Trends in total and high density lipoprotein cholesterol and their determinants in The Netherlands between 1993 and 1997

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Design of the ZWOT-CASE study: an observational study on the effectiveness of an integrated programme for cardiovascular risk management compared to usual care in general practice

Background

Cardiovascular diseases (CVD) contribute considerably to mortality and morbidity. Prevention of CVD by lifestyle change and medication is important and needs full attention.

In the Netherlands an integrated programme for cardiovascular risk management (CVRM), based on the Chronic Care Model (CCM), has been introduced in primary care in many regions in recent years, but its effects are unknown.

In the ZWOT-CASE study we will assess the effect of integrated care for CVRM in the region of Zwolle on two major cardiovascular risk factors: systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-cholesterol) in patients with or at high risk of CVD.

Methods

This study is a pragmatic observational study comparing integrated care for CVRM with usual care among patients aged 40–80 years with CVD (n = 370) or with a high CVD risk (n = 370) within 26 general practices. After 1 yr follow-up, primary outcomes (SBP and LDL-cholesterol level) are measured. Secondary outcomes include lifestyle habits (smoking, dietary habits, alcohol use, physical activity), risk factor awareness, 10-year risk of cardiovascular morbidity or mortality, health care consumption, patient satisfaction and quality of life.

Conclusion

The ZWOT-CASE study will provide insight in the effects of integrated care for CVRM in general practice in patients with CVD or at high CVD risk.

Trial registration

The ZWOlle Transmural Integrated Care for CArdiovaScular Risk Management Study; ClinicalTrials.gov; Identifier: NCT03428061; date of registration: 09-02-2018; This study has been retrospectively registered.

Trend of lipid and thyroid function tests in adults without overt thyroid diseases: A cohort from Tehran thyroid study

Context

While the role of overt hypothyroidism in lipid disorders is clear, the association between dyslipidemia and subclinical thyroid diseases remains unclarified.

Objective

To examine lipid trends based on thyroid function over a 10-year period.

Design

This is a prospective population based cohort study.

Setting

General community.

Participants

2383 euthyroid participants, as well as those with subclinical thyroid diseases, in all residents of district 13 of Tehran were examined. Subjects who were on levothyroxine, anti-hyperthyroid drugs, and glucocorticoids, those with a history of thyroid surgery or RAI and pregnant women were excluded.

Main outcome measures

Lipid trends in Model 1 were adjusted for age and follow up duration, and in Model 2 gender-specific multivariate adjustments were performed for thyroid status, diabetes mellitus, smoking status, education, BMI, lipid lowering medications, age and follow up duration by using generalized estimating equations.

Results

In every four years of assessments, there were significant decreases in levels of all lipid parameters (all Ps <0.001) except for HDL-C, in which a decrescendo-crescendo trend was observed. The results did not change after adjusting for thyroid status, consumption of lipid lowering drugs during the follow-up period, or other variables. There were significant decreases in the prevalence of hypercholesterolemia and hypertriglyceridemia (all Ps <0.001) during the follow-up period.

Conclusion

During a 10 year follow-up, decrescendo trends were observed in levels of total cholesterol, triglycerides, which were not be accounted for by the consumption of lipid lowering drugs and thyroid status.

Educational intervention to improve effectiveness in treatment and control of patients with high cardiovascular risk in low-resource settings in Argentina: study protocol of a cluster randomised controlled trial

INTRODUCTION

Hypercholesterolaemia is estimated to cause 2.6 million deaths annually and one-third of the cases of ischaemic heart disease. In Argentina, the prevalence of hypercholesterolaemia increased between 2005 and 2013 from 27.9% to 29.8%. Only one out of four subjects with a self-reported diagnosis of coronary heart disease is taking statins. Since 2014, statins (simvastatin 20 mg) are part of the package of drugs provided free-of-charge for patients according to cardiovascular disease (CVD) risk stratification. The goal of this study is to test whether a complex intervention targeting physicians and pharmacist assistants improves treatment and control of hypercholesterolaemia among patients with moderate-to-high cardiovascular risk in Argentina.

METHODS AND ANALYSIS

This is a cluster trial of 350 patients from 10 public primary care centres in Argentina to be randomised to either the intervention or usual care. The study is designed to have 90% statistical power to detect a 0.7 mmol/L reduction in low-density lipoproteins cholesterol from baseline to 12 months. The physician education programme consists of a 2-day initial intensive training and certification workshop followed by educational outreach visits (EOVs) conducted at 3, 6 and 9 months from the outset of the study. An on-site training to pharmacist assistants during the first EOV is performed at each intervention clinic. In addition, two intervention support tools are used: an app installed in physician's smartphones to serve as a decision aid to improve prescription of statins according to patient's CVD risk and a web-based platform tailored to send individualised SMS messages to patients.

ETHICS AND DISSEMINATION

Ethical approval was obtained from an independent ethics committee. Results of this study will be presented to the Ministry of Health of Argentina for potential dissemination and scale-up of the intervention programme to the entire national public primary care network in Argentina.

TRIAL REGISTRATION NUMBER

NCT02380911.

Trends in cardiovascular risk factor prevalence (1995-2000-2005) in northeastern Spain

Background

High prevalence of cardiovascular risk factors has been observed in Spain along with low incidence of acute myocardial infarction. Our objective was to determine the trends of cardiovascular risk factor prevalence between 1995 and 2005 in the 35-74-year-old population of Gerona, Spain.

Design

Comparison of cross-sectional studies were conducted in random population samples in 1995, 2000, and 2005 at Gerona, Spain.

Methods

An electrocardiogram was obtained, along with standardized measurements of body mass index, lipid profile, systolic and diastolic blood pressure, glycaemia, energy expenditure in physical activity, smoking, use of lipid-lowering and antihypertensive medications, and cardiovascular risk. Prevalence of diabetes, hypertension, and obesity was calculated and standardized for age.

