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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 Mente30
Estimated H-index: 30
(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).
  • References (55)
  • Citations (168)
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References55
Newest
Published on Dec 1, 2017in Nutrition Journal 3.57
Steven Hamley5
Estimated H-index: 5
(Deakin University)
A cornerstone of conventional dietary advice is the recommendation to replace saturated fatty acids (SFA) with mostly n-6 polyunsaturated fatty acids (PUFA) to reduce the risk of coronary heart disease (CHD). Many clinical trials aimed to test this advice and have had their results pooled in several meta-analyses. However, earlier meta-analyses did not sufficiently account for major confounding variables that were present in some of those trials. Therefore, the aim of the study was to account fo...
21 Citations Source Cite
Published on Nov 1, 2017in The Lancet 53.25
Victoria Miller2
Estimated H-index: 2
(Population Health Research Institute),
Andrew Mente30
Estimated H-index: 30
(Population Health Research Institute)
+ 352 AuthorsScott A. Lear39
Estimated H-index: 39
(Simon Fraser University)
Summary Background The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. Methods We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-i...
59 Citations Source Cite
Published on Oct 1, 2017in The Lancet Diabetes & Endocrinology 19.31
Andrew Mente30
Estimated H-index: 30
(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 ...
35 Citations Source Cite
Published on Sep 1, 2016in American Journal of Public Health 4.38
Edward Yu8
Estimated H-index: 8
,
Eric B. Rimm166
Estimated H-index: 166
+ 6 AuthorsJoAnn E. Manson231
Estimated H-index: 231
Objectives. To review the contributions of the Nurses’ Health Studies (NHSs) to the understanding of cardiovascular disease etiology in women.Methods. We performed a narrative review of the publications of the NHS and NHS II between 1976 and 2016.Results. Diets low in trans fat, saturated fat, refined carbohydrates, and sugar-sweetened beverages and rich in fruits and vegetables, whole grains, and sources of unsaturated fats are associated with reduced risk of cardiovascular disease. Healthy lif...
22 Citations Source Cite
Jaike Praagman3
Estimated H-index: 3
,
Ester Al de Jonge7
Estimated H-index: 7
+ 6 AuthorsOscar H. Franco74
Estimated H-index: 74
Objective— We assessed whether the association between dietary saturated fatty acids (SFA) and incident coronary heart disease (CHD) depends on the food source, the carbon chain length of SFA, and the substituting macronutrient. Approach and Results— From the Rotterdam Study, 4722 men and women (≥55 years) were included. Baseline (1990–1993) SFA intake was assessed using a validated food frequency questionnaire. CHD (nonfatal myocardial infarction and fatal CHD) was ascertained by medical record...
16 Citations Source Cite
Published on Aug 1, 2016in JAMA Internal Medicine 19.99
Dong D. Wang19
Estimated H-index: 19
(Harvard University),
Yanping Li43
Estimated H-index: 43
(Harvard University)
+ 5 AuthorsFrank B. Hu202
Estimated H-index: 202
(Harvard University)
Importance Previous studies have shown distinct associations between specific dietary fat and cardiovascular disease. However, evidence on specific dietary fat and mortality remains limited and inconsistent. Objective To examine the associations of specific dietary fats with total and cause-specific mortality in 2 large ongoing cohort studies. Design, Setting, and Participants This cohort study investigated 83 349 women from the Nurses’ Health Study (July 1, 1980, to June 30, 2012) and 42 884 me...
117 Citations Source Cite
Published on Aug 1, 2016in The Lancet 53.25
Martin O'Donnell50
Estimated H-index: 50
(National University of Ireland, Galway),
Siu Lim Chin3
Estimated H-index: 3
(Population Health Research Institute)
+ 43 AuthorsSteven Agapay1
Estimated H-index: 1
(Population Health Research Institute)
Summary Background Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. Methods We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute firs...
253 Citations Source Cite
Published on Apr 12, 2016in BMJ 23.56
Christopher E. Ramsden16
Estimated H-index: 16
(University of North Carolina at Chapel Hill),
Daisy Zamora11
Estimated H-index: 11
(University of North Carolina at Chapel Hill)
+ 7 AuthorsJoseph R. Hibbeln46
Estimated H-index: 46
(National Institutes of Health)
Objective To examine the traditional diet-heart hypothesis through recovery and analysis of previously unpublished data from the Minnesota Coronary Experiment (MCE) and to put findings in the context of existing diet-heart randomized controlled trials through a systematic review and meta-analysis. Design The MCE (1968-73) is a double blind randomized controlled trial designed to test whether replacement of saturated fat with vegetable oil rich in linoleic acid reduces coronary heart disease and ...
