Title

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.

Authors

Mahshid Dehghan, McMaster University, Hamilton, ON, Canada
Andrew Mente, McMaster University, Hamilton, ON, Canada
Xiaohe Zhang, McMaster University, Hamilton, ON, Canada
Sumathi Swaminathan, St John's National Academy of Health Sciences, Sarjapur Road, Koramangala, Bangalore, Karnataka, India
Wei Li, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Viswanathan Mohan, Madras Diabetes Research Foundation, Chennai, India
Romaina Iqbal, Aga Khan UniversityFollow
Rajesh Kumar, PGIMER School of Public Health, Chandigarh, India
Edelweiss Wentzel-Viljoen, North-West University, Potchefstroom, South Africa
Annika Rosengren, University of Gothenburg, Sweden
Leela Itty Amma, Medical College PO, Trivandrum, India
Alvaro Avezum, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
Jephat Chifamba, University of Zimbabwe, Harare, Zimbabwe
Rafael Diaz, Estudios Clínicos Latinoamérica, ECLA, Rosario, Argentina
Rasha Khatib, Birzeit University, Birzeit, occupied Palestinian territory
Scott Lear, Simon Fraser University, Burnaby, BC, Canada
Patricio Lopez-Jaramillo, Fundacion Oftalmologica de Santander-FOSCAL, Floridablanca-Santander, Colombia
Xiaoyun Liu, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Rajeev Gupta, Eternal Heart Care Centre and Research Institute, Jaipur, India
Noushin Mohammadifard, Isfahan University of Medical Sciences, Isfahan, Iran
Nan Gao, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Aytekin Oguz, Istanbul Medeniyet University, Goztepe, Istanbul, Turkey
Anis Safura Ramli, Universiti Teknologi MARA, Selangor, Malaysia
Pamela Seron, Universidad de La Frontera, Temuco, Araucanía, Chile
Yi Sun, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Andrzej Szuba, Wroclaw Medical University, Wroclaw, Poland
Lungiswa Tsolekile, University of the Western Cape, Bellville, Western Province, Cape Town, South Africa
Andreas Wielgosz, University of Ottawa, Ottawa, ON, Canada
Rita Yusuf, Independent University, Bangladesh, Dhaka, Bangladesh
Afzal Hussein Yusufali, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
Koon K. Teo, McMaster University, Hamilton, ON, Canada
Sumathy Rangarajan, McMaster University, Hamilton, ON, Canada
Gilles Dagenais, Université Laval, Institut Universitaire de Cardiologie, Ville de Québec, QC, Canada
Shrikant I. Bangdiwala, McMaster University, Hamilton, ON, Canada
Shofiqul Islam, 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 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], 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.

FUNDING:

Full funding sources listed at the end of the paper (see Acknowledgments).

Publication

Lancet

Creative Commons License

Creative Commons Attribution-Noncommercial-Share Alike 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.