer, and Health Cohort24. This study, with over 55,000 participants and 7,366 cases of type 2 diabetes, revealed a 25% lower incidence in men and a 38% lower incidence in women with the highest HNFI scores (5-6) after a 15.6-year follow-up.

The discrepancy in outcomes is likely due to the significantly larger participant pool (over 55,000) in the latter study24 compared to the smaller cohorts in the first two publications (4,923 and 2,285 participants)22,23. The substantial difference in sample sizes underscores the importance of considering study size and statistical power when interpreting findings.

In summary

The NND is a healthy plant-based diet made up of foods known to help manage blood lipids and reduce the risk of CVD and other metabolic factors, including being overweight and type 2 diabetes. It differs from the Mediterranean diet in that it prioritises foods locally sourced and culturally appropriate in Nordic countries, such as rye bread, certain berries, apples, pears and oil-rich fish. It also contains mainly polyunsaturated fatty acids as opposed to monounsaturated fats in the Mediterranean diet.

Intervention studies of groups at risk of CVD reveal the NND's protective role in terms of blood pressure, body weight, adiposity and blood lipids. Encouragingly, large cohort studies indicate the potential to significantly reduce CVD risk by more than half, and lower myocardial infarction risk by up to 45%. Moreover, the incremental benefits associated with gradual adoption of the diet offer a flexible approach to reducing risk gradually.

Of particular interest is the suggestion from a large cohort study that high compliance with the NND is linked to a reduced risk of developing type 2 diabetes, underlining the comprehensive health benefits associated with this dietary approach.