Results

A total of 7571 individuals (52.0% women) were included (response rate 72%). Low-density lipoprotein cholesterol > 3.4 mmol/l (130 mg/dl) (49.7%) and hypertension (39.1%) were the most prevalent cardiovascular risk factors. In 1995, 2000 and 2005, low-density lipoprotein cholesterol decreased in both men and women: 4.05-3.913.55 mmol/l (156-151-137 mg/dl) and 3.84-3.81-3.40 mmol/l (148-147-131 mg/dl), respectively. Increases were observed in lipid-lowering drug use (5.7-6.3-9.6% in men and 4.0-5.8-8.0% in women), controlled hypertension (14.8-35.4-37.7% in men and 21.3-36.9-45.0% in women); (all P-trends < 0.01), and obesity (greatest for men: 17.5-26.0-22.7%, P-trends = 0.020). Prevalence of myocardial infarction or possibly abnormal Q waves in electrocardiogram also increased significantly (3.9-4.7-6.4%, P-trends = 0.018).

Conclusions

The cardiovascular risk factor prevalence change in Gerona was marked in this decade by a shift of total cholesterol and low-density lipoprotein cholesterol distributions to the left, independent of the increase in lipid-lowering drug use, and better hypertension control with increased use of antihypertensive drugs. Eur J Cardiovasc Prev Rehabil 14:653-659 © 2007 The European Society of Cardiology

Trends in risk factors for coronary heart disease in the Netherlands

BACKGROUND

Favourable trends in risk factor levels in the general population may partly explain the decline in coronary heart disease (CHD) morbidity and mortality. Our aim was to present long-term national trends in established risk factors for CHD.

METHODS

Data were obtained from five data sources including several large scale population based surveys, cohort studies and general practitioner registers between 1988 and 2012. We applied linear regression models to age-standardized time trends to test for statistical significant trends. Analyses were stratified by sex and age (younger <65 and older ≥65 years adults).

RESULTS

The results demonstrated favourable trends in smoking (except in older women) and physical activity (except in older men). Unfavourable trends were found for body mass index (BMI) and diabetes mellitus prevalence. Although systolic blood pressure (SBP) and total cholesterol trends were favourable for older persons, SBP and total cholesterol remained stable in younger persons.

CONCLUSIONS

Four out of six risk factors for CHD showed a favourable or stable trend. The rise in diabetes mellitus and BMI is worrying with respect to CHD morbidity and mortality.

The effect of hypertension and diabetes management in Southwest China: a before- and after-intervention study

BACKGROUND

Non-communicable diseases are leading causes of disease burden in middle income countries. Little evidence exists to determine if the primary healthcare system can effectively manage non-communicable diseases. The purpose of this study was to examine the effectiveness of hypertension and diabetes management by the primary healthcare system.

METHODS

We used individual level data from the 2009 National Basic Public Health Services System to assess the effectiveness of hypertension and diabetes interventions on fasting plasma glucose, and blood pressure. We analyzed the associations between fasting plasma glucose, systolic or diastolic blood pressure and risk factors. The estimated average intervention effect on data balanced with confounding variables was assessed.

RESULTS

9543 individuals who had data for fasting plasma glucose, systolic blood pressure and diastolic blood pressure were included in this analysis. This study included 6681 patients with hypertension and 2222 with diabetes. The intervention lowered mean fasting plasma glucose by 0.5 mmol/L (0.4-0.6), lowered mean systolic blood pressure by 3.5 mm Hg (3.2-3.7), and lowered diastolic blood pressure by 2.9 mm Hg (2.7-3.2). Individuals who received medicinal treatment had 1.3 mmHg (0.8 to 1.8, P<0.01) lower diastolic blood pressure and 0.6 mmol/L (0.5-0.8, P<0.01) lower fasting plasma glucose than those who did not receive medicine. Generalized linear model indicated that medicinal treatment and baseline systolic blood pressure were significant positive predictors of change in systolic blood pressure. Age, living in urban areas and diabetic complications were significant negative predictors of change for systolic blood pressure.

CONCLUSION

The National Basic Public Health Services System in China using trained community healthcare workers and well-established guidelines can be effectively implement non-communicable disease prevention and management care paradigms.

N-6 and n-3 fatty acid cholesteryl esters in relation to incident stroke in a Dutch adult population: a nested case-control study

BACKGROUND AND AIMS

There are few prospective studies on fatty acid status in relation to incident stroke, with inconsistent results. We assessed the associations of plasma n-6 and n-3 PUFA in cholesteryl esters with the risk of total stroke and stroke subtypes in Dutch adults.

METHODS AND RESULTS

We conducted a nested case-control study using data from a population-based cohort study in adults aged 20-65 years. Blood sampling and data collection took place during 1993-1997 and subjects were followed for 8-13 years. We identified 179 incident cases of stroke and 179 randomly selected controls, matched on age, gender, and enrollment date. Odds ratios (OR) with 95% confidence intervals (95%CI) were calculated per standard deviation (SD) increase of PUFA in cholesteryl esters using multivariable conditional logistic regression. Cases comprised 93 ischemic, 50 hemorrhagic, and 36 unspecified strokes. The n-6 PUFA linoleic acid and arachidonic acid contributed ~55% and ~6.5% respectively to total plasma fatty acids, whereas the n-3 PUFA alpha-linolenic acid contributed ~0.5% and eicosapentaenoic acid plus docosahexaenoic acid (EPA-DHA) ~1.3%. After adjustment for confounders, n-6 and n-3 PUFA were not associated with incident total stroke or stroke subtypes. The OR (95% CI) for total stroke was 0.95 (0.74-1.23) per SD increase in linoleic acid and 1.02 (0.80-1.30) per SD increase in arachidonic acid. ORs (95% CI) for total stroke were 0.94 (0.72-1.21) for alpha-linolenic acid and 1.16 (0.94-1.45) for EPA-DHA.

CONCLUSION

In the present study, plasma n-6 or n-3 fatty acids were not related to incident stroke or stroke subtypes.

