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Miller V, Jenkins DA, Dehghan M, Srichaikul K, Rangarajan S, Mente A, Mohan V, Swaminathan S, Ismail R, Luz Diaz M, Ravindran RM, Zatonska K, Bahonar A, Altuntas Y, Khatib R, Lopez-Jaramillo P, Yusufali A, Yeates K, Chifamba J, Iqbal R, Yusuf R, Catherina Swart E, Bo H, Han G, Li X, Alhabib KF, Rosengren A, Avezum A, Lanas F, Yusuf S. Associations of the glycaemic index and the glycaemic load with risk of type 2 diabetes in 127 594 people from 20 countries (PURE): a prospective cohort study. Lancet Diabetes Endocrinol 2024; 12:330-338. [PMID: 38588684 DOI: 10.1016/s2213-8587(24)00069-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The association between the glycaemic index and the glycaemic load with type 2 diabetes incidence is controversial. We aimed to evaluate this association in an international cohort with diverse glycaemic index and glycaemic load diets. METHODS The PURE study is a prospective cohort study of 127 594 adults aged 35-70 years from 20 high-income, middle-income, and low-income countries. Diet was assessed at baseline using country-specific validated food frequency questionnaires. The glycaemic index and the glycaemic load were estimated on the basis of the intake of seven categories of carbohydrate-containing foods. Participants were categorised into quintiles of glycaemic index and glycaemic load. The primary outcome was incident type 2 diabetes. Multivariable Cox Frailty models with random intercepts for study centre were used to calculate hazard ratios (HRs). FINDINGS During a median follow-up of 11·8 years (IQR 9·0-13·0), 7326 (5·7%) incident cases of type 2 diabetes occurred. In multivariable adjusted analyses, a diet with a higher glycaemic index was significantly associated with a higher risk of diabetes (quintile 5 vs quintile 1; HR 1·15 [95% CI 1·03-1·29]). Participants in the highest quintile of the glycaemic load had a higher risk of incident type 2 diabetes compared with those in the lowest quintile (HR 1·21, 95% CI 1·06-1·37). The glycaemic index was more strongly associated with diabetes among individuals with a higher BMI (quintile 5 vs quintile 1; HR 1·23 [95% CI 1·08-1·41]) than those with a lower BMI (quintile 5 vs quintile 1; 1·10 [0·87-1·39]; p interaction=0·030). INTERPRETATION Diets with a high glycaemic index and a high glycaemic load were associated with a higher risk of incident type 2 diabetes in a multinational cohort spanning five continents. Our findings suggest that consuming low glycaemic index and low glycaemic load diets might prevent the development of type 2 diabetes. FUNDING Full funding sources are listed at the end of the Article.
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Affiliation(s)
- Victoria Miller
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - David A Jenkins
- Department of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada; Clinical Nutrition Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, ON, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Kristie Srichaikul
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Viswanathan Mohan
- Department of Diabetology, Madras Diabetes Research Foundation & Dr Mohan's Diabetes Specialties Centre, Chennai, India
| | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Rosnah Ismail
- Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | | | - Rekha M Ravindran
- Department of Health Sciences, Government of Kerala, Kerala, India; Health Action by People, Trivandrum, Kerala, India
| | | | - Ahmad Bahonar
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yuksel Altuntas
- University of Health Sciences Turkey, Faculty of Medicine, Istanbul Sisli Hamidiye Etfal Health Training Research Hospital, Clinic of Endocrinology and Metabolism, Sisli/Istabul, Türkiye
| | - Rasha Khatib
- Advocate Aurora Research Institute, Milwaukee, WI, USA; Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | | | | | - Karen Yeates
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Jephat Chifamba
- Department of Biomedical Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Romaina Iqbal
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Center for Health, Population and Development, Independent University, Dhaka, Bangladesh
| | | | - Hu Bo
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guoliang Han
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaocong Li
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyaadh, Saudi Arabia
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alvaro Avezum
- International Research Center, Hospital Alemão-Oswaldo Cruz & UNISA, São Paulo, SP Brazil
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Jenkins DJA, Willett WC, Yusuf S, Hu FB, Glenn AJ, Liu S, Mente A, Miller V, Bangdiwala SI, Gerstein HC, Sieri S, Ferrari P, Patel AV, McCullough ML, Le Marchand L, Freedman ND, Loftfield E, Sinha R, Shu XO, Touvier M, Sawada N, Tsugane S, van den Brandt PA, Shuval K, Khan TA, Paquette M, Sahye-Pudaruth S, Patel D, Siu TFY, Srichaikul K, Kendall CWC, Sievenpiper JL. Association of glycaemic index and glycaemic load with type 2 diabetes, cardiovascular disease, cancer, and all-cause mortality: a meta-analysis of mega cohorts of more than 100 000 participants. Lancet Diabetes Endocrinol 2024; 12:107-118. [PMID: 38272606 DOI: 10.1016/s2213-8587(23)00344-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND There is debate over whether the glycaemic index of foods relates to chronic disease. We aimed to assess the associations between glycaemic index (GI) and glycaemic load (GL) and type 2 diabetes, cardiovascular disease, diabetes-related cancers, and all-cause mortality. METHODS We did a meta-analysis of large cohorts (≥100 000 participants) identified from the Richard Doll Consortium. We searched the Cochrane Library, MEDLINE, PubMed, Embase, Web of Science, and Scopus for cohorts that prospectively examined associations between GI or GL and chronic disease outcomes published from database inception to Aug 4, 2023. Full-article review and extraction of summary estimates data were conducted by three independent reviewers. Primary outcomes were incident type 2 diabetes, total cardiovascular disease (including mortality), diabetes-related cancers (ie, bladder, breast, colorectal, endometrial, hepatic, pancreatic, and non-Hodgkin lymphoma), and all-cause mortality. We assessed comparisons between the lowest and highest quantiles of GI and GL, adjusting for dietary factors, and pooling their most adjusted relative risk (RR) estimates using a fixed-effects model. We also assessed associations between diets high in fibre and whole grains and the four main outcomes. The study protocol is registered with PROSPERO, CRD42023394689. FINDINGS From ten prospective large cohorts (six from the USA, one from Europe, two from Asia, and one international), we identified a total of 48 studies reporting associations between GI or GL and the outcomes of interest: 34 (71%) on various cancers, nine (19%) on cardiovascular disease, five (10%) on type 2 diabetes, and three (6%) on all-cause mortality. Consumption of high GI foods was associated with an increased incidence of type 2 diabetes (RR 1·27 [95% CI 1·21-1·34]; p<0·0001), total cardiovascular disease (1·15 [1·11-1·19]; p<0·0001), diabetes-related cancer (1·05 [1·02-1·08]; p=0·0010), and all-cause mortality (1·08 [1·05-1·12]; p<0·0001). Similar associations were seen between high GL and diabetes (RR 1·15 [95% CI 1·09-1·21]; p<0·0001) and total cardiovascular disease (1·15 [1·10-1·20]; p<0·0001). Associations between diets high in fibre and whole grains and the four main outcomes were similar to those for low GI diets. INTERPRETATION Dietary recommendations to reduce GI and GL could have effects on health outcomes that are similar to outcomes of recommendations to increase intake of fibre and whole grain. FUNDING Banting and Best and the Karuna Foundation.
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Affiliation(s)
- David J A Jenkins
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada.
| | - Walter C Willett
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Frank B Hu
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea J Glenn
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Simin Liu
- Center for Global Cardiometabolic Health, Department of Epidemiology, Department of Medicine, and Department of Surgery, Brown University, Providence, RI, USA
| | - Andrew Mente
- Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Victoria Miller
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sabina Sieri
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Pietro Ferrari
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Alpa V Patel
- Department of Population Science, American Cancer Society, Atlanta, GA, USA
| | | | - Loïc Le Marchand
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Erikka Loftfield
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rashmi Sinha
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xiao-Ou Shu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mathilde Touvier
- Université Sorbonne Paris Nord and Université Paris Cité, INSERM, INRAE, CNAM, Center of Research in Epidemiology and Statistics, Nutritional Epidemiology Research Team, Bobigny, France; French Network for Nutrition and Cancer Research, Jouy-en-Josas, France
| | - Norie Sawada
- Division of Cohort Research, National Cancer Center Institute for Cancer Control, Tokyo, Japan
| | - Shoichiro Tsugane
- Division of Cohort Research, National Cancer Center Institute for Cancer Control, Tokyo, Japan; International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan
| | - Piet A van den Brandt
- GROW School for Oncology and Developmental Biology, and Department of Epidemiology, Care and Public Health Research Institute-School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | - Tauseef Ahmad Khan
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada
| | - Melanie Paquette
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Sandhya Sahye-Pudaruth
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Darshna Patel
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Teenie Fei Yi Siu
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Korbua Srichaikul
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Cyril W C Kendall
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada; College of Pharmacy and Nutrition, University of Saskatchewan, SK, Canada
| | - John L Sievenpiper
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Clinical Nutrition & Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, St Michael's Hospital, Toronto, ON, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada
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Abstract
Dietary guidelines recommend intake targets for some essential minerals, based on observational and experimental evidence relating mineral intake levels to health outcomes. For prevention of cardiovascular disease, reducing sodium intake and increasing potassium intake are the principal tools. While reducing sodium intake has received greatest public health priority, emerging evidence suggests that increasing potassium intake may be a more important target for cardiovascular prevention. Increased potassium intake reduces blood pressure and mitigates the hypertensive effects of excess sodium intake, and the recent large Phase III SSaSS trial reported that increasing potassium intake (and reducing sodium intake) in populations with low potassium intake and high sodium intake, through salt substitution (25% KCl, 75%NaCl), reduces the risk of stroke in patients at increased cardiovascular risk. As key sources of potassium intake include fruit, vegetables, nuts, and legumes, higher potassium intake may be associated with healthy dietary patterns. The current review makes the case that increasing potassium intake might represent a more advantageous dietary strategy for prevention of cardiovascular disease. Future research should focus on addressing the independent effect of potassium supplementation in populations with low or moderate potassium intake, and determine effective strategies to increase potassium intake from diet.
