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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 Lancet59.10
· 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
Cite
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 Journal3.59
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...
Published on Nov 1, 2017in The Lancet59.10
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
(SFU: 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...
Published on Oct 1, 2017in The Lancet Diabetes & Endocrinology24.54
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 ...
Published on Sep 1, 2016in American Journal of Public Health5.38
Edward Yu8
Estimated H-index: 8
,
Eric B. Rimm166
Estimated H-index: 166
+ 6 AuthorsJoAnn E. Manson232
Estimated H-index: 232
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...
Published on Sep 1, 2016in Arteriosclerosis, Thrombosis, and Vascular Biology6.62
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...
Published on Aug 1, 2016in JAMA Internal Medicine20.77
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...
Published on Aug 1, 2016in The Lancet59.10
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...
Published on Apr 12, 2016in BMJ27.60
Christopher E. Ramsden16
Estimated H-index: 16
(UNC: University of North Carolina at Chapel Hill),
Daisy Zamora11
Estimated H-index: 11
(UNC: University of North Carolina at Chapel Hill)
+ 7 AuthorsJoseph R. Hibbeln46
Estimated H-index: 46
(NIH: 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 ...
Published on Apr 1, 2016in Indian Journal of Medical Research1.25
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...
Published on Feb 1, 2016in The American Journal of Clinical Nutrition6.57
Jaike Praagman3
Estimated H-index: 3
(UU: Utrecht University),
Joline W.J. Beulens48
Estimated H-index: 48
(UU: Utrecht University)
+ 4 AuthorsY. T. van der Schouw88
Estimated H-index: 88
(UU: 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...
Cited By168
Newest
Published on Dec 1, 2019in Cardiovascular Diabetology5.95
Alessandra Alves da Silva2
Estimated H-index: 2
(UFV: Universidade Federal de Viçosa),
Ana Paula Silva Caldas3
Estimated H-index: 3
(UFV: Universidade Federal de Viçosa)
+ 4 AuthorsJosefina Bressan25
Estimated H-index: 25
(UFV: Universidade Federal de Viçosa)
The triglyceride-glucose index (TyG index) is a tool for insulin resistance evaluation, however, little is known about its association with coronary artery disease (CAD), which is the major cardiovascular death cause, and what factors may be associated with TyG index. To evaluate the association between the TyG index and the prevalence of CAD phases, as well as cardiovascular risk factors. The baseline data of patients in secondary care in cardiology from Brazilian Cardioprotective Nutritional P...
Published on Apr 6, 2019in Lipids in Health and Disease2.65
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.
Published on 2019in Scientific Reports4.01
Gidon Eshel7
Estimated H-index: 7
(Bard College),
Paul Stainier (Harvard University)+ 1 AuthorsAkshay Swaminathan (Harvard University)
Because meat is more resource intensive than vegetal protein sources, replacing it with efficient plant alternatives is potentially desirable, provided these alternatives prove nutritionally sound. We show that protein conserving plant alternatives to meat that rigorously satisfy key nutritional constraints while minimizing cropland, nitrogen fertilizer (Nr) and water use and greenhouse gas (GHG) emissions exist, and could improve public health. We develop a new methodology for identifying nutri...
Published on Dec 1, 2019in Scientific Reports4.01
Tilakavati Karupaiah9
Estimated H-index: 9
(Taylors University),
Khun-Aik Chuah1
Estimated H-index: 1
(UKM: National University of Malaysia)
+ 4 AuthorsKalyana Sundram22
Estimated H-index: 22
We conducted this cross-sectional population study with a healthy multi-ethnic urban population (n = 577) in Malaysia, combining nutritional assessments with cardiometabolic biomarkers defined by lipid, atherogenic lipoproteins, inflammation and insulin resistance. We found diametrically opposing associations of carbohydrate (246·6 ± 57·7 g, 54·3 ± 6·5%-TEI) and fat (total = 64·5 ± 19·8 g, 31·6 ± 5·5%-TEI; saturated fat = 14·1 ± 2·7%-TEI) intakes as regards waist circumference, HDL-C, blood pres...
Published on May 16, 2019in Nature Reviews Cardiology17.42
Jason H.Y. Wu33
Estimated H-index: 33
(The George Institute for Global Health),
Renata Micha38
Estimated H-index: 38
(Tufts University),
Dariush Mozaffarian113
Estimated H-index: 113
(Tufts University)
The effect of dietary fats on cardiometabolic diseases, including cardiovascular diseases and type 2 diabetes mellitus, has generated tremendous interest. Many earlier investigations focused on total fat and conventional fat classes (such as saturated and unsaturated fats) and their influence on a limited number of risk factors. However, dietary fats comprise heterogeneous molecules with diverse structures, and growing research in the past two decades supports correspondingly complex health effe...
Published on 2019in Advances in Nutrition7.24
Kristin Hirahatake1
Estimated H-index: 1
(UCI: University of California, Irvine),
Richard S. Bruno33
Estimated H-index: 33
(OSU: Ohio State University)
+ 3 AuthorsSean H. Adams33
Estimated H-index: 33
(University of Arkansas for Medical Sciences)
Published on Sep 20, 2019
Peter Horton79
Estimated H-index: 79
(University of Sheffield),
Christian John Reynolds10
Estimated H-index: 10
(University of Sheffield)
+ 1 AuthorsGavin Milligan
Achieving global food security requires a new approach that integrates not only all aspects of the growing, harvesting and processing of food (necessary to ensure sufficient affordable and sustainable production to alleviate hunger) but also the complexities associated with food consumption including deterring unhealthy overconsumption. Inefficiencies occur at various points along the agri-food supply chain but at present they are inadequately conceptualized via separate accounts of food loss, f...
Published on Sep 19, 2019in European Journal of Preventive Cardiology5.64
Tommaso Gori41
Estimated H-index: 41
,
Kudrat Rakhimov
Published on May 16, 2019in European Heart Journal23.24
Russell J. de Souza35
Estimated H-index: 35
(McMaster University),
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute),
Sonia S. Anand74
Estimated H-index: 74
(McMaster University)
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