N-6 and N-3 fatty acid cholesteryl esters in relation to fatal CHD in a Dutch adult population: a nested case-control study and meta-analysis

Background

Dietary polyunsaturated fatty acids (PUFA) are inversely related to coronary heart disease (CHD) in epidemiological studies. We examined the associations of plasma n-6 and n-3 PUFA in cholesteryl esters with fatal CHD in a nested case-control study. Additionally, we performed a dose-response meta-analysis of similar prospective studies on cholesteryl ester PUFA.

Methods

We used data from two population-based cohort studies in Dutch adults aged 20–65y. Blood and data collection took place from 1987–1997 and subjects were followed for 8–19y. We identified 279 incident cases of fatal CHD and randomly selected 279 controls, matched on age, gender, and enrollment date. Odds ratios (OR) were calculated per standard deviation (SD) increase of cholesteryl ester PUFA.

Results

After adjustment for confounders, the OR (95%CI) for fatal CHD per SD increase in plasma linoleic acid was 0.89 (0.74–1.06). Additional adjustment for plasma total cholesterol and systolic blood pressure attenuated this association (OR:0.95; 95%CI: 0.78–1.15). Arachidonic acid was not associated with fatal CHD (OR per SD:1.11; 95%CI: 0.92–1.35). The ORs (95%CI) for fatal CHD for an SD increase in n-3 PUFA were 0.92 (0.74–1.15) for alpha-linolenic acid and 1.06 (0.88–1.27) for EPA-DHA. In the meta-analysis, a 5% higher linoleic acid level was associated with a 9% lower risk (relative risk: 0.91; 95% CI: 0.84–0.98) of CHD. The other fatty acids were not associated with CHD.

Conclusion

In this Dutch population, n-6 and n-3 PUFA in cholesteryl esters were not significantly related to fatal CHD. Our data, together with findings from previous prospective studies, support that linoleic acid in plasma cholesteryl is inversely associated with CHD.

Do obesity and parental history of myocardial infarction improve cardiovascular risk prediction?

BACKGROUND

In clinical practice, individuals at increased risk of cardiovascular diseases (CVD) are identified on the basis of age, sex, smoking, blood pressure, and serum total and high-density lipoprotein cholesterol. We examined whether CVD risk prediction improved when obesity (body mass index ≥30 kg/m(2)) and premature (<70 years) parental myocardial infarction (MI) were added to the classical risk factor model.

METHODS

Risk factors were measured in 1993-97 in 12,818 participants (53% female) aged 35-65 in the Dutch MORGEN project. Cases of fatal and nonfatal CVD during 10 years of follow up were identified through record linkage. Classical risk factor equations, obtained by Cox proportional hazard analysis, were extended with obesity, paternal MI, and maternal MI. We calculated the net reclassification index (NRI), a measure for correct reclassification of subjects, to check improvement in risk prediction using 5 and 10% increments in absolute CVD risk.

RESULTS

A CVD event occurred in 280 men and 140 women. Obesity and maternal MI were positively and significantly related to total CVD after adjustment for classical risk factors (both hazard ratios ∼1.5). Adding obesity and parental MI to CVD risk prediction yielded a significant NRI of 4.5% in men and a non-significant NRI of 2.6% in women when 5% risk categories were used. For 10% categories, the NRIs were slightly larger (5.5% and 3.3%, respectively). The improvements in risk prediction were mainly due to obesity.

CONCLUSION

Modest improvements in CVD risk prediction can be obtained when obesity and, to a lesser extent, parental MI are added to the risk function.

Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study

BACKGROUND

Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community.

METHODS

We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching.

RESULTS

NCDSS had data for 65,619 individuals aged 25 years or older (11,686 of whom in rural areas); of these, 64,694 (11,521 in rural areas) had data for SBP and 50,202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (-0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (-0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method.

INTERPRETATION

Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel.

FUNDING

None.

Paternal and maternal history of myocardial infarction and cardiovascular diseases incidence in a Dutch cohort of middle-aged persons

BACKGROUND

A positive parental history of myocardial infarction (MI) is an independent risk factor for cardiovascular diseases (CVD). However, different definitions of parental history have been used. We evaluated the impact of parental gender and age of onset of MI on CVD incidence.

METHODS

Baseline data were collected between 1993 and 1997 in 10,524 respondents aged 40-65 years. CVD events were obtained from the National Hospital Discharge Register and Statistics Netherlands. We used proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for CVD incidence and adjusted for lifestyle and biological risk factors.

RESULTS

At baseline, 36% had a parental history of MI. During 10-year follow-up, 914 CVD events occurred. The age and gender adjusted HR was 1.3 (95% CI 1.1-1.5) for those with a paternal MI, 1.5 (1.2-1.8) for those with a maternal MI and 1.6 (1.2-2.2) for those with both parents with an MI. With decreasing parental age of MI, HR increased from 1.2 (1.0-1.6) for age ≥70 years to 1.5 (1.2-1.8) for age <60 years for a paternal MI and from 1.1 (0.9-1.5) to 2.2 (1.6-3.0) for a maternal MI. The impact of having a mother with MI before age 60 significantly differed in women [(2.9 (1.8-4.6)] and men [1.5 (0.9-2.6)]. Adjustment only slightly influenced HRs for maternal MI.

CONCLUSIONS

Respondents with a parental history of MI have an increased CVD incidence, in particular with parental onset of MI before age 70. A maternal history of MI before age 60 was the strongest predictor of CVD incidence.

Linoleic acid intake, plasma cholesterol and 10-year incidence of CHD in 20,000 middle-aged men and women in the Netherlands

We studied the associations of a difference in linoleic acid or carbohydrate intake with plasma cholesterol levels and risk of CHD in a prospective cohort study in the Netherlands. Data on diet (FFQ) and plasma total and HDL-cholesterol were available at baseline (1993-7) of 20,069 men and women, aged 20-65 years, who were initially free of CVD. Incidence of CHD was assessed through linkage with mortality and morbidity registers. During an average of 10 years of follow-up, 280 CHD events occurred. The intake of linoleic acid ranged from 3·6 to 8·0 % of energy (en%), whereas carbohydrate intake ranged from 47·6 to 42·5 en% across quintiles of linoleic acid intake. Linoleic acid intake was inversely associated with total cholesterol and HDL-cholesterol in women but not in men. Linoleic acid intake was not associated with the ratio of total to HDL-cholesterol. No association was observed between linoleic acid intake and CHD incidence, with hazard ratios varying between 0·83 and 1·00 (all P>0·05) compared to the bottom quintile. We conclude that a 4-5 en% difference in linoleic acid or carbohydrate intake did not translate into either a different ratio of total to HDL-cholesterol or a different CHD incidence.