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Affiliation(s)
- Martin O'Donnell
- College of Medicine, Nursing and Health Sciences, HRB-Clinical Research Facility, University of Galway, Newcastle Rd, Galway H91 TK33, Ireland
| | - Salim Yusuf
- Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Liffert Vogt
- Department of Internal Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Andrew Mente
- College of Medicine, Nursing and Health Sciences, HRB-Clinical Research Facility, University of Galway, Newcastle Rd, Galway H91 TK33, Ireland
| | - Franz H Messerli
- Department of BioMedical Research, University of Bern, Switzerland
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4
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Sikorski C, Miller V, Dehghan M, Paré G, Teo K, Anand SS, Yusuf S, Mente A. Individual- and supply-level macronutrient intakes are well correlated over a 50-year period (1961-2011) in 18 countries in Asia, North America, and Europe. Nutr Res 2023; 119:109-118. [PMID: 37801760 DOI: 10.1016/j.nutres.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 10/08/2023]
Abstract
Reliable information on dietary trends is essential. We compared individual-level dietary estimates for total energy, carbohydrate, fat, and protein intake over time with national supply data from the Global Expanded Nutrient Supply Model (186 paired estimates from 1961 to 2011, 18 countries). We hypothesized that supply data would overestimate individual measures and that the two measures would be weakly correlated. Individual- and supply-level estimates were compared using Spearman correlation coefficients and linear mixed-effect models were used to estimate the differences between measures. Overall, the correlations between individual- and supply-level measures were moderate for energy (rs = 0.34) and carbohydrate (rs = 0.39), strong for fat (rs = 0.85), and protein (rs = 0.69). Trends in total energy measured by individual-level surveys and total energy supply were positively correlated in 38.9% of countries, whereas trends in macronutrients aligned between estimates in most countries. Supply-level dietary data overestimated individual-level intakes, especially in higher income countries in Europe and in the United States. In the United States, supply-level data exceeded individual-level estimates by 26.3% to 29.9% for energy, carbohydrate, and fat, whereas protein estimates were similar between measures. In Europe, supply-level estimates overestimated individual-level intake by 19.9% for energy, 17.0% for carbohydrate, 13.7% for fat, and 7.7% for protein, whereas estimates for energy and macronutrients were similar in Asia. In Asia and lower income countries, our findings generally support the use of supply-level data in the absence of individual-level data, though this finding may be related to smaller sample size and differences in underlying national statistics that inform supply data.
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Affiliation(s)
- Claudia Sikorski
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | - Victoria Miller
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada
| | - Guillaume Paré
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, L8S 4L8, Canada; The Thrombosis and Atherosclerosis Research Institute (TaARI), Department of Medicine, David Braley Research Institute, McMaster University, Hamilton, Ontario, L8L 2X2, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, L8L 2X2, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
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5
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Mente A, Dehghan M, Rangarajan S, O'Donnell M, Hu W, Dagenais G, Wielgosz A, Lear SA, Wei L, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Swaminathan S, Kaur M, Vijayakumar K, Mohan V, Gupta R, Szuba A, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Nasir NM, Karsidag K, Rosengren A, Yusufali A, Wentzel-Viljoen E, Chifamba J, Dans A, Alhabib KF, Yeates K, Teo K, Gerstein HC, Yusuf S. Diet, cardiovascular disease, and mortality in 80 countries. Eur Heart J 2023:ehad269. [PMID: 37414411 PMCID: PMC10361015 DOI: 10.1093/eurheartj/ehad269] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/31/2023] [Accepted: 04/25/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. METHODS AND RESULTS A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). CONCLUSION A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- HRB-Clinical Research Facility, University of Galway, Galway, Connacht, Ireland
| | - Weihong Hu
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
| | - Gilles Dagenais
- Department of Medicine, Université Laval Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City G1V 4G5, Canada
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott A Lear
- Faculty of Health Sciences, and Department of Biomedical Physiology & Kinesiology, Simon Fraser University Vancouver, Burnaby, British Columbia, Canada
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, Xicheng District, China
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Universidad Nacional de Rosario, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz & UNISA, Sao Paulo, São Paulo estado, SP Brazil
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Medical School, Universidad de Santander (UDES), Bucaramanga, Santander, Colombia
| | - Fernando Lanas
- Francisco Salazar, Universidad de La Frontera, Temuco, Araucanía, Chile
| | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, Karnataka, India
| | - Manmeet Kaur
- Postgraduate Institute of Medical Education and Research, School of Public Health, Chandigarh, Punjab and Haryana, India
| | - K Vijayakumar
- Health Action by People, Amrita Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Viswanathan Mohan
- Director and Chief of Diabetes Research, Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
| | - Andrzej Szuba
- Department of Internal Medicine, Wroclaw Medical University, 4th Military Hospital, Wroclaw, Lower Silesian Voivodeship, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Rita Yusuf
- Department of Life Sciences, Independent University, Bangladesh, Bashundhara, Dhaka, Dhaka District, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Isfahan Province, Iran
| | - Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nafiza Mat Nasir
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, Malaysia
| | - Kubilay Karsidag
- Department of Internal Medicine, Division of Endocrinology, Medical Faculty of Istanbul University, Istanbul, Istanbul Province, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Västergötland, Sweden
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | - Edelweiss Wentzel-Viljoen
- Faculty of Health Sciences, Centre of Excellence for Nutrition, Potchefstroom, North West Province, South Africa
| | - Jephat Chifamba
- College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Harare Metropolitan Province, Zimbabwe
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Ermita, Manila, Metro Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Riyadh Province, Saudi Arabia
| | - Karen Yeates
- Department of Medicine, Queen's University, 94 Stuart Street, Etherington Hall, Kingston, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, 2nd Floor, Room C2-105, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Johnston B, De Smet S, Leroy F, Mente A, Stanton A. Non-communicable disease risk associated with red and processed meat consumption-magnitude, certainty, and contextuality of risk? Anim Front 2023; 13:19-27. [PMID: 37073320 PMCID: PMC10105855 DOI: 10.1093/af/vfac095] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Affiliation(s)
- Bradley Johnston
- Department of Nutrition, College of Agriculture and Life Sciences, Texas A&M University, College Station, Texas, USA
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, Texas, USA
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Stefaan De Smet
- Laboratory for Animal Nutrition and Animal Product Quality, Faculty of Bioscience Engineering, Ghent University, Coupure Links 653, B-9000 Ghent, Belgium
| | - Frédéric Leroy
- Industrial Microbiology and Food Biotechnology (IMDO), Faculty of Sciences and Bioengineering Sciences, Vrije Universiteit Brussel, Pleinlaan 2, B-1050 Brussels, Belgium
| | - Andrew Mente
- Population Health Research Institute and Hamilton Health Sciences, and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Sikorski C, Yang S, Stennett R, Miller V, Teo K, Anand SS, Paré G, Yusuf S, Dehghan M, Mente A. Changes in energy, macronutrient, and food consumption in 47 countries over the last 70 years (1950-2019): a systematic review and meta-analysis. Nutrition 2023; 108:111941. [PMID: 36702047 DOI: 10.1016/j.nut.2022.111941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES We aimed to systematically examine trends in dietary energy, macronutrient, and food consumption in different geographic regions. METHODS We searched Medline, Embase, CINAHL, and organizations for studies and reports using individual-level dietary assessments from 1950 to 2019 (PROSPERO CRD42022302843) and quantified changes using multivariable linear mixed-effects models. RESULTS We identified 109 articles and reports from 47 countries, including Europe and Australasia (47% of studies), Asia (30%), Latin America (13%), the Middle East (6%), and North America (4%). In Southeast and East Asia, carbohydrate intake decreased, whereas fat consumption increased; the opposite pattern occurred in North America; and fat decreased while carbohydrate intake remained stable in Europe and Australasia. Consumption of carbohydrate and fat were stable in South Asia, Latin America, and the Middle East, but data were limited in these regions. A greater increase in national gross domestic product over time was associated with decreased carbohydrate and increased fat and protein intake. Dietary saturated fatty acid intake decreased in Northern and Eastern Europe and was stable in other regions. Changes in food varied by region; East and Southeast Asia increased meat, fish, dairy, egg, fruit, and vegetable consumption and decreased intake of grains, roots and tubers, legumes, whereas North America decreased dairy and red meat but increased eggs, nuts, poultry, and vegetable oil intake. Intakes of fruits, nuts, legumes, and roots and tubers were below recommendations in most regions. CONCLUSIONS Our findings indicate regional variations in dietary trends and identify countries that would benefit from nutritional policies aimed at decreasing lower-quality carbohydrate foods and increasing consumption of fruits, vegetables, nuts, legumes, and dairy.
