Background/Objectives: The relationship between sustainable dietary patterns and cardiovascular disease (CVD) remains unclear. Therefore, we aim to evaluate the association between adherence to the Healthy and Sustainable Dietary Recommendations for the Spanish Population Index (HS-DRSI) and subclinical atherosclerosis.

Methods: A cross-sectional analysis was conducted among of 2,305 middle-aged men without CVD from the Aragon Workers’ Health Study. Dietary intake was assessed using a validated food frequency questionnaire, from which the HS-DRSI was calculated. Atherosclerotic plaques in carotid and femoral arteries were identified by ultrasounds. Logistic regression models evaluated the association between HS-DRSI adherence and presence of plaque. Restricted cubic spline models with 3 knots were used for the dose-response analysis.

Results: Participants with the highest adherence to the HS-DRSI (8-13 points) had a risk of plaque in the femoral territory and in at least one other territory that was about 25% lower than those with the lowest adherence (1-5 points). A slight U-shaped pattern was observed for carotid plaque and any plaque. Overall, the risk of all types of atherosclerosis decreased by approximately 10% per 1-SD (2-point) increase in the index.

Conclusions/Recommendations: Our results suggest that adherence to the HS-DRSI is associated with lower presence of subclinical atherosclerosis. Therefore, including sustainability criteria in national dietary guidelines may also protect cardiovascular health.

Funding: Health Research Fund FIS PI24/00479 and PI23/00240 (State Secretary of R+D and FEDER/FSE Instituto de Salud Carlos III., Spain).