Dose-dependent cholesterol-lowering effects of phytosterol/phytostanol-enriched margarine in statin users and statin non-users under free-living conditions

OBJECTIVE

To assess the effectiveness (extent to which an intervention works in daily medical practice) of the use of phytosterol/phytostanol-enriched margarines to lower total and non-HDL cholesterol levels in users and non-users of statins.

DESIGN

Retrospective cohort study.

SETTING

Data were obtained from questionnaires on health and food intake from a population-based longitudinal cohort linked to pharmacy-dispensing records.

SUBJECTS

The analysis included 3829 men and women (aged 31-71 years) who were examined during 1998-2002 and re-examined at 5-year follow-up during 2003-2007.

RESULTS

Recommended doses of margarines were consumed by only 9 % of the subjects. Serum total cholesterol decreased by respectively -0·16 (95 % CI -0·26, -0·05) mmol/l, -1·40 (95 % CI -1·51, -1·30) mmol/l and -1·64 (95 % CI -1·91, -1·37) mmol/l in subjects who started to use phytosterols/phytostanols only, statins only or a combination of both compounds at some point in time between examination and re-examination, compared with subjects who did not start using phytosterols/phytostanols or statins. Cholesterol-lowering effects of the phytosterols/phytostanols were similar in statin users and statin non-users and increased with increasing intake of enriched margarine (no intake, 0; low intake, -0·017 (95 % CI -0·16, 0·13) mmol/l; medium intake, -0·089 (95 % CI -0·22, 0·038) mmol/l; high intake, -0·32 (95 % CI -0·50, -0·14) mmol/l).

CONCLUSIONS

Although recommended intake levels of the enriched margarines were not reached by all persons, these data show that under customary conditions of use phytosterols/phytostanols are effective in lowering cholesterol levels in both statin users and non-users.

National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants

BACKGROUND

Excess bodyweight is a major public health concern. However, few worldwide comparative analyses of long-term trends of body-mass index (BMI) have been done, and none have used recent national health examination surveys. We estimated worldwide trends in population mean BMI.

METHODS

We estimated trends and their uncertainties of mean BMI for adults 20 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (960 country-years and 9·1 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean BMI by age, country, and year, accounting for whether a study was nationally representative.

FINDINGS

Between 1980 and 2008, mean BMI worldwide increased by 0·4 kg/m(2) per decade (95% uncertainty interval 0·2-0·6, posterior probability of being a true increase >0·999) for men and 0·5 kg/m(2) per decade (0·3-0·7, posterior probability >0·999) for women. National BMI change for women ranged from non-significant decreases in 19 countries to increases of more than 2·0 kg/m(2) per decade (posterior probabilities >0·99) in nine countries in Oceania. Male BMI increased in all but eight countries, by more than 2 kg/m(2) per decade in Nauru and Cook Islands (posterior probabilities >0·999). Male and female BMIs in 2008 were highest in some Oceania countries, reaching 33·9 kg/m(2) (32·8-35·0) for men and 35·0 kg/m(2) (33·6-36·3) for women in Nauru. Female BMI was lowest in Bangladesh (20·5 kg/m(2), 19·8-21·3) and male BMI in Democratic Republic of the Congo 19·9 kg/m(2) (18·2-21·5), with BMI less than 21·5 kg/m(2) for both sexes in a few countries in sub-Saharan Africa, and east, south, and southeast Asia. The USA had the highest BMI of high-income countries. In 2008, an estimated 1·46 billion adults (1·41-1·51 billion) worldwide had BMI of 25 kg/m(2) or greater, of these 205 million men (193-217 million) and 297 million women (280-315 million) were obese.

INTERPRETATION

Globally, mean BMI has increased since 1980. The trends since 1980, and mean population BMI in 2008, varied substantially between nations. Interventions and policies that can curb or reverse the increase, and mitigate the health effects of high BMI by targeting its metabolic mediators, are needed in most countries.

FUNDING

Bill & Melinda Gates Foundation and WHO.

National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3·0 million participants

BACKGROUND

Data for trends in serum cholesterol are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. Previous analyses of trends in serum cholesterol were limited to a few countries, with no consistent and comparable global analysis. We estimated worldwide trends in population mean serum total cholesterol.

METHODS

We estimated trends and their uncertainties in mean serum total cholesterol for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (321 country-years and 3·0 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean total cholesterol by age, country, and year, accounting for whether a study was nationally representative.

FINDINGS

In 2008, age-standardised mean total cholesterol worldwide was 4·64 mmol/L (95% uncertainty interval 4·51-4·76) for men and 4·76 mmol/L (4·62-4·91) for women. Globally, mean total cholesterol changed little between 1980 and 2008, falling by less than 0·1 mmol/L per decade in men and women. Total cholesterol fell in the high-income region consisting of Australasia, North America, and western Europe, and in central and eastern Europe; the regional declines were about 0·2 mmol/L per decade for both sexes, with posterior probabilities of these being true declines 0·99 or greater. Mean total cholesterol increased in east and southeast Asia and Pacific by 0·08 mmol/L per decade (-0·06 to 0·22, posterior probability=0·86) in men and 0·09 mmol/L per decade (-0·07 to 0·26, posterior probability=0·86) in women. Despite converging trends, serum total cholesterol in 2008 was highest in the high-income region consisting of Australasia, North America, and western Europe; the regional mean was 5·24 mmol/L (5·08-5·39) for men and 5·23 mmol/L (5·03-5·43) for women. It was lowest in sub-Saharan Africa at 4·08 mmol/L (3·82-4·34) for men and 4·27 mmol/L (3·99-4·56) for women.