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Affiliation(s)
- Claudia Sikorski
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Shuling Yang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rosain Stennett
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Victoria Miller
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Guillaume Paré
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Department of Medicine, David Braley Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Reddin C, Ferguson J, Murphy R, Clarke A, Judge C, Griffith V, Alvarez A, Smyth A, Mente A, Yusuf S, O'Donnell MJ. Global mean potassium intake: a systematic review and Bayesian meta-analysis. Eur J Nutr 2023:10.1007/s00394-023-03128-6. [PMID: 36882596 PMCID: PMC10349712 DOI: 10.1007/s00394-023-03128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/20/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Increasing potassium intake, especially in populations with low potassium intake and high sodium intake, has emerged as an important population-level intervention to reduce cardiovascular events. Current guideline recommendations, such as those made by the World Health Organisation, recommend a potassium intake of > 3.5 g/day. We sought to determine summary estimates for mean potassium intake and sodium/potassium (Na/K) ratio in different regions of the world. METHODS We performed a systematic review and meta-analysis. We identified 104 studies, that included 98 nationally representative surveys and 6 multi-national studies. To account for missingness and incomparability of data, a Bayesian hierarchical imputation model was applied to estimating summary estimates of mean dietary potassium intake (primary outcome) and sodium/potassium ratio. RESULTS Overall, 104 studies from 52 countries were included (n = 1,640,664). Mean global potassium intake was 2.25 g/day (57 mmol/day) (95% credible interval (CI) 2.05-2.44 g/day), with highest intakes in Eastern and Western Europe (mean intake 3.53g/day, 95% CI 3.05-4.01 g/day and 3.29 g/day, 95% CI 3.13-3.47 g/day, respectively) and lowest intakes in East Asia (mean intake 1.89 g/day; 95% CI 1.55-2.25 g/day). Approximately 31% (95% CI, 30-41%) of global population included have an estimated potassium intake > 2.5 g/day, with 14% (95% CI 11-17%) above 3.5 g/day. CONCLUSION Global mean potassium intake (2.25 g/day) falls below current guideline recommended intake level of > 3.5 g/day, with only 14% (95% CI 11-17%) of the global population achieving guideline-target mean intake. There was considerable regional variation, with lowest mean potassium intake reported in Asia, and highest intake in Eastern and Western Europe.
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Affiliation(s)
- Catriona Reddin
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland.
- Wellcome Trust-HRB, Irish Clinical Academic Training, Galway, Ireland.
| | - John Ferguson
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
| | - Robert Murphy
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
| | - Aoibhin Clarke
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
| | - Conor Judge
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
- Wellcome Trust-HRB, Irish Clinical Academic Training, Galway, Ireland
| | - Vincent Griffith
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
| | - Alberto Alvarez
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
| | - Andrew Smyth
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Martin J O'Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway University Hospital, Newcastle Road, Galway, H91YR71, Ireland
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute and Hamilton Health Sciences, and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Philip Britz-McKibbin
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Hamilton, ON, Canada
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Dehghan M, Mente A, Rangarajan S, Mohan V, Swaminathan S, Avezum A, Lear SA, Rosengren A, Poirier P, Lanas F, Lopez-Jaramillo P, Soman B, Wang C, Orlandini A, Mohammadifard N, AlHabib KF, Chifamba J, Yusufali AH, Iqbal R, Khatib R, Yeates K, Puoane T, Altuntas Y, Co HU, Li S, Liu W, Zatońska K, Yusuf R, Ismail N, Miller V, Yusuf S. Ultra-processed foods and mortality: analysis from the Prospective Urban and Rural Epidemiology study. Am J Clin Nutr 2023; 117:55-63. [PMID: 36789944 DOI: 10.1016/j.ajcnut.2022.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/26/2022] [Accepted: 10/28/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Higher intake of ultra-processed foods (UPFs) has been associated with increased risk of CVD and mortality in observational studies from Western countries but data from non-Western countries are limited. OBJECTIVES We aimed to assess the association between consumption of UPFs and risk of mortality and major CVD in a cohort from multiple world regions. DESIGN This analysis includes 138,076 participants without a history of CVD between the ages of 35 and 70 y living on 5 continents, with a median follow-up of 10.2 y. We used country-specific validated food-frequency questionnaires to determine individuals' food intake. We classified foods and beverages based on the NOVA classification into UPFs. The primary outcome was total mortality (CV and non-CV mortality) and secondary outcomes were incident major cardiovascular events. We calculated hazard ratios using multivariable Cox frailty models and evaluated the association of UPFs with total mortality, CV mortality, non-CV mortality, and major CVD events. RESULTS In this study, 9227 deaths and 7934 major cardiovascular events were recorded during the follow-up period. We found a diet high in UPFs (≥2 servings/d compared with 0 intake) was associated with higher risk of mortality (HR: 1.28; 95% CI: 1.15, 1.42; P-trend < 0.001), CV mortality (HR: 1.17; 95% CI: 0.98, 1.41; P-trend = 0.04), and non-CV mortality (HR: 1.32; 95% CI 1.17, 1.50; P-trend < 0.001). We did not find a significant association between UPF intake and risk of major CVD. CONCLUSIONS A diet with a high intake of UPFs was associated with a higher risk of mortality in a diverse multinational study. Globally, limiting the consumption of UPFs should be encouraged.
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Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Sarjapur Road, Koramangala, Bangalore, Karnataka, India
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University c/o Healthy Heart Program, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, VGR Region, Sweden
| | - Paul Poirier
- Heart and Lung Institute, Laval University, Quebec City, QC, Canad
| | | | | | - Biju Soman
- Health Action by People, Thiruvananthapuram, Kerala, India
| | - Chuangshi Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | | | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jephat Chifamba
- University of Zimbabwe, Faculty of Medicine and Health Sciences, Unit of Physiology, Harare, Zimbabwe
| | - Afzal Hussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine & Advocate Research Institute, Advocate Health Care, IL, USA
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Canada
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Yuksel Altuntas
- University of Health Sciences Turkey, Faculty of Medicine, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, Clinic of Endocrinology and Metabolism, Sisli, Istanbul, Turkey
| | - Homer Uy Co
- University of the Philippines College of Medicine, Manila, Philippines
| | - Sidong Li
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weida Liu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | | | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan, Kuala Lumpur, Malaysia
| | - Victoria Miller
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Mathiaparanam S, Nori de Macedo A, Mente A, Poirier P, Lear SA, Wielgosz A, Teo KK, Yusuf S, Britz-Mckibbin P. The Prevalence and Risk Factors Associated with Iodine Deficiency in Canadian Adults. Nutrients 2022; 14:nu14132570. [PMID: 35807751 PMCID: PMC9268597 DOI: 10.3390/nu14132570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 02/04/2023] Open
Abstract
Iodine is a trace micronutrient that is critical for normal thyroid function and human health. Inadequate dietary intake is associated with cognitive impairment, infertility, growth retardation and iodine deficiency disorders in affected populations. Herein, we examined the prevalence of iodine deficiency in adults (median age of 61 years) based on the analysis of 24 h urine samples collected from 800 participants in four clinical sites across Canada in the Prospective Urban and Rural Epidemiological (PURE) study. Urinary iodide together with thiocyanate and nitrate were measured using a validated capillary electrophoresis assay. Protective/risk factors associated with iodine deficiency were identified using a binary logistic regression model, whereas daily urinary iodine concentration (24 h UIC, μg/L) and urinary iodine excretion (24 h UIE, μg/day) were compared using complementary statistical methods with covariate adjustments. Overall, our Canadian adult cohort had adequate iodine status as reflected by a median UIC of 111 μg/L with 11.9% of the population <50 μg/L categorized as having moderate to severe iodine deficiency. Iodine adequacy was also evident with a median 24 h UIE of 226 μg/day as a more robust metric of iodine status with an estimated average requirement (EAR) of 7.1% (< 95 μg/day) and a tolerable upper level (UL) of 1.8% (≥1100 μg/day) based on Canadian dietary reference intake values. Participants taking iodine supplements (OR = 0.18; p = 6.35 × 10−5), had greater 24 h urine volume (OR = 0.69; p = 4.07 × 10−4), excreted higher daily urinary sodium (OR = 0.71; p = 3.03 × 10−5), and/or were prescribed thyroxine (OR = 0.33; p = 1.20 × 10−2) had lower risk for iodine deficiency. Self-reported intake of dairy products was most strongly associated with iodine status (r = 0.24; p = 2.38 × 10−9) after excluding for iodine supplementation and T4 use. Participants residing in Quebec City (OR = 2.58; p = 1.74 × 10−4) and Vancouver (OR = 2.54; p = 3.57 × 10−4) were more susceptible to iodine deficiency than Hamilton or Ottawa. Also, greater exposure to abundant iodine uptake inhibitors from tobacco smoking and intake of specific goitrogenic foods corresponded to elevated urinary thiocyanate and nitrate, which were found for residents from Quebec City as compared to other clinical sites. Recent public health policies that advocate for salt restriction and lower dairy intake may inadvertently reduce iodine nutrition of Canadians, and further exacerbate regional variations in iodine deficiency risk.
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Affiliation(s)
- Stellena Mathiaparanam
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.N.d.M.)
| | - Adriana Nori de Macedo
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.N.d.M.)
- Departamento de Química, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (K.K.T.); (S.Y.)
| | - Paul Poirier
- Faculté de Pharmacie, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, QC G1V 4G5, Canada;
| | - Scott A. Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby and Division of Cardiology, Providence Health Care, Vancouver, BC V5A 1S6, Canada;
| | - Andreas Wielgosz
- University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Koon K. Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (K.K.T.); (S.Y.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (K.K.T.); (S.Y.)
| | - Philip Britz-Mckibbin
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada; (S.M.); (A.N.d.M.)
