Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study

Published on Nov 1, 2017in The Lancet 53.25
· DOI :10.1016/S0140-6736(17)32252-3
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute),
Andrew Mente29
Estimated H-index: 29
(McMaster University)
+ 352 AuthorsR Mapanga4
Estimated H-index: 4
Abstract
Summary Background The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear. Methods The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35–70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3–9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. Findings During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12–1·46], p trend =0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67–0·87], p trend trend =0·0088; monounsaturated fat: HR 0·81 [0·71–0·92], p trend trend vs quintile 1, HR 0·79 [95% CI 0·64–0·98], p trend =0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality. Interpretation High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings. Funding Full funding sources listed at the end of the paper (see Acknowledgments).
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References55
Published on Jan 31, 1980
Ancel Keys67
Estimated H-index: 67
1,425 Citations Source Cite
Published on Jun 10, 2015in Cochrane Database of Systematic Reviews 6.75
Lee Hooper50
Estimated H-index: 50
(University of East Anglia),
Nicole Martin5
Estimated H-index: 5
(University of London)
+ 1 AuthorsGeorge Davey-Smith173
Estimated H-index: 173
(University of Bristol)
Background Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally it is unclear whether the energy from saturated fats that are lost in the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein. This review is part of a series split from and updating an overarching review. Objectives To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO),...
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Published on Oct 1, 2015in Journal of the American College of Cardiology 16.83
Yanping Li42
Estimated H-index: 42
(Harvard University),
Adela Hruby18
Estimated H-index: 18
(Harvard University)
+ 8 AuthorsBarry M. Popkin317
Estimated H-index: 317
(Harvard University)
Abstract Background The associations between dietary saturated fats and the risk of coronary heart disease (CHD) remain controversial, but few studies have compared saturated with unsaturated fats and sources of carbohydrates in relation to CHD risk. Objectives This study sought to investigate associations of saturated fats compared with unsaturated fats and different sources of carbohydrates in relation to CHD risk. Methods We followed 84,628 women (Nurses’ Health Study, 1980 to 2010), and 42,9...
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Published on Jul 13, 1996in BMJ 23.56
Alberto Ascherio115
Estimated H-index: 115
(Harvard University),
Eric B. Rimm165
Estimated H-index: 165
(Harvard University)
+ 3 AuthorsBarry M. Popkin317
Estimated H-index: 317
(Harvard University)
Abstract Objective : To examine the association between fat intake and the incidence of coronary heart disease in men of middle age and older. Design : Cohort questionnaire study of men followed up for six years from 1986. Setting : The health professionals follow up study in the United States. Subjects : 43 757 health professionals aged 40 to 75 years free of diagnosed cardiovascular disease or diabetes in 1986. Main outcome measure : Incidence of acute myocardial infarction or coronary death. ...
614 Citations Source Cite
Published on Oct 1, 2013in Public Health Nutrition 2.48
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute),
Solange Martinez1
Estimated H-index: 1
(University of La Frontera)
+ 4 AuthorsAnwar T. Merchant ScD Mph Dmd35
Estimated H-index: 35
(University of South Carolina)
Objective FFQ are commonly used to rank individuals by their food and nutrient intakes in large epidemiological studies. The purpose of the present study was to develop and validate an FFQ to rank individuals participating in an ongoing Prospective Urban and Rural Epidemiological (PURE) study in Chile. Design An FFQ and four 24 h dietary recalls were completed over 1 year. Pearson correlation coefficients, energy-adjusted and de-attenuated correlations and weighted kappa were computed between th...
13 Citations Source Cite
Published on May 25, 2012in PLOS ONE 2.77
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute),
Silvia del Cerro1
Estimated H-index: 1
+ 4 AuthorsAnwar T. Merchant ScD Mph Dmd35
Estimated H-index: 35
(University of South Carolina)
Background The Food Frequency Questionnaire (FFQ) is the most commonly used method for ranking individuals based on long term food intake in large epidemiological studies. The validation of an FFQ for specific populations is essential as food consumption is culture dependent. The aim of this study was to develop a Semi-quantitative Food Frequency Questionnaire (SFFQ) and evaluate its validity and reproducibility in estimating nutrient intake in urban and rural areas of Argentina. Methods/Princip...
