Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study
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Date
2017Author
Dehghan, Mahshid
Wentzel-Viljoen, Edelweiss
Mente, Andrew
Zhang, Xiaohe
Swaminathan, Sumathi
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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 followup
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], ptrend=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], ptrend<0·0001; saturated fat, HR 0·86 [0·76–0·99],
ptrend=0·0088; monounsaturated fat: HR 0·81 [0·71–0·92], ptrend<0·0001; and polyunsaturated fat: HR 0·80 [0·71–0·89],
ptrend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI
0·64–0·98], ptrend=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
URI
http://hdl.handle.net/10394/26295https://doi.org/10.1016/S0140-6736(17)32252-3
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32252-3/fulltext
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