- Correspondence:
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12
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Akhabir L, Stringer R, Desai D, Mandhane PJ, Azad MB, Moraes TJ, Subbarao P, Turvey SE, Paré G, Anand SS, Anand SS, Atkinson SA, Azad MB, Becker AB, Brook J, Denburg JA, Desai D, de Souza RJ, Gupta M, Kobor M, Lefebvre DL, Lou W, Mandhane PJ, McDonald S, Mente A, Meyre D, Moraes TJ, Morrison K, Paré G, Sears MR, Subbarao P, Teo KK, Turvey SE, Wilson J, Yusuf S, Atkinson S, Wahi G, Zulyniak MA. DNA methylation changes in cord blood and the developmental origins of health and disease – a systematic review and replication study. BMC Genomics 2022; 23:221. [PMID: 35305575 PMCID: PMC8933946 DOI: 10.1186/s12864-022-08451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 03/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Environmental exposures in utero which modify DNA methylation may have a long-lasting impact on health and disease in offspring. We aimed to identify and replicate previously published genomic loci where DNA methylation changes are attributable to in utero exposures in the NutriGen birth cohort studies Alliance.
Methods
We reviewed the literature to identify differentially methylated sites of newborn DNA which are associated with the following five traits of interest maternal diabetes, pre-pregnancy body mass index (BMI), diet during pregnancy, smoking, and gestational age. We then attempted to replicate these published associations in the Canadian Healthy Infant Longitudinal Development (CHILD) and the South Asian birth cohort (START) cord blood epigenome-wide data.
Results
We screened 68 full-text articles and identified a total of 17 cord blood epigenome-wide association studies (EWAS) of the traits of interest. Out of the 290 CpG sites reported, 19 were identified in more than one study; all of them associated with maternal smoking. In CHILD and START EWAS, thousands of sites associated with gestational age were identified and maintained significance after correction for multiple testing. In CHILD, there was differential methylation observed for 8 of the published maternal smoking sites. No other traits tested (i.e., folate levels, gestational diabetes, birthweight) replicated in the CHILD or START cohorts.
Conclusions
Maternal smoking during pregnancy and gestational age are strongly associated with differential methylation in offspring cord blood, as assessed in the EWAS literature and our birth cohorts. There are a limited number of reported methylation sites associated in more than two independent studies related to pregnancy. Additional large studies of diverse populations with fine phenotyping are needed to produce robust epigenome-wide data in order to further elucidate the effect of intrauterine exposures on the infants’ methylome.
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13
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Savija N, Leong DP, Pinthus J, Karampatos S, Shayegan B, Mian R, Rangarajan S, Fradet V, de Souza RJ, Mente A, Dehghan M. Development and Comparability of a Short Food-Frequency Questionnaire to Assess Diet in Prostate Cancer Patients: The Role of Androgen Deprivation Therapy in CArdiovascular Disease - A Longitudinal Prostate Cancer Study (RADICAL PC) Substudy. Curr Dev Nutr 2021; 5:nzab106. [PMID: 34870071 PMCID: PMC8634316 DOI: 10.1093/cdn/nzab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There are few concise tools to evaluate dietary habits in men with prostate cancer in Canada. OBJECTIVE The aim was to develop a short food-frequency questionnaire (SFFQ) in a cohort of prostate cancer patients. METHODS A total of 130 men with prostate cancer completed the SFFQ and a validated comprehensive food-frequency questionnaire (CFFQ). Both questionnaires were administered at baseline and 6 mo later. RESULTS We found good correlation between the SFFQ and the CFFQ for seafood, dairy, egg, fruits, potatoes, grains, soft drinks, and processed meat (Spearman rank correlation >0.5). Moderate correlation was found for meat, sweets, vegetables, protein, and carbohydrates (Spearman rank correlation: 0.3-0.5). We found a weaker correlation for total fat measured by SFFQ and CFFQ (Spearman rank correlation <0.3). There was adequate reproducibility during the 6-mo follow-up among all food groups and nutrients, with the exception of meat. CONCLUSIONS Our SFFQ can be considered an appropriate tool to be used for measuring the habitual dietary intake of prostate cancer patients. This trial was registered at www.clinicaltrials.gov as NCT03127631.
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Affiliation(s)
- Nevena Savija
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Sarah Karampatos
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Bobby Shayegan
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Rajibul Mian
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vincent Fradet
- Department of Surgery, Laval University, Quebec City, Quebec, Canada
- Laval University Cancer Research Center, Quebec City, Quebec, Canada
| | - Russell J de Souza
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Astrup A, Teicholz N, Magkos F, Bier DM, Brenna JT, King JC, Mente A, Ordovas JM, Volek JS, Yusuf S, Krauss RM. Dietary Saturated Fats and Health: Are the U.S. Guidelines Evidence-Based? Nutrients 2021; 13:3305. [PMID: 34684304 PMCID: PMC8541481 DOI: 10.3390/nu13103305] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/08/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022] Open
Abstract
The last decade has seen nearly 20 papers reviewing the totality of the data on saturated fats and cardiovascular outcomes, which, altogether, have demonstrated a lack of rigorous evidence to support continued recommendations either to limit the consumption of saturated fatty acids or to replace them with polyunsaturated fatty acids. These papers were unfortunately not considered by the process leading to the most recent U.S. Dietary Guidelines for Americans, the country's national nutrition policy, which recently reconfirmed its recommendation to limit saturated fats to 10% or less of total energy intake, based on insufficient and inconsistent evidence. Continuation of a cap on saturated fat intake also fails to consider the important effects of the food matrix and the overall dietary pattern in which saturated fatty acids are consumed.
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Affiliation(s)
- Arne Astrup
- Healthy Weight Center, Novo Nordisk Foundation, Tuborg Havnevej 19, 2900 Hellerup, Denmark
| | | | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958 Frederiksberg C, Denmark;
| | - Dennis M. Bier
- Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
| | - J. Thomas Brenna
- Department of Pediatrics, Dell Pediatric Research Institute, University of Texas at Austin, Austin, TX 78723, USA;
- Department of Chemistry, Dell Pediatric Research Institute, University of Texas at Austin, Austin, TX 78723, USA
- Department of Nutrition, Dell Pediatric Research Institute, University of Texas at Austin, Austin, TX 78723, USA
| | - Janet C. King
- Department of Nutritional Sciences and Toxicology, University of California-Berkeley, Berkeley, CA 94720, USA;
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (S.Y.)
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - José M. Ordovas
- Nutrition and Genomics Laboratory, Human Nutrition Research Center of Aging, Tufts University, Boston, MA 02111, USA;
- IMDEA Food Institute, 28049 Madrid, Spain
| | - Jeff S. Volek
- Department of Human Sciences, Ohio State University, Columbus, OH 43210, USA;
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada; (A.M.); (S.Y.)
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Ronald M. Krauss
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA 94609, USA;
- Department of Medicine, University of California-San Francisco, San Francisco, CA 94609, USA
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15
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Iqbal R, Dehghan M, Mente A, Rangarajan S, Wielgosz A, Avezum A, Seron P, AlHabib KF, Lopez-Jaramillo P, Swaminathan S, Mohammadifard N, Zatońska K, Bo H, Varma RP, Rahman O, Yusufali A, Lu Y, Ismail N, Rosengren A, Imeryuz N, Yeates K, Chifamba J, Dans A, Kumar R, Xiaoyun L, Tsolekile L, Khatib R, Diaz R, Teo K, Yusuf S. Associations of unprocessed and processed meat intake with mortality and cardiovascular disease in 21 countries [Prospective Urban Rural Epidemiology (PURE) Study]: a prospective cohort study. Am J Clin Nutr 2021; 114:1049-1058. [PMID: 33787869 DOI: 10.1093/ajcn/nqaa448] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dietary guidelines recommend limiting red meat intake because it is a major source of medium- and long-chain SFAs and is presumed to increase the risk of cardiovascular disease (CVD). Evidence of an association between unprocessed red meat intake and CVD is inconsistent. OBJECTIVE The study aimed to assess the association of unprocessed red meat, poultry, and processed meat intake with mortality and major CVD. METHODS The Prospective Urban Rural Epidemiology (PURE) Study is a cohort of 134,297 individuals enrolled from 21 low-, middle-, and high-income countries. Food intake was recorded using country-specific validated FFQs. The primary outcomes were total mortality and major CVD. HRs were estimated using multivariable Cox frailty models with random intercepts. RESULTS In the PURE study, during 9.5 y of follow-up, we recorded 7789 deaths and 6976 CVD events. Higher unprocessed red meat intake (≥250 g/wk vs. <50 g/wk) was not significantly associated with total mortality (HR: 0.93; 95% CI: 0.85, 1.02; P-trend = 0.14) or major CVD (HR: 1.01; 95% CI: 0.92, 1.11; P-trend = 0.72). Similarly, no association was observed between poultry intake and health outcomes. Higher intake of processed meat (≥150 g/wk vs. 0 g/wk) was associated with higher risk of total mortality (HR: 1.51; 95% CI: 1.08, 2.10; P-trend = 0.009) and major CVD (HR: 1.46; 95% CI: 1.08, 1.98; P-trend = 0.004). CONCLUSIONS In a large multinational prospective study, we did not find significant associations between unprocessed red meat and poultry intake and mortality or major CVD. Conversely, a higher intake of processed meat was associated with a higher risk of mortality and major CVD.