References

  1. Krznarić Ž, Karas I, Ljubas Kelečić D, Vranešić Bender D. The Mediterranean and Nordic Diet: A Review of Differences and Similarities of Two Sustainable, Health-Promoting Dietary Patterns. Front Nutr. 2021;8:683678. doi:10.3389/fnut.2021.683678
  2. Mithril C, Dragsted LO, Meyer C, Tetens I, Biltoft-Jensen A, Astrup A. Dietary composition and nutrient content of the New Nordic Diet. Public Health Nutr. 2013;16(5):777-785. doi:10.1017/S1368980012004521
  3. Kanerva N, Kaartinen NE, Schwab U, Lahti-Koski M, Männistö S. The Baltic Sea Diet Score: a tool for assessing healthy eating in Nordic countries. Public Health Nutr. 2014;17(8):1697-1705. doi:10.1017/S1368980013002395
  4. Mithril C, Dragsted LO, Meyer C, Blauert E, Holt MK, Astrup A. Guidelines for the New Nordic Diet. Public Health Nutr. 2012;15(10):1941-1947. doi:10.1017/S136898001100351X
  5. Poulsen SK, Due A, Jordy AB, et al. Health effect of the New Nordic Diet in adults with increased waist circumference: a 6-mo randomized controlled trial. Am J Clin Nutr. 2014;99(1):35-45. doi:10.3945/ajcn.113.069393
  6. Adamsson V, Reumark A, Fredriksson IB, et al. Effects of a healthy Nordic diet on cardiovascular risk factors in hypercholesterolaemic subjects: a randomized controlled trial (NORDIET). J Intern Med. 2011;269(2):150-159. doi:10.1111/j.1365-2796.2010.02290.x
  7. Marklund M, Magnusdottir OK, Rosqvist F, et al. A dietary biomarker approach captures compliance and cardiometabolic effects of a healthy Nordic diet in individuals with metabolic syndrome. J Nutr. 2014;144(10):1642-1649. doi:10.3945/jn.114.193771
  8. Uusitupa M, Hermansen K, Savolainen MJ, et al. Effects of an isocaloric healthy Nordic diet on insulin sensitivity, lipid profile and inflammation markers in metabolic syndrome -- a randomized study (SYSDIET). J Intern Med. 2013;274(1):52-66. doi:10.1111/joim.12044
  9. Ohlsson B. An Okinawan-based Nordic diet improves glucose and lipid metabolism in health and type 2 diabetes, in alignment with changes in the endocrine profile, whereas zonulin levels are elevated. Exp Ther Med. 2019;17(4):2883-2893. doi:10.3892/etm.2019.7303
  10. Poulsen SK, Crone C, Astrup A, Larsen TM. Long-term adherence to the New Nordic Diet and the effects on body weight, anthropometry and blood pressure: a 12-month follow-up study. Eur J Nutr. 2015;54(1):67-76. doi:10.1007/s00394-014-0686-z
  11. Ramezani-Jolfaie N, Mohammadi M, Salehi-Abargouei A. Effects of a healthy Nordic diet on weight loss in adults: a systematic review and meta-analysis of randomized controlled clinical trials. Eat Weight Disord. 2020;25(5):1141-1150. doi:10.1007/s40519-019-00773-x
  12. Brader L, Uusitupa M, Dragsted LO, Hermansen K. Effects of an isocaloric healthy Nordic diet on ambulatory blood pressure in metabolic syndrome: a randomized SYSDIET sub-study. Eur J Clin Nutr. 2014;68(1):57-63. doi:10.1038/ejcn.2013.192
  13. Gunge VB, Andersen I, Kyrø C, et al. Adherence to a healthy Nordic food index and risk of myocardial infarction in middle-aged Danes: the diet, cancer and health cohort study. Eur J Clin Nutr. 2017;71(5):652-658. doi:10.1038/ejcn.2017.1
  14. Risérus U. Healthy Nordic diet and cardiovascular disease. Journal of Internal Medicine. 2015;278(5):542-544. doi:10.1111/joim.12408
  15. Li Y, Hruby A, Bernstein AM, et al. Saturated Fats Compared With Unsaturated Fats and Sources of Carbohydrates in Relation to Risk of Coronary Heart Disease: A Prospective Cohort Study. Journal of the American College of Cardiology. 2015;66(14):1538-1548. doi:10.1016/j.jacc.2015.07.055
  16. Mensink RP, World Health Organization. Effects of Saturated Fatty Acids on Serum Lipids and Lipoproteins: A Systematic Review and Regression Analysis. World Health Organization; 2016. Accessed October 16, 2023. https://iris.who.int/handle/10665/246104
  17. Roswall N, Sandin S, Scragg R, et al. No association between adherence to the healthy Nordic food index and cardiovascular disease amongst Swedish women: a cohort study. J Intern Med. 2015;278(5):531-541. doi:10.1111/joim.12378
  18. Hansen CP, Overvad K, Kyrø C, et al. Adherence to a Healthy Nordic Diet and Risk of Stroke: A Danish Cohort Study. Stroke. 2017;48(2):259-264. doi:10.1161/STROKEAHA.116.015019
  19. Tertsunen HM, Hantunen S, Tuomainen TP, Virtanen JK. Healthy Nordic diet and risk of disease death among men: the Kuopio Ischaemic Heart Disease Risk Factor Study. Eur J Nutr. 2020;59(8):3545-3553. doi:10.1007/s00394-020-02188-2
  20. Tertsunen HM, Hantunen S, Tuomainen TP, Salonen JT, Virtanen JK. A healthy Nordic diet score and risk of incident CHD among men: the Kuopio Ischaemic Heart Disease Risk Factor Study. British Journal of Nutrition. 2022;127(4):599-606. doi:10.1017/S0007114521001227
  21. Mirmiran P, Estaki S, Yadegari A, Golzarand M, Azizi F. Adherence to a modified nordic diet and the risk of cardiovascular events in a non-nordic population: a prospective cohort study. Eur J Clin Nutr. 2023;77(9):919-924. doi:10.1038/s41430-023-01325-4
  22. Kanerva N, Rissanen H, Knekt P, Havulinna AS, Eriksson JG, Männistö S. The healthy Nordic diet and incidence of Type 2 Diabetes — 10-year follow-up. Diabetes Research and Clinical Practice. 2014;106(2):e34-e37. doi:10.1016/j.diabres.2014.08.016
  23. Tertsunen HM, Hantunen S, Tuomainen TP, Virtanen JK. Adherence to a healthy Nordic diet and risk of type 2 diabetes among men: the Kuopio Ischaemic Heart Disease Risk Factor Study. Eur J Nutr. 2021;60(7):3927-3934. doi:10.1007/s00394-021-02569-1
  24. Lacoppidan SA, Kyrø C, Loft S, et al. Adherence to a Healthy Nordic Food Index Is Associated with a Lower Risk of Type-2 Diabetes--The Danish Diet, Cancer and Health Cohort Study. Nutrients. 2015;7(10):8633-8644. doi:10.3390/nu7105418

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