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Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study

Published on Oct 1, 2017in The Lancet Diabetes & Endocrinology 19.31
· DOI :10.1016/S2213-8587(17)30283-8
Andrew Mente30
Estimated H-index: 30
(McMaster University),
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute)
+ 420 AuthorsR Mapanga4
Estimated H-index: 4
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 Rural Epidemiology (PURE) study. Habitual food intake was measured with validated food frequency questionnaires. We assessed the associations between nutrients (total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol) and cardiovascular disease risk markers using multilevel modelling. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intakes by use of nutrient density models. We did simulation modelling in which we assumed that the effects of saturated fatty acids on cardiovascular disease events was solely related to their association through an individual risk marker, and then compared these simulated risk marker-based estimates with directly observed associations of saturated fatty acids with cardiovascular disease events. Findings Participants were enrolled into the study from Jan 1, 2003, to March 31, 2013. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, but also with higher HDL cholesterol and apolipoprotein A1 (ApoA1), and lower triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ratio of apolipoprotein B (ApoB) to ApoA1 (all p trend trend trend =0·0014]). Higher intakes of total fat, saturated fatty acids, and carbohydrates were associated with higher blood pressure, whereas higher protein intake was associated with lower blood pressure. Replacement of saturated fatty acids with carbohydrates was associated with the most adverse effects on lipids, whereas replacement of saturated fatty acids with unsaturated fats improved some risk markers (LDL cholesterol and blood pressure), but seemed to worsen others (HDL cholesterol and triglycerides). The observed associations between saturated fatty acids and cardiovascular disease events were approximated by the simulated associations mediated through the effects on the ApoB-to-ApoA1 ratio, but not with other lipid markers including LDL cholesterol. Interpretation Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk. Funding Full funding sources listed at the end of the paper (see Acknowledgments).
  • References (31)
  • Citations (35)
Published on Nov 1, 2017in The Lancet 53.25
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute),
Andrew Mente30
Estimated H-index: 30
(McMaster University)
+ 352 AuthorsAnders H. Rosengren84
Estimated H-index: 84
(University of Gothenburg)
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 fo...
168 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 Oct 20, 2015in PLOS ONE 2.77
Jonathan Sackner-Bernstein19
Estimated H-index: 19
(Hastings Entertainment),
David Kanter1
Estimated H-index: 1
(Georgetown University Law Center),
Sanjay Kaul59
Estimated H-index: 59
(Cedars-Sinai Medical Center)
Background Reduced calorie, low fat diet is currently recommended diet for overweight and obese adults. Prior data suggest that low carbohydrate diets may also be a viable option for those who are overweight and obese. Purpose Compare the effects of low carbohydrate versus low fats diet on weight and atherosclerotic cardiovascular disease risk in overweight and obese patients. Data Sources Systematic literature review via PubMed (1966–2014). Study Selection Randomized controlled trials with ≥8 w...
39 Citations Source Cite
Published on Aug 28, 2014in The New England Journal of Medicine 79.26
Abstr Act85
Estimated H-index: 85
(Population Health Research Institute),
Salim Yusuf Mb Bs DPhil Frcpc209
Estimated H-index: 209
(Population Health Research Institute)
+ 37 AuthorsF. Lu1
Estimated H-index: 1
The mean INTERHEART Risk Score was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries (P<0.001). However, the rates of major cardiovascular events (death from cardiovascular causes, myocardial infarction, stroke, or heart failure) were lower in high-income countries than in middle- and low-income countries (3.99 events per 1000 personyears vs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Case fatality rates were al...
297 Citations Source Cite
Published on Aug 14, 2014in The New England Journal of Medicine 79.26
Andrew Mente30
Estimated H-index: 30
Sumathy Rangarajan34
Estimated H-index: 34
+ 25 AuthorsPrem Mony14
Estimated H-index: 14
Methods We studied 102,216 adults from 18 countries. Estimates of 24-hour sodium and potassium excretion were made from a single fasting morning urine specimen and were used as surrogates for intake. We assessed the relationship between electrolyte excretion and blood pressure, as measured with an automated device. Results Regression analyses showed increments of 2.11 mm Hg in systolic blood pressure and 0.78 mm Hg in diastolic blood pressure for each 1-g increment in estimated sodium excretion....