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Affiliation(s)
- Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Mahshid Dehghan
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew Mente
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andreas Wielgosz
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, University of Santo Amaro (UNISA), Sao Paulo, SP Brazil
| | - Pamela Seron
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, India
| | - Noushin Mohammadifard
- Isfahan University of Medical Sciences, Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan, Iran
| | | | - Hu Bo
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ravi Prasad Varma
- Health Action by People, Thiruvananthapuram and Achutha Menon Center for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Omar Rahman
- University of Liberal Arts, Dhaka, Bangladesh
| | - AfzalHussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Yin Lu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Annika Rosengren
- University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Neşe Imeryuz
- Department of Internal Medicine and Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Karen Yeates
- Queen's University, Department of Medicine, Canada and Pamoja Tunaweza Research Center, Moshi, Tanzania
| | - Jephat Chifamba
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | - Rajesh Kumar
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Liu Xiaoyun
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lungi Tsolekile
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Rasha Khatib
- Birzeit University, Institute for Community and Public Health, Birzeit, Palestine.,Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | - Rafael Diaz
- Clinical Studies Latin America, Rosario, Santa Fe, Argentina
| | - Koon Teo
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Salim Yusuf
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
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16
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Mente A, Dehghan M, Yusuf S. Fishing for an Association With Sudden Cardiac Death-Reply. JAMA Intern Med 2021; 181:1140-1141. [PMID: 34152372 DOI: 10.1001/jamainternmed.2021.3036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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17
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Narula N, Wong ECL, Dehghan M, Mente A, Rangarajan S, Lanas F, Lopez-Jaramillo P, Rohatgi P, Lakshmi PVM, Varma RP, Orlandini A, Avezum A, Wielgosz A, Poirier P, Almadi MA, Altuntas Y, Ng KK, Chifamba J, Yeates K, Puoane T, Khatib R, Yusuf R, Boström KB, Zatonska K, Iqbal R, Weida L, Yibing Z, Sidong L, Dans A, Yusufali A, Mohammadifard N, Marshall JK, Moayyedi P, Reinisch W, Yusuf S. Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study. BMJ 2021; 374:n1554. [PMID: 34261638 PMCID: PMC8279036 DOI: 10.1136/bmj.n1554] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the relation between intake of ultra-processed food and risk of inflammatory bowel disease (IBD). DESIGN Prospective cohort study. SETTING 21 low, middle, and high income countries across seven geographical regions (Europe and North America, South America, Africa, Middle East, south Asia, South East Asia, and China). PARTICIPANTS 116 087 adults aged 35-70 years with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data (country specific validated FFQs were used to document baseline dietary intake). Participants were followed prospectively at least every three years. MAIN OUTCOME MEASURES The main outcome was development of IBD, including Crohn's disease or ulcerative colitis. Associations between ultra-processed food intake and risk of IBD were assessed using Cox proportional hazard multivariable models. Results are presented as hazard ratios with 95% confidence intervals. RESULTS Participants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (interquartile range 8.9-11.2 years), 467 participants developed incident IBD (90 with Crohn's disease and 377 with ulcerative colitis). After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD (hazard ratio 1.82, 95% confidence interval 1.22 to 2.72 for ≥5 servings/day and 1.67, 1.18 to 2.37 for 1-4 servings/day compared with <1 serving/day, P=0.006 for trend). Different subgroups of ultra-processed food, including soft drinks, refined sweetened foods, salty snacks, and processed meat, each were associated with higher hazard ratios for IBD. Results were consistent for Crohn's disease and ulcerative colitis with low heterogeneity. Intakes of white meat, red meat, dairy, starch, and fruit, vegetables, and legumes were not associated with incident IBD. CONCLUSIONS Higher intake of ultra-processed food was positively associated with risk of IBD. Further studies are needed to identify the contributory factors within ultra-processed foods. STUDY REGISTRATION ClinicalTrials.gov NCT03225586.
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Affiliation(s)
- Neeraj Narula
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Emily C L Wong
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Fernando Lanas
- Department of Internal Medicine, Universidad de La Frontera, Temuco, Chile
| | - Patricio Lopez-Jaramillo
- Masira Research Institute, Universidad de Santander (UDES) Fundación Oftalmológica de Santander-FOSCAL-Bucaramanga, Colombia
| | - Priyanka Rohatgi
- Department of Nutrition and Dietetics, Apollo Hospitals, Bangalore, India
| | - P V M Lakshmi
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, SCTIMST and Health Action by People, Thiruvananthapuram, India
| | - Andres Orlandini
- Department of Cardiology, Estudios Clinicos Latinoamerica ECLA Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, Brazil
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul Poirier
- Faculté de pharmacie, Université Laval Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - Majid A Almadi
- Department of Medicine, Division of Gastroenterology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yuksel Altuntas
- University of Health Sciences, Faculty of Medicine, Istanbul Sisli Hamidiye Etfal Health Training and Research Hospital, Clinic of Endocrinology and Metabolism Sisli/Istanbul, Turkey
| | - Kien Keat Ng
- Faculty of Medicine and Defence Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Bellville. South Africa
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Rita Yusuf
- Advocate Research Institute, Advocate Health Care, IL, USA
- School of Life Sciences, Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
| | - Kristina Bengtsson Boström
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | - Liu Weida
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences Mentougou District, Beijing, China
| | - Zhu Yibing
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences Mentougou District, Beijing, China
| | - Li Sidong
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences Mentougou District, Beijing, China
| | - Antonio Dans
- Section of Adult Medicine and Medical Research Unit, University of Philippines, Manila, Philippines
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - John K Marshall
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Paul Moayyedi
- Department of Medicine (Division of Gastroenterology) and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Walter Reinisch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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18
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute and Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Martin O'Donnell
- Population Health Research Institute and Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Salim Yusuf
- Population Health Research Institute and Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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19
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O'Donnell M, Mente A, Alderman MH, Brady AJB, Diaz R, Gupta R, López-Jaramillo P, Luft FC, Lüscher TF, Mancia G, Mann JFE, McCarron D, McKee M, Messerli FH, Moore LL, Narula J, Oparil S, Packer M, Prabhakaran D, Schutte A, Sliwa K, Staessen JA, Yancy C, Yusuf S. Salt and cardiovascular disease: insufficient evidence to recommend low sodium intake. Eur Heart J 2021; 41:3363-3373. [PMID: 33011774 DOI: 10.1093/eurheartj/ehaa586] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/09/2019] [Accepted: 07/10/2020] [Indexed: 12/19/2022] Open
Abstract
Several blood pressure guidelines recommend low sodium intake (<2.3 g/day, 100 mmol, 5.8 g/day of salt) for the entire population, on the premise that reductions in sodium intake, irrespective of the levels, will lower blood pressure, and, in turn, reduce cardiovascular disease occurrence. These guidelines have been developed without effective interventions to achieve sustained low sodium intake in free-living individuals, without a feasible method to estimate sodium intake reliably in individuals, and without high-quality evidence that low sodium intake reduces cardiovascular events (compared with moderate intake). In this review, we examine whether the recommendation for low sodium intake, reached by current guideline panels, is supported by robust evidence. Our review provides a counterpoint to the current recommendation for low sodium intake and suggests that a specific low sodium intake target (e.g. <2.3 g/day) for individuals may be unfeasible, of uncertain effect on other dietary factors and of unproven effectiveness in reducing cardiovascular disease. We contend that current evidence, despite methodological limitations, suggests that most of the world's population consume a moderate range of dietary sodium (2.3-4.6g/day; 1-2 teaspoons of salt) that is not associated with increased cardiovascular risk, and that the risk of cardiovascular disease increases when sodium intakes exceed 5 g/day. While current evidence has limitations, and there are differences of opinion in interpretation of existing evidence, it is reasonable, based upon observational studies, to suggest a population-level mean target of <5 g/day in populations with mean sodium intake of >5 g/day, while awaiting the results of large randomized controlled trials of sodium reduction on incidence of cardiovascular events and mortality.
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Affiliation(s)
- Martin O'Donnell
- HRB-Clinical Research Facility, NUI Galway, Newcastle Road, Galway, Ireland.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Michael H Alderman
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Rafael Diaz
- Instituto Cardiovascular de Rosario, Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Rajeev Gupta
- Academic Research Development Unit, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India
| | - Patricio López-Jaramillo
- Fundación Oftalmológica de Santander, Instituto Masira, Universidad de Santander, Bucaramanga, Santander, Colombia
| | - Friedrich C Luft
- D Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine, Medical Faculty of the Charité, Berlin, Germany
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Giuseppe Mancia
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | | | | | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lynn L Moore
- Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jagat Narula
- The Mount Sinai Medical Centre, New York, NY, USA
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Milton Packer
- Baylor Hear and Vascular Institute, Baylor University Medical Centre, Dallas, TX, USA
| | - Dorairaj Prabhakaran
- Centre for Chronic Conditions & Injuries, Public Health Foundation of India, Gurugram, India
| | - Alta Schutte
- The George Institute for Global Health, Level 5, 1 King Street, Newtown, New South Wales 2042, Australia
| | - Karen Sliwa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jan A Staessen
- Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
| | - Clyde Yancy
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 N Saint Claire, Chicago, IL, USA
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
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20
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Mohan D, Mente A, Dehghan M, Rangarajan S, O'Donnell M, Hu W, Dagenais G, Wielgosz A, Lear S, Wei L, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Swaminathan S, Kaur M, Vijayakumar K, Mohan V, Gupta R, Szuba A, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Yusoff K, Gulec S, Rosengren A, Yusufali A, Wentzel-Viljoen E, Chifamba J, Dans A, Alhabib KF, Yeates K, Teo K, Gerstein HC, Yusuf S. Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries. JAMA Intern Med 2021; 181:631-649. [PMID: 33683310 PMCID: PMC7941252 DOI: 10.1001/jamainternmed.2021.0036] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown. OBJECTIVE To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease. DESIGN, SETTING, AND PARTICIPANTS This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies-147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020. EXPOSURES Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish. MAIN OUTCOMES AND MEASURES Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death). RESULTS Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]). CONCLUSIONS AND RELEVANCE Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.