27 Citations Source Cite
Published on Oct 5, 2011in PLOS ONE 2.77
Koert N.J. Burger34
Estimated H-index: 34
(Utrecht University),
Joline W.J. Beulens46
Estimated H-index: 46
(Utrecht University)
+ 2 AuthorsDaphne L. van der A40
Estimated H-index: 40
Background The associations of glycemic load (GL) and glycemic index (GI) with the risk of cardiovascular diseases (CVD) are not well-established, particularly in men, and may be modified by gender. Objective To assess whether high dietary GL and GI increase the risk of CVD in men and women. Methods A large prospective cohort study (EPIC-MORGEN) was conducted within the general Dutch population among 8,855 men and 10,753 women, aged 21–64 years at baseline (1993–1997) and free of diabetes and CV...
50 Citations Source Cite
Published on Jan 1, 2009in Annals of Nutrition and Metabolism 3.05
Pekka Puska23
Estimated H-index: 23
(National Institute for Health and Welfare)
Background/Methods: The exceptionally high mortality from cardiovascular disease (CVD) in the Finnish population in the 1970s ensued the initiation of preventive health intervention
43 Citations Source Cite
Published on May 22, 2012in Circulation 18.88
S Parish54
Estimated H-index: 54
(Clinical Trial Service Unit),
Alison Offer7
Estimated H-index: 7
(Clinical Trial Service Unit)
+ 5 AuthorsRory Collins128
Estimated H-index: 128
(Clinical Trial Service Unit)
Background—Low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol are established risk factors for vascular disease, but lipoprotein particle concentrations may be stronger determinants of risk. Methods and Results—Associations between vascular events and baseline concentrations of cholesterol fractions, apolipoproteins B and A1, and lipoprotein particles assessed by nuclear magnetic resonance were considered in the Heart Protection Study randomized trial of sim...
130 Citations Source Cite
Published on Dec 20, 2012in PLOS ONE 2.77
Jingyao Fan3
Estimated H-index: 3
(Peking Union Medical College),
Yiqing Song3
Estimated H-index: 3
(Peking University)
+ 2 AuthorsWeili Zhang17
Estimated H-index: 17
(Peking Union Medical College)
Background The relationship between dietary glycemic index, glycemic load and risk of coronary heart disease (CHD), stroke, and stroke-related mortality is inconsistent.
73 Citations Source Cite
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Cited By145
Published on Sep 1, 2016in Atherosclerosis 4.47
Marcus E. Kleber45
Estimated H-index: 45
(Heidelberg University),
Graciela Delgado19
Estimated H-index: 19
(Heidelberg University)
+ 2 AuthorsClemens von Schacky25
Estimated H-index: 25
(Ludwig Maximilian University of Munich)
Background Saturated fatty acids are thought to be harmful by increasing the risk for cardiovascular events. Objective We examined the associations of erythrocyte saturated fatty acids with total and cardiovascular mortality in patients referred for coronary angiography. Methods Red blood cell saturated fatty acid (RBC SFA) proportions were measured by gas chromatography at baseline in 3259 participants of the Ludwigshafen Risk and Cardiovascular Health study. Associations of saturated fatty aci...
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Published on Nov 1, 2017in The Lancet 53.25
Christopher E. Ramsden16
Estimated H-index: 16
(National Institutes of Health),
Anthony F. Domenichiello12
Estimated H-index: 12
(National Institutes of Health)
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Published on Sep 7, 2017in NEJM Journal Watch
Bruce H. Soloway2
Estimated H-index: 2
Standard dietary advice to restrict total fat and saturated fatty acids (<30% and <10% of total energy, respectively) is based largely on a few
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Published on Oct 1, 2017in The Lancet Diabetes & Endocrinology 19.31
Andrew Mente29
Estimated H-index: 29
(McMaster University),
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute)
+ 420 AuthorsSun Yi5
Estimated H-index: 5
(Peking Union Medical College)
Summary Background The relation between dietary nutrients and cardiovascular disease risk markers in many regions worldwide is unknown. In this study, we investigated the effect of dietary nutrients on blood lipids and blood pressure, two of the most important risk factors for cardiovascular disease, in low-income, middle-income, and high-income countries. Methods We studied 125 287 participants from 18 countries in North America, South America, Europe, Africa, and Asia in the Prospective Urban ...
