Title

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

Authors

Andrew Mente, McMaster University, Hamilton, ON, Canada.
Mahshid Dehghan, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Sumathy Rangarajan, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Matthew McQueen, McMaster University, Hamilton, ON, Canada.
Gilles Dagenais, Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada.
Andreas Wielgosz, University of Ottawa, Ottawa, ON, Canada.
Scott Lear, Simon Fraser University, Vancouver, BC, Canada.
Wei Li, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
Hui Chen, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
Sun Yi, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
Yang Wang, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
Rafael Diaz, Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina.
Alvaro Avezum, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil.
Patricio Lopez-Jaramillo, Fundación Oftalmológica de Santander-FOSCAL, Floridablanca, Santander, Colombia.
Pamela Seron, Universidad de La Frontera, Temuco, Araucanía, Chile.
Rajesh Kumar, School of Public Health, Chandigarh, India.
Rajeev Gupta, Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India.
Viswanathan Mohan, Madras Diabetes Research Foundation, Chennai, India.
Sumathi Swaminathan, St John's Research Institute, Koramangala, Bangalore, India.
Raman Kutty, Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, India.
Katarzyna Zatonska, Medical University of Wroclaw, Wrocław, Poland.
Romaina Iqbal, Aga Khan UniversityFollow
Rita Yusuf, Independent University, Dhaka, Bangladesh.
Noushin Mohammadifard, Isfahan University of Medical Sciences, Isfahan, Iran.
Rasha Khatib, Birzeit University, Birzeit, occupied Palestinian territory.
Nafiza Mat Nasir, Universiti Teknologi MARA, Shah Alam, Malaysia.
Noorhassim Ismail, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
Aytekin Oguz, Istanbul Medeniyet University, Goztepe, Istanbul, Turkey.
Annika Rosengren, University of Gothenburg and Sahlgrenska University Hospital/Östra, Göteborg, Sweden.
Afzalhussein Yusufali, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
Edelweiss Wentzel-Viljoen, North-West University, Potchefstroom, South Africa.
Thandi Puoane, University of the Western Cape, Cape Town, South Africa.
Jephat Chifamba, University of Zimbabwe, Harare, Zimbabwe.
Koon Teo, McMaster University, Hamilton, ON, Canada.
Sonia S. Anand, McMaster University, Hamilton, ON, Canada.
Salim Yusuf, McMaster University, Hamilton, ON, Canada.

Document Type

Article

Department

Community Health Sciences

Abstract

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 ptrend<0·0001). Higher carbohydrate intake was associated with lower total cholesterol, LDL cholesterol, and ApoB, but also with lower HDL cholesterol and ApoA1, and higher triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ApoB-to-ApoA1 ratio (all ptrend<0·0001, apart from ApoB [ptrend=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.

Publication

Lancet Diabetes and Endocrinology

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.