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Affiliation(s)
- Deepa Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Weihong Hu
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Gilles Dagenais
- Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada, G1V 4G5
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott Lear
- Faculty of Health Sciences, and Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, SP Brazil
| | | | - Fernando Lanas
- Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | | | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Vijayakumar
- Health Action by People, Amrita Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Rajasthan University of Health Sciences, Jaipur, India
| | - Andrzej Szuba
- Wroclaw Medical University, Department of Internal Medicine, 4th Military Hospital, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi Pakistan
| | - Rita Yusuf
- Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine.,Advocate Research Institute, Advocate Health Care, Chicago, Illinois
| | - Khalid Yusoff
- Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia, UCSI University, Cheras, Selangor, Malaysia
| | - Sadi Gulec
- Cardiology Department, Ankara University Medical School, Ankara, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | | | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Antonio Dans
- University of the Philippines, Ermita, Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Karen Yeates
- Department of Medicine, Etherington Hall, Queen's University, Kingston, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Jenkins DJA, Dehghan M, Mente A, Bangdiwala SI, Rangarajan S, Srichaikul K, Mohan V, Avezum A, Díaz R, Rosengren A, Lanas F, Lopez-Jaramillo P, Li W, Oguz A, Khatib R, Poirier P, Mohammadifard N, Pepe A, Alhabib KF, Chifamba J, Yusufali AH, Iqbal R, Yeates K, Yusoff K, Ismail N, Teo K, Swaminathan S, Liu X, Zatońska K, Yusuf R, Yusuf S. Glycemic Index, Glycemic Load, and Cardiovascular Disease and Mortality. N Engl J Med 2021; 384:1312-1322. [PMID: 33626252 DOI: 10.1056/nejmoa2007123] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population. METHODS This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used country-specific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause. RESULTS In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease. CONCLUSIONS In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death. (Funded by the Population Health Research Institute and others.).
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Affiliation(s)
- David J A Jenkins
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Mahshid Dehghan
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Andrew Mente
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Shrikant I Bangdiwala
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Sumathy Rangarajan
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Kristie Srichaikul
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Viswanathan Mohan
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Alvaro Avezum
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Rafael Díaz
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Annika Rosengren
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Fernando Lanas
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Patricio Lopez-Jaramillo
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Wei Li
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Aytekin Oguz
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Rasha Khatib
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Paul Poirier
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Noushin Mohammadifard
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Andrea Pepe
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Khalid F Alhabib
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Jephat Chifamba
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Afzal Hussein Yusufali
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Romaina Iqbal
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Karen Yeates
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Khalid Yusoff
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Noorhassim Ismail
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Koon Teo
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Sumathi Swaminathan
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Xiaoyun Liu
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Katarzyna Zatońska
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Rita Yusuf
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
| | - Salim Yusuf
- From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.)
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22
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Liu X, Bai Y, Li S, O'Donnell M, Mente A, Yin L, Hu B, Cheng X, Liu W, Bai X, Wang Y, Sun Y, Li X, Liu L, Yusuf S, Li W. Associations of estimated 24-h urinary sodium excretion with mortality and cardiovascular events in Chinese adults: a prospective cohort study. J Hypertens 2021; 39:484-493. [PMID: 33031177 DOI: 10.1097/hjh.0000000000002647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate the associations of sodium excretion with blood pressure, mortality and cardiovascular diseases in Chinese population. METHODS We studied 39 366 individuals aged 35-70 years from 115 urban and rural communities in 12 centers across mainland China. Trained research staff conducted face-to-face interview to record baseline information of all participants based on questionnaires, and collected their morning fasting urine samples to estimate 24-h sodium excretion (24hUNaE). Multivariable frailty Cox regression accounting for clustering by centre was performed to examine the association between estimated 24hUNaE and the primary composite outcome of death and major cardiovascular events in a Chinese population. RESULTS Mean 24hUNaE was 5.68 (SD 1.69) g/day. After a median follow-up of 8.8 years, the composite outcome occurred in 3080 (7.8%) participants, of which 1426 (3.5%) died and 2192 (5.4%) suffered from cardiovascular events. 24hUNaE was positively associated with increased SBP and DBP. Using the 24hUNaE level of 4-4.99 g/day as the reference group, a 24hUNaE of either lower (<3 g/day) or higher (≥7 g/day) was associated with an increased risk of the composite outcome with a hazard ratio of 1.22 (95% confidence interval: 1.01-1.49) and 1.15 (95% confidence interval: 1.01-1.30), respectively. A similar trend was observed between 24hUNaE level and risk of death or major cardiovascular events. CONCLUSION These findings support a positive association between estimated urinary sodium excretion and blood pressure, and a possible J-shaped pattern of association between sodium excretion and clinical outcomes, with the lowest risk in participants with sodium excretion between 3 and 5 g/day.
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Affiliation(s)
- Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
- Phase I Clinical Trial Center Beijing Shijitan Hospital, Capital Medical University, Beijing
| | - Yinxiao Bai
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Sidong Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Andrew Mente
- Department of Health Research Methods, Evidence and Impact, McMaster University
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Lu Yin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Bo Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Xiaoru Cheng
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Weida Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Xiulin Bai
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Yang Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Yi Sun
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Xiaomeng Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
| | - Lisheng Liu
- Beijing Hypertension League Institute, Beijing, PR China
| | - Salim Yusuf
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, PR China
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23
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Bhavadharini B, Mohan V, Dehghan M, Rangarajan S, Swaminathan S, Rosengren A, Wielgosz A, Avezum A, Lopez-Jaramillo P, Lanas F, Dans AL, Yeates K, Poirier P, Chifamba J, Alhabib KF, Mohammadifard N, Zatońska K, Khatib R, Vural Keskinler M, Wei L, Wang C, Liu X, Iqbal R, Yusuf R, Wentzel-Viljoen E, Yusufali A, Diaz R, Keat NK, Lakshmi PVM, Ismail N, Gupta R, Palileo-Villanueva LM, Sheridan P, Mente A, Yusuf S. White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries. Diabetes Care 2020; 43:2643-2650. [PMID: 32873587 PMCID: PMC7576435 DOI: 10.2337/dc19-2335] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 07/08/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study. RESEARCH DESIGN AND METHODS Data on 132,373 individuals aged 35-70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model. RESULTS During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02-1.40; P for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13-2.30; P for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08-1.86; P for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77-1.40; P for trend = 0.38). CONCLUSIONS Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.
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Affiliation(s)
- Balaji Bhavadharini
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Patricio Lopez-Jaramillo
- Instituto Masira, Medical School, Universidad de Santander, and Fundación Oftalmológica de Santander-Clínica Carlos Ardila Lulle, Bucaramanga, Colombia
| | | | - Antonio L Dans
- University of the Philippines College of Medicine, Manila, Philippines
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Canada
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Jephat Chifamba
- Department of Physiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Katarzyna Zatońska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Rasha Khatib
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Mirac Vural Keskinler
- Department of Internal Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Chuangshi Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical University, Dubai Health Authority, Dubai, United Arab Emirates
| | - Rafael Diaz
- Estudios Clínicos Latinoamerica, Rosario, Santa Fe, Argentina
| | - Ng Kien Keat
- Universiti Teknologi MARA, Sungai Buloh, Malaysia.,University College Sedaya International University, Cheras, Malaysia
| | - P V M Lakshmi
- School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Lia M Palileo-Villanueva
- University of the Philippines College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Patrick Sheridan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
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24
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Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada
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25
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de Souza RJ, Dehghan M, Mente A, Bangdiwala SI, Ahmed SH, Alhabib KF, Altuntas Y, Basiak-Rasała A, Dagenais GR, Diaz R, Amma LI, Kelishadi R, Khatib R, Lear SA, Lopez-Jaramillo P, Mohan V, Poirier P, Rangarajan S, Rosengren A, Ismail R, Swaminathan S, Wentzel-Viljoen E, Yeates K, Yusuf R, Teo KK, Anand SS, Yusuf S. Association of nut intake with risk factors, cardiovascular disease, and mortality in 16 countries from 5 continents: analysis from the Prospective Urban and Rural Epidemiology (PURE) study. Am J Clin Nutr 2020; 112:208-219. [PMID: 32433740 DOI: 10.1093/ajcn/nqaa108] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/21/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The association of nuts with cardiovascular disease and deaths has been investigated mostly in Europe, the USA, and East Asia, with few data available from other regions of the world or from low- and middle-income countries. OBJECTIVE To assess the association of nuts with mortality and cardiovascular disease (CVD). METHODS The Prospective Urban Rural Epidemiology study is a large multinational prospective cohort study of adults aged 35-70 y from 16 low-, middle-, and high-income countries on 5 continents. Nut intake (tree nuts and ground nuts) was measured at the baseline visit, using country-specific validated FFQs. The primary outcome was a composite of mortality or major cardiovascular event [nonfatal myocardial infarction (MI), stroke, or heart failure]. RESULTS We followed 124,329 participants (age = 50.7 y, SD = 10.2; 41.5% male) for a median of 9.5 y. We recorded 10,928 composite events [deaths (n = 8,662) or major cardiovascular events (n = 5,979)]. Higher nut intake (>120 g per wk compared with <30 g per mo) was associated with a lower risk of the primary composite outcome of mortality or major cardiovascular event [multivariate HR (mvHR): 0.88; 95% CI: 0.80, 0.96; P-trend = 0.0048]. Significant reductions in total (mvHR: 0.77; 95% CI: 0.69, 0.87; P-trend <0.0001), cardiovascular (mvHR: 0.72; 95% CI: 0.56, 0.92; P-trend = 0.048), and noncardiovascular mortality (mvHR: 0.82; 95% CI: 0.70, 0.96; P-trend = 0.0046) with a trend to reduced cancer mortality (mvHR: 0.81; 95% CI: 0.65, 1.00; P-trend = 0.081) were observed. No significant associations of nuts were seen with major CVD (mvHR: 0.91; 95% CI: 0.81, 1.02; P-trend = 0.14), stroke (mvHR: 0.98; 95% CI: 0.84, 1.14; P-trend = 0.76), or MI (mvHR: 0.86; 95% CI: 0.72, 1.04; P-trend = 0.29). CONCLUSIONS Higher nut intake was associated with lower mortality risk from both cardiovascular and noncardiovascular causes in low-, middle-, and high-income countries.