INTERPRETATION

Nutritional policies and pharmacological interventions should be used to accelerate improvements in total cholesterol in regions with decline and to curb or prevent the rise in Asian populations and elsewhere. Population-based surveillance of cholesterol needs to be improved in low-income and middle-income countries.

FUNDING

Bill & Melinda Gates Foundation and WHO.

Exploring genetic determinants of plasma total cholesterol levels and their predictive value in a longitudinal study

BACKGROUND

Plasma total cholesterol (TC) levels are highly genetically determined. Although ample evidence of genetic determination of separate lipoprotein cholesterol levels has been reported, using TC level directly as a phenotype in a relatively large broad-gene based association study has not been reported to date.

METHODS AND RESULTS

We genotyped 361 single nucleotide polymorphisms (SNPs) across 243 genes based on pathways potentially relevant to cholesterol metabolism in 3575 subjects that were examined thrice over 11 years. Twenty-three SNPs were associated with TC levels after adjustment for multiple testing. We used 12 of them (rs7412 and rs429358 in APOE, rs646776 in CELSR2, rs1367117 in APOB, rs6756629 in ABCG5, rs662799 in APOA5, rs688 in LDLR, rs10889353 in DOCK7, rs2304130 in NCAN, rs3846662 in HMGCR, rs2275543 in ABCA1, rs7275 in SMARCA4) that were confirmed in previous candidate association or genome-wide-association studies to define a gene risk score (GRS). Average TC levels increased from 5.23 ± 0.82 mmol/L for those with 11 or less cholesterol raising alleles to 6.03 ± 1.11 mmol/L for those with 18 or more (P for trend<0.0001). The association with TC levels was slightly stronger when the weighted GRS that weighted the magnitude of allelic effects was used.

CONCLUSION

A panel of common genetic variants in the genes pivotal in cholesterol metabolism could possibly help identify those people who are at risk of high cholesterol levels.

Marine (n-3) fatty acids, fish consumption, and the 10-year risk of fatal and nonfatal coronary heart disease in a large population of Dutch adults with low fish intake

We assessed the dose-response relations within a low range of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and fish intake on fatal coronary heart disease (CHD) and nonfatal myocardial infarction (MI). In a Dutch population-based cohort study, EPA+DHA and fish intake were assessed at baseline among 21,342 participants aged 20-65 y with no history of MI or stroke. Hazard ratios were calculated with Cox proportional-hazard models. During 9-14 y of follow-up (mean 11.3 y), 647 participants (3%) died, of which 82 of CHD. Fatal CHD mainly comprised MI (64 cases). In total, 252 participants survived an MI. Median intakes in quartiles of EPA+DHA were 40, 84, 151, and 234 mg/d. Medians of fish consumption in quartiles were 1.1, 4.2, 10.7, and 17.3 g/d. Compared with the lowest quartile of EPA+DHA, participants in the top quartile had a 49% lower risk of fatal CHD (95% CI: 6-73%) and a 62% lower risk of fatal MI (95% CI: 23-81%). We observed inverse dose-response relations for EPA+DHA intake and fatal CHD (P-trend = 0.05) and fatal MI (P-trend = 0.01). Results were similar for fish consumption. Nonfatal MI was not associated with EPA+DHA or fish intake. In conclusion, in populations with a low fish consumption, EPA+DHA and fish may lower fatal CHD and MI risk in a dose-responsive manner. Low intakes of EPA+DHA or fish do not seem to protect against nonfatal MI.

Body mass index and waist circumference predict both 10-year nonfatal and fatal cardiovascular disease risk: study conducted in 20,000 Dutch men and women aged 20-65 years

AIMS

Body mass index (BMI) and waist circumference (WC) are both predictors of cardiovascular diseases (CVD). We compared absolute risk, hazard ratio (HR), and population attributable risk of nonfatal and fatal CVD for BMI and WC in a large prospective cohort study with an average follow-up of 10 years.

METHODS AND RESULTS

Anthropometric data were measured between 1993 and 1997 in a general population sample of over 20,000 men and women aged 20-65 years in the Netherlands. All risks were adjusted for age and sex. Absolute risk of nonfatal CVD was on average 10 times higher than that of fatal CVD. In obese respondents (BMI >or=30 kg/m2), relative risk of fatal CVD was four-fold higher [HR=4.0 95% confidence interval (CI)=2.4-6.6], whereas risk of nonfatal CVD was two-fold higher (HR=1.8 95% CI=1.6-2.2) than in normal-weight respondents. Similar associations were observed for WC (>or=88 vs. <80 cm in women and >or=102 vs. 94 cm in men). In persons with overweight or obesity (BMI >or=25 kg/m2), half of all fatal CVD (attributable risk=54%, 95% CI=30-70) and a quarter of nonfatal CVD was ascribed to their overweight. On the population level, one-third of all fatal CVD cases could be attributed to overweight and obesity (population attributable risk=35%, 95% CI=14-52), and about one in seven of nonfatal CVD cases.

CONCLUSION

The associations of BMI and WC with CVD risk were equally strong. Overweight and obesity had a stronger impact on fatal CVD than on nonfatal CVD.

Does rheumatoid arthritis equal diabetes mellitus as an independent risk factor for cardiovascular disease? A prospective study

OBJECTIVE

Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD), but longitudinal observations are limited and the precise magnitude is unknown. We prospectively assessed the incidence of CVD in patients with RA compared with patients with type 2 diabetes mellitus (DM) and the general population.

METHODS

The 3-year incidence rate of CVD was determined in a prospective cohort (the Cardiovascular Research and Rheumatoid Arthritis Study) of 353 outpatients with RA, and was compared with that in 1,852 population-based cohort study participants (155 had type 2 DM). We investigated fatal and nonfatal CVD (according to International Classification of Diseases, Ninth Revision criteria) and used Cox proportional hazards models to assess the incidence of CVD in RA, type 2 DM, and the general population.