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Published on Oct 1, 2017in The Lancet Diabetes & Endocrinology 19.31
Nita G. Forouhi73
Estimated H-index: 73
(University of Cambridge),
Naveed Sattar113
Estimated H-index: 113
(University of Oxford),
Fumiaki Imamura27
Estimated H-index: 27
(University of Cambridge)
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Cornelie Nienaber-Rousseau4
Estimated H-index: 4
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Olusola F. Sotunde2
Estimated H-index: 2
+ 6 AuthorsH. Salome Kruger12
Estimated H-index: 12
The rising prevalence of obesity and excessive adiposity are global public health concerns. Understanding determinants of changes in adiposity over time is critical for informing effective evidence-based prevention or treatment. However, limited information is available to achieve this objective. Cultural, demographic, environmental, and behavioral factors including socio-economic status (SES) likely account for obesity development. To this end, we related these variables to anthropometric measu...
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Published on Oct 1, 2017in Cell Metabolism 20.57
Meenakshi Ravichandran2
Estimated H-index: 2
(École Polytechnique Fédérale de Lausanne),
Gerald Grandl4
Estimated H-index: 4
,
Michael Ristow47
Estimated H-index: 47
(École Polytechnique Fédérale de Lausanne)
The prospective cohort study, named PURE, found that in >135,000 participants from 18 countries, nutritive carbohydrates increase human mortality, whereas dietary fat reduces it, requesting a fundamental change of current nutritional guidelines. Experimental evidence from animal models provides synergizing mechanistic concepts as well as pharmacological options to mimic low-carb or ketogenic diets.
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Published on Dec 1, 2017in Nutrition Metabolism and Cardiovascular Diseases 3.32
Peter M. Clifton64
Estimated H-index: 64
(University of South Australia),
Jennifer B. Keogh38
Estimated H-index: 38
(University of South Australia)
Abstract Aims Over the last 7 years there has been intense debate about the advice to reduce saturated fat and increase polyunsaturated fat to reduce CVD risk. The aim of this review was to examine systematic reviews and meta-analyses since 2010 on this topic plus additional cohort studies and interventions not included in these reviews. Data Synthesis High saturated and trans fat intake (which elevates LDL like saturated fat) in the Nurses and Health Professional Follow-Up Studies combined is a...
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Published on Oct 20, 2017in Nutrients 4.20
Tsutomu Sasaki27
Estimated H-index: 27
We are what we eat. There are three aspects of feeding: what, when, and how much. These aspects represent the quantity (how much) and quality (what and when) of feeding. The quantitative aspect of feeding has been studied extensively, because weight is primarily determined by the balance between caloric intake and expenditure. In contrast, less is known about the mechanisms that regulate the qualitative aspects of feeding, although they also significantly impact the control of weight and health....
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Published on Nov 8, 2017in Frontiers in Public Health
Tanja Pekez-Pavlisko1
Estimated H-index: 1
,
Maja Račić3
Estimated H-index: 3
(University of East Sarajevo),
Srebrenka Kusmuk1
Estimated H-index: 1
(University of East Sarajevo)
Background: During the transition processes, the Western Balkan countries were affected by conflicts and transition related changes. Life expectancy in these countries is lower, while the mortality from non-communicable diseases is higher in comparison with western and northern parts of Europe. The primary aim of this study was to analyze the treatment possibilities for the most common non-communicable diseases in the Western Balkan countries. The secondary aim was to understand and compare the ...
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