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Affiliation(s)
- Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | | | - Andrew Mente
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | | | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yuksel Altuntas
- Department of Endocrinology and Metabolism, University of Health Sciences, Sisli Hamidiye Etfal Teaching and Research Hospital , Istanbul, Turkey
| | | | | | - Rafael Diaz
- Estudios Clinicos Latinoamerica (ECLA), Rosario, Santa Fe, Argentina
| | - Leela Itty Amma
- Health Action by People/Amrita Institute of Medical Sciences, Kerala, India
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine.,Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | - Scott A Lear
- Population Health Research Institute, Hamilton, ON, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Patricio Lopez-Jaramillo
- Instituto Masira, Medical School, Facultad de Ciencias de la Salud, Universidad de Santander (UDES) and Fundacion Oftalmologica de Santander (FOSCAL), Bucaramanga, Colombia
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Chennai, India.,Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Paul Poirier
- Institut universitaire de cardiologie et de pneumologie de Québec, Quebec, Canada
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rosnah Ismail
- Community Health Department, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | | | - Edelweiss Wentzel-Viljoen
- Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Karen Yeates
- Department of Medicine, Division of Nephrology, Queens University, Ontario, Canada
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Koon K Teo
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, Faculty of Health Sciences, McMaster University, Ontario, Canada
| | - Sonia S Anand
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, Faculty of Health Sciences, McMaster University, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, Faculty of Health Sciences, McMaster University, Ontario, Canada
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26
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Dehghan M, Mente A, Rangarajan S, Mohan V, Lear S, Swaminathan S, Wielgosz A, Seron P, Avezum A, Lopez-Jaramillo P, Turbide G, Chifamba J, AlHabib KF, Mohammadifard N, Szuba A, Khatib R, Altuntas Y, Liu X, Iqbal R, Rosengren A, Yusuf R, Smuts M, Yusufali A, Li N, Diaz R, Yusoff K, Kaur M, Soman B, Ismail N, Gupta R, Dans A, Sheridan P, Teo K, Anand SS, Yusuf S. Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr 2020; 111:795-803. [PMID: 31965140 PMCID: PMC7138651 DOI: 10.1093/ajcn/nqz348] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/26/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Eggs are a rich source of essential nutrients, but they are also a source of dietary cholesterol. Therefore, some guidelines recommend limiting egg consumption. However, there is contradictory evidence on the impact of eggs on diseases, largely based on studies conducted in high-income countries. OBJECTIVES Our aim was to assess the association of egg consumption with blood lipids, cardiovascular disease (CVD), and mortality in large global studies involving populations from low-, middle-, and high-income countries. METHODS We studied 146,011 individuals from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Egg consumption was recorded using country-specific validated FFQs. We also studied 31,544 patients with vascular disease in 2 multinational prospective studies: ONTARGET (Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects with Cardiovascular Disease). We calculated HRs using multivariable Cox frailty models with random intercepts to account for clustering by study center separately within each study. RESULTS In the PURE study, we recorded 14,700 composite events (8932 deaths and 8477 CVD events). In the PURE study, after excluding those with history of CVD, higher intake of egg (≥7 egg/wk compared with <1 egg/wk intake) was not significantly associated with blood lipids, composite outcome (HR: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.74), total mortality (HR: 1.04; 95% CI: 0.94, 1.15; P-trend = 0.38), or major CVD (HR: 0.92; 95% CI: 0.83, 1.01; P-trend = 0.20). Similar results were observed in ONTARGET/TRANSCEND studies for composite outcome (HR 0.97; 95% CI: 0.76, 1.25; P-trend = 0.09), total mortality (HR: 0.88; 95% CI: 0.62, 1.24; P-trend = 0.55), and major CVD (HR: 0.97; 95% CI: 0.73, 1.29; P-trend = 0.12). CONCLUSIONS In 3 large international prospective studies including ∼177,000 individuals, 12,701 deaths, and 13,658 CVD events from 50 countries in 6 continents, we did not find significant associations between egg intake and blood lipids, mortality, or major CVD events. The ONTARGET and TRANSCEND trials were registered at clinicaltrials.gov as NCT00153101. The PURE trial was registered at clinicaltrials.gov as NCT03225586.
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Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada,Address correspondence to MD (e-mail: )
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Viswanathan Mohan
- Dr. Mohan's Diabetes Specialities Centre, Gopalapuram, Chennai, India
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, India
| | - Andreas Wielgosz
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Pamela Seron
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Ginette Turbide
- Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jephat Chifamba
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland,Department of Internal Medicine, 4th Military Hospital in Wroclaw, Wroclaw, Poland
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine,Advocate Research Institute, Advocate Health Care, Chicago, IL, USA
| | - Yuksel Altuntas
- Clinic of Endocrinology and Metabolism Sisli, Istanbul Sisli Hamidiye Etfal Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Marius Smuts
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | | | - Ning Li
- Qingshan Lake Community Health Service Center, Nanchang City, China
| | - Rafael Diaz
- Clinical Studies Latin America, Rosario, Santa Fe, Argentina
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia,Department of Medicine, UCSI University, Cheras, Selangor, Malaysia
| | - Manmeet Kaur
- Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
| | - Biju Soman
- Health Action by People, Thiruvananthapuram, India,Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, India
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | - Patrick Sheridan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Bhavadharini B, Dehghan M, Mente A, Rangarajan S, Sheridan P, Mohan V, Iqbal R, Gupta R, Lear S, Wentzel-Viljoen E, Avezum A, Lopez-Jaramillo P, Mony P, Varma RP, Kumar R, Chifamba J, Alhabib KF, Mohammadifard N, Oguz A, Lanas F, Rozanska D, Bengtsson Bostrom K, Yusoff K, Tsolkile LP, Dans A, Yusufali A, Orlandini A, Poirier P, Khatib R, Hu B, Wei L, Yin L, Deeraili A, Yeates K, Yusuf R, Ismail N, Mozaffarian D, Teo K, Anand SS, Yusuf S. Association of dairy consumption with metabolic syndrome, hypertension and diabetes in 147 812 individuals from 21 countries. BMJ Open Diabetes Res Care 2020; 8:8/1/e000826. [PMID: 32423962 PMCID: PMC7326257 DOI: 10.1136/bmjdrc-2019-000826] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/07/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study. METHODS The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes). RESULTS In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend<0.0001) was associated with a lower prevalence of MetS after multivariable adjustment. Higher intakes of whole fat dairy consumed alone (OR 0.72, 95% CI 0.66 to 0.78, p-trend<0.0001), or consumed jointly with low fat dairy (OR 0.89, 95% CI 0.80 to 0.98, p-trend=0.0005), were associated with a lower MetS prevalence. Low fat dairy consumed alone was not associated with MetS (OR 1.03, 95% CI 0.77 to 1.38, p-trend=0.13). In prospective analysis, 13 640 people with incident hypertension and 5351 people with incident diabetes were recorded. Higher intake of total dairy (at least two servings/day vs zero serving/day) was associated with a lower incidence of hypertension (HR 0.89, 95% CI 0.82 to 0.97, p-trend=0.02) and diabetes (HR 0.88, 95% CI 0.76 to 1.02, p-trend=0.01). Directionally similar associations were found for whole fat dairy versus each outcome. CONCLUSIONS Higher intake of whole fat (but not low fat) dairy was associated with a lower prevalence of MetS and most of its component factors, and with a lower incidence of hypertension and diabetes. Our findings should be evaluated in large randomized trials of the effects of whole fat dairy on the risks of MetS, hypertension, and diabetes.