114 Citations Source Cite
Published on Apr 1, 2016in Indian Journal of Medical Research 1.51
Indu Mani1
Estimated H-index: 1
(St. John's Medical College),
Anura V. Kurpad40
Estimated H-index: 40
(St. John's Medical College)
Recommended dietary allowances for fat and fatty acid (FA) intakes are set on global standards aimed at prevention of lifestyle diseases. Yet, the fat composition of a diet is both ethnic/region specific as well as income dependent. Indian diets are predominantly vegetarian and relatively low in fat. Furthermore, the main sources of fat are of plant origin rather than animal origin. This results in a diet that is relatively low in saturated FA, high in n-6 polyunsaturated fatty acids (PUFA), and...
4 Citations Source Cite
Published on Feb 1, 2016in The American Journal of Clinical Nutrition 6.55
Jaike Praagman3
Estimated H-index: 3
(Utrecht University),
Joline W.J. Beulens48
Estimated H-index: 48
(Utrecht University)
+ 4 AuthorsY. T. van der Schouw88
Estimated H-index: 88
(Utrecht University)
Background: The association between saturated fatty acid (SFA) intake and ischemic heart disease (IHD) risk is debated. Objective: We sought to investigate whether dietary SFAs were associated with IHD risk and whether associations depended on 1) the substituting macronutrient, 2) the carbon chain length of SFAs, and 3) the SFA food source. Design: Baseline (1993-1997) SFA intake was measured with a foodfrequency questionnaire among 35,597 participants from the European Prospective Investigation...
63 Citations Source Cite
Cited By168
Newest
Published on Apr 6, 2019in Lipids in Health and Disease 2.66
Yongjian Zhu (Zhengzhou University), Yacong Bo (Zhengzhou University), Yanhua Liu (Zhengzhou University)
Background Several epidemiological studies have investigated the association between dietary fat intake and cardiovascular disease. However, dietary recommendations based on systematic review and meta-analysis might be more credible.
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Published on Jul 3, 2019in OncoImmunology 5.50
Sarah Levesque4
Estimated H-index: 4
,
Jonathan Pol14
Estimated H-index: 14
+ 3 AuthorsGuido Kroemer191
Estimated H-index: 191
(Pierre-and-Marie-Curie University)
ABSTRACTDietary interventions have a profound impact on whole body metabolism, including oncometabolism (the metabolic features allowing cancer cells to proliferate) and immunometabolism (the catabolic and anabolic reactions that regulate immune responses). Recent preclinical studies demonstrated that multiple dietary changes can improve anticancer immunosurveillance of chemo-, radio- and immunotherapy. These findings have fostered the design of clinical trials evaluating the capacity of dietary...
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Published on Jun 1, 2019in The Lancet Global Health 18.70
David R. Jacobs143
Estimated H-index: 143
(University of Minnesota),
Daan Kromhout105
Estimated H-index: 105
(University Medical Center Groningen)
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Published on Jun 1, 2019in International Journal of Cardiology 4.03
Paul A. Camacho11
Estimated H-index: 11
(Autonomous University of Bucaramanga),
Johanna Otero2
Estimated H-index: 2
+ 16 AuthorsCarlos Cure2
Estimated H-index: 2
(Universidad del Norte, Colombia)
Abstract Background Dyslipidemia is a major risk factor for cardiovascular diseases (CVD). Worldwide, a third of ischemic heart disease is due to abnormal cholesterol levels and it is the most common cause of cardiovascular deaths in Colombia. In Colombia, no representative, large-scale study has assessed the prevalence of dyslipidemia. The aim of the present analysis was to identify the magnitude of the problem in Colombia, a middle-income-country with large regional, geographic, and socio-econ...
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Published on Jun 1, 2019in Nature Reviews Microbiology 31.85
Erica D. Sonnenburg8
Estimated H-index: 8
(Stanford University),
Justin L. Sonnenburg38
Estimated H-index: 38
(Stanford University)
Human-associated microbial communities have adapted to environmental pressures. Doses of antibiotics select for a community with increased antibiotic resistance, inflammation is accompanied by expansion of community members equipped to flourish in the presence of immune effectors and Western diets shift the microbiota away from fibre degraders in favour of species that thrive on mucus. Recent data suggest that the microbiota of industrialized societies differs substantially from the recent ances...
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