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

Dehghan M 1 , Mente A 2 , Zhang X 3 , Swaminathan S 4 , Li W 5 , Mohan V 6 Show all authors , Iqbal R 7 , Kumar R 8 , Wentzel-Viljoen E 9 , Rosengren A 10 , Amma LI 11 , Avezum A 12 , Chifamba J 13 , Diaz R 14 , Khatib R 15 , Lear S 16 , Lopez-Jaramillo P 17 , Liu X 5 , Gupta R 18 , Mohammadifard N 19 , Gao N 5 , Oguz A 20 , Ramli AS 21 , Seron P 22 , Sun Y 5 , Szuba A 23 , Tsolekile L 24 , Wielgosz A 25 , Yusuf R 26 , Hussein Yusufali A 27 , Teo KK 3 , Rangarajan S 3 , Dagenais G 28 , Bangdiwala SI 3 , Islam S 3 , Anand SS 29 , Yusuf S 3 , Prospective Urban Rural Epidemiology (PURE) study investigators

Affiliations 

  • 1 Population Health Research Institute, McMaster University, Hamilton, ON, Canada. Electronic address: mahshid.dehghan@phri.ca
  • 2 Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
  • 3 Population Health Research Institute, McMaster University, Hamilton, ON, Canada
  • 4 St John's Research Institute, St John's National Academy of Health Sciences, Sarjapur Road, Koramangala, Bangalore, Karnataka, India
  • 5 State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
  • 6 Madras Diabetes Research Foundation, Chennai, India
  • 7 Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 8 PGIMER School of Public Health, Chandigarh, India
  • 9 Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
  • 10 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
  • 11 Health Action by People TC 1/1706, Medical College PO, Trivandrum, India
  • 12 Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
  • 13 University of Zimbabwe, College of Health Sciences, Department of Physiology, Harare, Zimbabwe
  • 14 Estudios Clínicos Latinoamérica, ECLA, Rosario, Argentina
  • 15 Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory
  • 16 Faculty of Health Sciences, Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC, Canada
  • 17 Fundacion Oftalmologica de Santander-FOSCAL, Floridablanca-Santander, Colombia
  • 18 Eternal Heart Care Centre and Research Institute, Jaipur, India
  • 19 Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  • 20 Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Goztepe, Istanbul, Turkey
  • 21 Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia
  • 22 Universidad de La Frontera, Temuco, Araucanía, Chile
  • 23 Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
  • 24 University of the Western Cape, Bellville, Western Province, Cape Town, South Africa
  • 25 University of Ottawa Department of Medicine, Ottawa, ON, Canada
  • 26 Independent University, Bangladesh, Dhaka, Bangladesh
  • 27 Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  • 28 Université Laval, Institut Universitaire de Cardiologie, Ville de Québec, QC, Canada
  • 29 Department of Medicine, McMaster University, Hamilton, ON, Canada
Lancet, 2017 Nov 04;390(10107):2050-2062.
PMID: 28864332 DOI: 10.1016/S0140-6736(17)32252-3

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).

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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