RESULTS

The 3-year incidence of CVD was 9.0% in patients with RA and 4.3% in the general population, corresponding with an incidence rate of 3.30 per 100 patient-years (95% confidence interval [95% CI] 2.08-4.25) and 1.51 per 100 person-years (95% CI 1.18-1.84), respectively. Compared with the general population, the age- and sex-adjusted hazard ratio (HR) for RA was 1.94 (95% CI 1.24-3.05, P = 0.004). Neither exclusion of patients with prior CVD at baseline nor adjustment for cardiovascular risk factors significantly influenced this. Compared with the nondiabetic population, nondiabetic patients with RA and those with type 2 DM had comparable HRs, 2.16 (95% CI 1.28-3.63, P = 0.004) and 2.04 (95% CI 1.12-3.67, P = 0.019), respectively.

CONCLUSION

The risk of CVD in RA was significantly elevated compared with the general population, and comparable with the magnitude of risk in type 2 DM.

Hypoalphalipoproteinemia in populations of Native American ancestry: an opportunity to assess the interaction of genes and the environment

PURPOSE OF THIS REVIEW

Our aim is to review the environmental and genetic factors associated with hypoalphalipoproteinemia in populations of Native American ancestry. We examine the strength of the association and outline the population-specific genetic factors that lead to a higher susceptibilty for this condition.

RECENT FINDINGS

Low HDL is the most common lipid abnormality in populations of Native American ancestry. Population-based surveys carried out in Latin America and in Mexican Americans shows that 40-60% of adults have hypoalphalipoproteinemia. The contribution of this trait to the metabolic syndrome is greater in individuals with Native American ancestry than in other ethnic groups. Several environmental factors have contributed to this phenomenon (i.e. high dietary content of carbohydrates and fat due to cultural factors and a growing incidence of obesity). In addition, results from recent genetic studies show that certain hypoalphalipoproteinemia susceptibility alleles are ethnic specific for Native Americans. The variant R230C of the ATP-binding cassette transporter subfamily A member 1 gene (ABC-A1) is common among mestizos (10.9% in Mexican mestizos) and its presence has a significant negative effect on HDL cholesterol levels (-4.2%). An additional noteworthy finding is that the R230C variant appears to be specific for the Amerindian populations. Its allele frequency is 0.28 in Mayans, 0.214 in Purepechas, 0.203 in Yaquis and 0.179 among Teenek. In contrast, the C230 allele has not been found in African, European, Chinese or South Asian populations.

SUMMARY

The assessment of the genetic and environmental determinants of hypoalphalipoproteinemia in populations of Native American origin provides an opportunity to assess the population-specific interactions between genes and the environment

Lipid-lowering treatment for all could substantially reduce the burden of macrovascular complications of diabetes patients in the Netherlands

BACKGROUND

We aimed to quantify the potential health benefits of increased use of lipid-lowering treatment (LLT), according to current guidelines, for the Dutch diabetes population.

DESIGN

Simulation study.

METHODS

We compared the long-term health outcomes for a scenario in which all diabetes patients received LLT to those in a 'current practice' scenario, in which 28% received LLT. The model reflected the Dutch diabetes population 40-80 years of age, in 2003. Sensitivity analyses were performed, using more conservative assumptions.

RESULTS

Over the lifetime, LLT for all diabetes patients reduced the expected cumulative incidences of coronary heart disease (CHD) and stroke by, respectively, 6 and 9%. Average life expectancy of Dutch diabetes patients would increase by 0.33 years, ranging from 0.14 years for patients aged 70-79 years, to 0.84 years for patients aged 40-49 years at the start of the simulation. Life-long treatment for patients aged 50-59 contributed most to the life years gained (55,000 out of 146,000). With reduced effectiveness of LLT and fewer patients starting LLT, the cumulative incidences of both CHD and stroke would decrease by approximately 2%. The number needed to treat to prevent one incident case of cardiovascular disease over lifetime was 20 for CHD and 44 for stroke.

CONCLUSION

This simulation study shows that increased use of LLT can substantially reduce the expected future burden of CHD and stroke in the Dutch diabetes population.

Customary use of plant sterol and plant stanol enriched margarine is associated with changes in serum plant sterol and stanol concentrations in humans

The consumption of products enriched with plant sterol or stanol esters lowers serum total and LDL-cholesterol concentrations, thereby most likely reducing the risk of coronary heart disease. However, using plant sterol (not plant stanol) enriched products elevates serum plant sterol concentrations in humans. This may be unwanted because health effects of elevated serum plant sterol concentrations are still controversial. Within postlaunch monitoring of functional foods, we compared serum plant sterol and plant stanol concentrations among users of plant sterol (n = 67) or plant stanol (n = 13) enriched margarines with those of matched nonusers (n = 81) in the ongoing Dutch Doetinchem cohort study. Subjects (aged 29-67 y) were examined in 1994-1998 (before the introduction of enriched margarines) and re-examined in 1999-2003. Serum concentrations of plant sterols and stanols were measured in samples from nonfasting subjects by GLC-MS. Intake of plant sterols was 1.1 +/- 0.6 g/d and was associated with a decrease of serum total cholesterol concentration of 0.25 +/- 0.91 mmol/L (4%, P < 0.05), a change that differed (P < 0.05) from the nonsignificant increase in nonusers (+2%, 0.12 +/- 0.78 mmol/L, P = 0.16). Cholesterol-standardized serum sitosterol and campesterol increased in plant sterol users by 22% (P < 0.0001) and 103% (P < 0.0001), respectively. Cholesterol-standardized serum sitostanol and campestanol increased in plant stanol users by 197% (P = 0.02) and 196% (P = 0.01). To our knowledge, these data are the first to show changes in serum cholesterol, plant sterol, and plant stanol concentrations after (long-term) consumption of plant sterol and stanol enriched margarines in a free-living population in a nonexperimental setting. Whether the increased serum sterol concentrations result in adverse side effects needs to be investigated in future postlaunch monitoring studies.

Exposure and effectiveness of phytosterol/-stanol-enriched margarines

BACKGROUND

Studies on effectiveness of phytosterol/-stanol-enriched margarines in the community have received low priority. For postlaunch monitoring purposes including risk-benefit analyses, it is needed to investigate both exposure and effectiveness of these margarines.