323 Citations Source Cite
Published on Jun 24, 2014in Circulation 18.88
Robert H. Eckel96
Estimated H-index: 96
John M. Jakicic66
Estimated H-index: 66
+ 13 AuthorsSidney C. Smith Mdfacc157
Estimated H-index: 157
Preamble and Transition to ACC/AHA Guidelines to The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVDs); improve the management …
1,143 Citations Source Cite
Published on May 1, 2014in American Journal of Cardiology 3.17
Aaqib H. Malik1
Estimated H-index: 1
(Yale University),
Yasir Akram2
Estimated H-index: 2
+ 2 AuthorsValentine Yanchou Njike24
Estimated H-index: 24
(Yale University)
The impact of sugar-sweetened beverages (SSBs) on blood pressure (BP) has been debated, with some evidence suggesting that their increased intake is related to higher risk of developing hypertension. We conducted a systematic review exploring the relation between consumption of SSB and BP. A comprehensive search in 5 electronic databases along with a bibliography search was performed. The keywords "sugar sweetened beverages," "sugary drinks," "added sugars," "blood pressure," and "hypertension" ...
53 Citations Source Cite
Lukas Schwingshackl30
Estimated H-index: 30
Georg F. Hoffmann63
Estimated H-index: 63
Abstract Dietary fat plays an important role in the primary prevention of cardiovascular disease, but long-term (≥12 months) effects of different percentages of fat in the diet on blood lipid levels remain to be established. Our systematic review and meta-analysis focused on randomized controlled trials assessing the long-term effects of low-fat diets compared with diets with high amounts of fat on blood lipid levels. Relevant randomized controlled trials were identified searching MEDLINE, EMBAS...
74 Citations Source Cite
Cited By35
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 May 3, 2019in Journal of Periodontology 3.39
Dayana Dias Mendonça , Mariana Vargas Furtado8
Estimated H-index: 8
(Universidade Federal do Rio Grande do Sul)
+ 6 AuthorsAlex Nogueira Haas17
Estimated H-index: 17
Source Cite
Published on May 1, 2019in Journal of Nutrition 4.40
Daniel Boateng7
Estimated H-index: 7
(Kwame Nkrumah University of Science and Technology),
Cecilia Galbete7
Estimated H-index: 7
+ 14 AuthorsFrank P. Mockenhaupt34
Estimated H-index: 34
Source Cite
Published on Apr 1, 2019in Journal of Diabetes 3.21
Zachary T. Bloomgarden39
Estimated H-index: 39
(Icahn School of Medicine at Mount Sinai),
Yehuda Handelsman38
Estimated H-index: 38
Source Cite
Published on Mar 1, 2019in Global Food Security 3.49
R. Kristina5
Estimated H-index: 5
(International Livestock Research Institute),
Francis Ejobi6
Estimated H-index: 6
(Makerere University)
+ 5 AuthorsDelia Grace23
Estimated H-index: 23
(International Livestock Research Institute)
Abstract Pig production is thriving in Uganda and the demand for pork is increasing, therefore offering potential for increased income from pig production and marketing. The consumers’ preferences determine and potentially drive this demand but are largely unknown in the context of Uganda. As part of a multi-disciplinary assessment of smallholder pig value chains we investigated these preferences in one of the four thematic subgroups with 292 smallholder pig farmers. In addition, 79 consumers in...
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Published on Jan 1, 2019in Brain Research Bulletin 3.44
Tian-Bi Zhu1
Estimated H-index: 1
(Hunan University of Traditional Chinese Medicine),
Zhao Zhang7
Estimated H-index: 7
(Peking Union Medical College)
+ 4 AuthorsNai-Hong Chen26
Estimated H-index: 26
(Hunan University of Traditional Chinese Medicine)
Abstract Since the metabolic disorder may be the high risk that contribute to the progress of Alzheimer’s disease (AD). Overtaken of High-fat, high-glucose or high-cholesterol diet may hasten the incidence of AD in later life, due to the metabolic dysfunction. But the metabolism of lipid in brain and the exact effect of lipid to brain or to the AD’s pathological remain controversial. Here we summarize correlates of lipid metabolism and AD to provide more foundation for the daily nursing of AD se...
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Published on Jan 1, 2019
Optimal blood pressure control is associated with an average 50% decrease in incident HF and thus underlying the importance of BP-lowering strategies to prevent HF. Non-pharmacological interventions are recognized as the cornerstone of hypertension prevention and an important adjunctive strategy in individuals already diagnosed with hypertension. Numerous interventions were tested for the efficacy on BP control, but very limited data is yet available to confirm a benefit on the clinical course o...
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Published on Dec 4, 2018in Nutrients 4.20
Emmanouil Korakas1
Estimated H-index: 1
George Dimitriadis27
Estimated H-index: 27
+ 1 AuthorsVaia Lambadiari16
Estimated H-index: 16
The role of nutrition in the pathogenesis of cardiovascular disease has long been debated. The established notion of the deleterious effects of fat is recently under question, with numerous studies demonstrating the benefits of low-carbohydrate, high-fat diets in terms of obesity, diabetes, dyslipidemia, and metabolic derangement. Monounsaturated and polyunsaturated fatty acids, especially n-3 PUFAs (polyunsaturated fatty acids), are the types of fat that favor metabolic markers and are key comp...
2 Citations Source Cite