OBJECTIVE

To study the use and effectiveness of phytosterol/-stanol-enriched margarine.

DESIGN, SETTING AND SUBJECTS

The study population consisted of 2379 subjects that participated in a community intervention study ('Hartslag Limburg') aged 28-76 years. In 1998 and 2003, blood samples for total and high-density lipoprotein (HDL) cholesterol were obtained. A general questionnaire and food frequency questionnaire (FFQ) were administered. From 1999 onwards, phytosterol/-stanol-enriched margarines were introduced on the Dutch market. On the basis of 2003 data, subjects were classified in users of (a) phytosterol/-stanol-enriched margarine, (b) cholesterol-lowering drugs, (c) the combination (both enriched margarine and drugs) and (d) neither enriched margarines nor cholesterol-lowering drugs.

RESULTS

Mean (+/-s.d.) daily intake of phytosterol-enriched margarine (n=99) and phytostanol-enriched margarine (n=16) was 14+/-9 g. From 1998 to 2003, total serum cholesterol concentration changed significantly different among the four groups: in the combination users -2.04+/-1.50 mmol/l (-29%), in cholesterol-lowering drug users -1.09+/-1.17 mmol/l (-17%), in the enriched margarine users -0.24+/-0.75 mmol/l (-4%) and in non-users +0.10+/-0.72 mmol/l (+2%)(P<0.05).

CONCLUSION

Recommended doses are not consumed, but phytosterol/-stanol-enriched margarines can modestly reduce serum total cholesterol in the community. These margarines cannot equal the effect of cholesterol-lowering drugs, but may act additively. Further investigation of the health effects that may occur during simultaneous cholesterol lowering drugs and phytosterol-or -stanol-enriched margarines usage is important, as well as community education about the cholesterol lowering foods and drugs.

SPONSORSHIP

Netherlands Organization for Health Research and Development (ZonMW) (data collection of Hartslag Limburg and further data- analyses).

Effectiveness of customary use of phytosterol/-stanol enriched margarines on blood cholesterol lowering

Postlaunch monitoring of functional foods can encompass monitoring of effectiveness under conditions of customary use. To this end, the effectiveness of phytosterol/-stanol enriched margarine consumption in free-living conditions was investigated with data from the Dutch "Doetinchem cohort study". In total, 4,505 subjects (aged 26-70 years) were examined in 1994-1998 and re-examined during 1999-2003. A general and a food frequency questionnaire and non-fasting blood samples for total and HDL cholesterol determination were obtained. Subjects were stratified into phytosterol/-stanol enriched margarine users (n = 84) and non-users (n = 4,421) based on the re-examination data, as these margarines were available on the Dutch market from 1999 onwards. Mean spontaneous daily use (g +/- SD) of phytosterol-containing margarine (n = 71) was 15 +/- 8 and of phytostanol-containing margarine (n = 13) 9+/-6. After five years, total blood cholesterol had increased with 0.26 mmol/l in non-users while it had not significantly changed in users. The difference in total blood cholesterol change in users versus non-users was -0.30 mmol/l (p < 0.001). The beneficial effect of the phytosterol/-stanol enriched margarine, used under customary conditions can be characterized as a stabilization of cholesterol levels. This is the first report finding a modest beneficial effect on blood cholesterol level under customary conditions thereby partly confirming findings from clinical trials.

Common variants in the ATP-sensitive K+ channel genes KCNJ11 (Kir6.2) and ABCC8 (SUR1) in relation to glucose intolerance: population-based studies and meta-analyses

AIMS

To evaluate the relation between common variants in the ATP-sensitive K+ channel genes and glucose intolerance.

METHODS

We conducted a meta-analysis of reported association studies in Caucasian populations for common variants in the ABCC8 (exons 16 and 18) and the KCNJ11 (E23K) gene and examined sources of heterogeneity in the results. The meta-analysis was based on 7768-10216 subjects (depending on the gene variant), and included two new population-based studies in the Netherlands with 725 cases and 742 controls.

RESULTS

For the KCNJ11 variant, the summary odds ratio (OR) for glucose intolerance was 1.12 (1.01-1.23, P=0.03) for the EK genotype and 1.44 (1.17-1.78, P=0.0007) for the KK genotype, as compared with the EE genotype. For the ABCC8 exon 16 variant, the OR was 1.06 (0.94-1.19, P=0.34) for ct and 0.93 (0.71-1.20, P=0.56) for tt, as compared with the cc genotype. For ABCC8 exon 18, the OR was 1.20 (0.97-1.49, P=0.10) for CT/TT, as compared with the CC genotype. Studies of the ABCC8 variants that were published first or had smaller sample sizes (for the exon 18 variant) showed stronger associations, which may indicate publication bias. For the ABCC8 exon 18 and the KCNJ11 variant, associations were stronger for studies of clinical diabetes than newly detected glucose intolerance. The population attributable risk for clinical Type 2 diabetes was 6.2% for the KCNJ11 KK genotype and 10.1% for the KCNJ11 EK and KK genotype combined.

CONCLUSIONS

The common KCNJ11 E23K gene variant, but not the ABCC8 exon 16 or exon 18 variant, was consistently associated with Type 2 diabetes.

Achieving lipid goals in Europe: how large is the treatment gap?

Despite the established benefits of decreasing low-density lipoprotein cholesterol levels in reducing morbidity and mortality from coronary heart disease, not all patients who would benefit from lipid-lowering therapy are being managed appropriately. An in-depth review of the literature (2000-2003) demonstrates that the 'treatment gap' varies across different clinical settings. Although the use of lipid-lowering agents has increased in recent years, there continues to be a widespread failure in the achievement of recommended lipid levels. A combination of the use of the most efficacious statins, together with intervention strategies to ensure that all eligible individuals receive appropriate treatment to achieve lipid goals, are important considerations in minimizing the burden of dyslipidemia in Europe.

The insulin receptor substrate-1 Gly972Arg polymorphism is not associated with Type 2 diabetes mellitus in two population-based studies

AIMS

The insulin receptor substrate-1 (IRS-1) gene is among the most frequently studied candidate genes for Type 2 diabetes, but findings have been inconsistent. This may have been due to generally small study sizes, or to interaction with body fatness as suggested by studies of insulin sensitivity. The aim of this study was to test the hypothesis that the IRS-1 Gly972Arg variant increases risk of Type 2 diabetes.

METHODS

We conducted two large population-based studies including a total of 725 cases and 742 control subjects, who were Caucasian Dutch men and women aged 40-70 years. We calculated odds ratios adjusted for body mass index, study centre, sex and age.

RESULTS

Carriers of the Arg allele did not have a higher prevalence of newly detected (OR 0.49, 95% CI 0.24-1.01) or treated (OR 0.71, 0.37-1.35) Type 2 diabetes in the first study, or a higher prevalence of glucose intolerance (OR 1.07, 0.71-1.59) in the second study. The summary odds ratio was 0.86 (0.62-1.17) for carrying the Arg allele as compared with the Gly/Gly genotype. Associations did not differ appreciably by degree of obesity. Also, the Arg variant was not associated with detrimental values for body mass index, waist circumference, plasma HDL-and total cholesterol or hypertension.

CONCLUSIONS

Our findings indicate that the IRS-1 Gly972Arg variant does not substantially increase risk of common Type 2 diabetes, or Type 2 diabetes in obese persons.

Potential intake of phytosterols/-stanols: results of a simulation study

BACKGROUND

Different doses of phytosterols/-stanols up to a maximum of 4.0 g/day have been used in human safety studies, whereas only one small-scale study investigated some detailed clinical information about consumption levels exceeding 8.6 g/day.

OBJECTIVE

To determine which population groups are likely to be at risk of excessive intakes if liberal enrichment of foods with phytosterols/-stanols will be allowed.

DESIGN AND SUBJECTS

Cross-sectional study among a representative sample (n=23 106) of the Dutch population, aged 20-60 y (MORGEN-project, 1993-1997). Phytosterol/-stanol intake was assessed with virtual replacement of one to four ordinary foods in the diet with enriched products. Percentile values were used to describe the distribution in simulated intake for different groups in the population, varying in sociodemographic and health characteristics. Multiple linear regression was used to describe the contribution of the different population characteristics to the simulated phytosterol/-stanol intake.

RESULTS

If three commonly consumed products (margarine, cheese, yoghurt) were completely replaced, the median daily phytosterol/-stanol intake will be about 5.5 g in men and 4.6 g in women. In males, the intake above the 90th percentile will exceed 8.6 g/day. Women will approach this level. Especially, age, body mass index, socioeconomic status, subjective health, smoking behaviour, alcohol consumption, pregnancy (women) and high cholesterol level (men) contributed to the variance in the simulated intake (P<0.05), although the total explained variance was low (1-3%).

CONCLUSIONS

If liberal phytosterol/-stanol fortification is allowed, the daily intake might exceed the recommended intake level as well as our 'cutoff' level of 8.6 g/day. Postlaunch monitoring to identify consumers and real intake levels, refinement of scenario buiding, as well as human safety studies for levels above 8.6 g/day are necessary.

Trends in the trans-fatty acid composition of the diet in a metropolitan area: the Minnesota Heart Survey

OBJECTIVE

In this study, we examine trends in dietary intake of trans-fatty acids from 1980-1982 to 1995-1997 using data collected as part of the Minnesota Heart Survey (MHS).

DESIGN

The MHS is an ongoing observational epidemiologic study among independent cross-sectional probability samples of adults. Twenty-four-hour dietary recalls were collected on a subset of participants. To obtain trans-fatty acid intake estimates, the dietary recall records were recalculated using the University of Minnesota Nutrition Coordinating Center Food and Nutrient Database. Subjects/setting The survey population included noninstitutionalized adults aged 25 to 74 years residing in the Minneapolis-St. Paul, MN, metropolitan area. Statistical analysis Mean intake estimates were generated for each survey, and a generalized linear mixed model was used to test the null hypothesis of no difference in the age-adjusted sex-specific means between 1980-1982, 1985-1987, 1990-1992, and 1995-1997.

RESULTS

Downward trends in dietary intake of trans-fatty acids were found between 1980-1982 and 1995-1997. For example, for men mean intake of total trans-fatty acids declined from 8.3 g per day in 1980-1982 to 6.2 g per day in 1995-1997 (P<.001). Represented as a percentage of energy, similar declines were seen with mean intake of total trans-fatty acids decreasing from 3.0% of total energy in 1980-1982 to 2.2% of total energy in 1995-1997 (P<.001).

APPLICATIONS/CONCLUSIONS

It seems that intake of trans-fatty acids is on the decline. Consideration should be given to additional changes in the food supply and consumer food choices that may result in further reduction in consumption of trans-fatty acids.

Hypertension is frequently present in patients with reflux esophagitis or Barrett's esophagus but not in those with non-ulcer dyspepsia

BACKGROUND: Elevated mortality due to cardiovascular disease has been reported for patients with Barrett's esophagus (BE). We compared the prevalence of risk factors for cardiovascular disease in patients with BE, reflux esophagitis (RE), and non-ulcer dyspepsia (NUD) with that of the general population. METHODS: Patients with upper gastrointestinal complaints and BE, RE, or NUD were compared with a matched cohort from the general population using a questionnaire and blood pressure and cholesterol measurements. RESULTS: Hypertension occurred more frequently in patients with BE (odds ratio 5.1, P<0.0001) and RE (odds ratio 3.8, P<0.001), but not in those with NUD. Serum total cholesterol was higher in BE (P=0.02) and borderline in RE (P=0.06) but not in NUD. Mean HDL cholesterol levels, body mass index, and smoking did not differ. CONCLUSIONS: This study suggests that BE and RE found at diagnostic endoscopy are associated with an increased prevalence of hypertension and a higher total cholesterol level than in the general population. If so, this would explain the increased mortality during the follow-up of BE patients, and it should be taken into account when designing or evaluating follow-up studies of BE.