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Affiliation(s)
- Balaji Bhavadharini
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Patrick Sheridan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Viswanathan Mohan
- Epidemiology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
- Diabetology, Dr Mohan's Diabetes Specialities Centre Gopalapuram, Chennai, Tamil Nadu, India
| | | | - Rajeev Gupta
- Preventive Cardiology, Eternal Heart Care Centre & Research Institute, Jaipur, Rajasthan, India
| | - Scott Lear
- Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | | | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Prem Mony
- St John's Medical College & Research Institute, Bengaluru, Karnataka, India
| | - Ravi Prasad Varma
- Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, Kerala, India
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | - Aytekin Oguz
- Internal Medicine, Goztepe Training and Research Hospital, Istanbul, Marmara, Turkey
| | | | | | | | - Khalid Yusoff
- Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia
| | | | - Antonio Dans
- University of the Philippines System, Quezon City, Metro Manila, Philippines
| | | | | | - Paul Poirier
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Quebec, Quebec City, Quebec, Canada
| | - Rasha Khatib
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bo Hu
- Peking Union Medical College School of Basic Medicine, Beijing, China
| | - Li Wei
- Medical Research & Biometrics Center, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Lu Yin
- Peking Union Medical College School of Basic Medicine, Beijing, China
| | - Ai Deeraili
- Xinjiang Uighur Autonomous Region Center for Disease Control and Prevention, Wulumuqi, Xinjiang, China
| | | | - Rita Yusuf
- Independent University, Dhaka, Bangladesh
| | | | - Dariush Mozaffarian
- Tufts Friedman School of Nutrition Science & Policy, Boston, Massachusetts, USA
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Yusuf S, Joseph P, Rangarajan S, Islam S, Mente A, Hystad P, Brauer M, Kutty VR, Gupta R, Wielgosz A, AlHabib KF, Dans A, Lopez-Jaramillo P, Avezum A, Lanas F, Oguz A, Kruger IM, Diaz R, Yusoff K, Mony P, Chifamba J, Yeates K, Kelishadi R, Yusufali A, Khatib R, Rahman O, Zatonska K, Iqbal R, Wei L, Bo H, Rosengren A, Kaur M, Mohan V, Lear SA, Teo KK, Leong D, O'Donnell M, McKee M, Dagenais G. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet 2020; 395:795-808. [PMID: 31492503 PMCID: PMC8006904 DOI: 10.1016/s0140-6736(19)32008-2] [Citation(s) in RCA: 808] [Impact Index Per Article: 202.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels. METHODS In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs. FINDINGS Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs. INTERPRETATION Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Philip Joseph
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Shofiqul Islam
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Perry Hystad
- School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Michael Brauer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Rajeev Gupta
- Eternal Heart Care Centre & Research Institute, Jaipur, India
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Antonio Dans
- Department of Cardiac Sciences, University of Philippines, Manila, Philippines
| | - Patricio Lopez-Jaramillo
- Fundación Oftalmológica de Santander Clínica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia; Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Alvaro Avezum
- Department of Medicine, Universidade de Santo Amaro, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Iolanthe M Kruger
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica (ECLA), Rosario, Santa Fe, Argentina
| | - Khalid Yusoff
- Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Prem Mony
- St John's Research Institute, St John's Medical College, Bangalore, India
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Roya Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Afzalhussein Yusufali
- Department of Medicine, Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Rasha Khatib
- Institute for Community and Public Health, Birzeit University, Birzeit, Palestine; Advocate Health Care, Chicago, IL, USA
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Li Wei
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hu Bo
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Manmeet Kaur
- School of Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Chennai, India; Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Koon K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Darryl Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Martin O'Donnell
- Department of Medicine, National University of Ireland Galway, London, UK
| | - Martin McKee
- Department of Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Gilles Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, QC, Canada
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Mente A, O’Donnell M, Yusuf S. Letter by Mente et al Regarding Article “Urinary Sodium Excretion, Blood Pressure, and Risk of Future Cardiovascular Disease and Mortality in Subjects Without Prior Cardiovascular Disease”. Hypertension 2019; 74:e26. [DOI: 10.1161/hypertensionaha.119.13321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- A. Mente
- Population Health Research Institute, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, CA
| | | | - S. Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, CA
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30
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8L 2X2, Canada.
| | - Martin J O'Donnell
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada; Health Research Board-Clinical Research Facility, National University of Ireland, Galway, Ireland
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada
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O'Donnell M, Mente A, Rangarajan S, McQueen MJ, O'Leary N, Yin L, Liu X, Swaminathan S, Khatib R, Rosengren A, Ferguson J, Smyth A, Lopez-Jaramillo P, Diaz R, Avezum A, Lanas F, Ismail N, Yusoff K, Dans A, Iqbal R, Szuba A, Mohammadifard N, Oguz A, Yusufali AH, Alhabib KF, Kruger IM, Yusuf R, Chifamba J, Yeates K, Dagenais G, Wielgosz A, Lear SA, Teo K, Yusuf S. Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: prospective cohort study. BMJ 2019; 364:l772. [PMID: 30867146 PMCID: PMC6415648 DOI: 10.1136/bmj.l772] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. DESIGN International prospective cohort study. SETTING 18 high, middle, and low income countries, sampled from urban and rural communities. PARTICIPANTS 103 570 people who provided morning fasting urine samples. MAIN OUTCOME MEASURES Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). RESULTS Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). CONCLUSIONS These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.
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Affiliation(s)
- Martin O'Donnell
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Andrew Mente
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Matthew J McQueen
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Neil O'Leary
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Lu Yin
- Medical Research & Biometrics Centre, National Centre for Cardiovascular Diseases Cardiovascular, Fengcunxili, Mentougou District, Beijing, China
| | - Xiaoyun Liu
- Medical Research & Biometrics Centre, National Centre for Cardiovascular Diseases Cardiovascular, Fengcunxili, Mentougou District, Beijing, China
| | - Sumathi Swaminathan
- Division of Nutrition, St John's Research Institute, Bangalore, Karnataka, India
| | - Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - John Ferguson
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Andrew Smyth
- HRB-Clinical Research Facility, Galway University Hospital, NUI Galway, Galway, Ireland
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander (FOSCAL), Medical School, Universidad de Santander, Floridablanca-Santander, Colombia
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Instituto Cardiovascular de Rosario, Rosario, Santa Fe, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | | | - Noorhassim Ismail
- Department of Community Health. University Kebangsaan Malaysia Medical Centre, Malaysia
| | - Khalid Yusoff
- Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Antonio Dans
- University of the Philippines-Manila, Ermita, Manila, Philippines
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Atyekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
| | - Afzal Hussein Yusufali
- Hatta Hospital, Dubai Medical University, Dubai Health Authority. Dubai, United Arab Emirates
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University. Riyadh, Saudi Arabia
| | - Iolanthe M Kruger
- Faculty of Health Science, North-West University, Potchefstroom campus, Potchefstroom, South Africa
| | - Rita Yusuf
- School of Life Sciences and The Centre for Health, Population and Development. Independent University, Bangladesh, Dhaka, Bangladesh
| | - Jephat Chifamba
- University of Zimbabwe, College of Health Sciences, Physiology Department, Harare, Zimbabwe
| | - Karen Yeates
- Department of Medicine, Division of Nephrology, Queen's University, Kingston, Canada
| | - Gilles Dagenais
- Laval University Heart and Lungs Institute, Quebec City, QC, Canada
| | | | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, and Division of Cardiology, Providence Health Care, BC, Canada
| | - Koon Teo
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
| | - Salim Yusuf
- Population Health Research Institute, DBCVS Research Institute, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2, Canada
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Dehghan M, Mente A, Rangarajan S, Sheridan P, Mohan V, Iqbal R, Gupta R, Lear S, Wentzel-Viljoen E, Avezum A, Lopez-Jaramillo P, Mony P, Varma RP, Kumar R, Chifamba J, Alhabib KF, Mohammadifard N, Oguz A, Lanas F, Rozanska D, Bostrom KB, Yusoff K, Tsolkile LP, Dans A, Yusufali A, Orlandini A, Poirier P, Khatib R, Hu B, Wei L, Yin L, Deeraili A, Yeates K, Yusuf R, Ismail N, Mozaffarian D, Teo K, Anand SS, Yusuf S. Association of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE): a prospective cohort study. Lancet 2018; 392:2288-2297. [PMID: 30217460 DOI: 10.1016/s0140-6736(18)31812-9] [Citation(s) in RCA: 245] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 07/30/2018] [Accepted: 08/01/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Dietary guidelines recommend minimising consumption of whole-fat dairy products, as they are a source of saturated fats and presumed to adversely affect blood lipids and increase cardiovascular disease and mortality. Evidence for this contention is sparse and few data for the effects of dairy consumption on health are available from low-income and middle-income countries. Therefore, we aimed to assess the associations between total dairy and specific types of dairy products with mortality and major cardiovascular disease. METHODS The Prospective Urban Rural Epidemiology (PURE) study is a large multinational cohort study of individuals aged 35-70 years enrolled from 21 countries in five continents. Dietary intakes of dairy products for 136 384 individuals were recorded using country-specific validated food frequency questionnaires. Dairy products comprised milk, yoghurt, and cheese. We further grouped these foods into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios (HRs) were calculated using multivariable Cox frailty models with random intercepts to account for clustering of participants by centre. FINDINGS Between Jan 1, 2003, and July 14, 2018, we recorded 10 567 composite events (deaths [n=6796] or major cardiovascular events [n=5855]) during the 9·1 years of follow-up. Higher intake of total dairy (>2 servings per day compared with no intake) was associated with a lower risk of the composite outcome (HR 0·84, 95% CI 0·75-0·94; ptrend=0·0004), total mortality (0·83, 0·72-0·96; ptrend=0·0052), non-cardiovascular mortality (0·86, 0·72-1·02; ptrend=0·046), cardiovascular mortality (0·77, 0·58-1·01; ptrend=0·029), major cardiovascular disease (0·78, 0·67-0·90; ptrend=0·0001), and stroke (0·66, 0·53-0·82; ptrend=0·0003). No significant association with myocardial infarction was observed (HR 0·89, 95% CI 0·71-1·11; ptrend=0·163). Higher intake (>1 serving vs no intake) of milk (HR 0·90, 95% CI 0·82-0·99; ptrend=0·0529) and yogurt (0·86, 0·75-0·99; ptrend=0·0051) was associated with lower risk of the composite outcome, whereas cheese intake was not significantly associated with the composite outcome (0·88, 0·76-1·02; ptrend=0·1399). Butter intake was low and was not significantly associated with clinical outcomes (HR 1·09, 95% CI 0·90-1·33; ptrend=0·4113). INTERPRETATION Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational cohort. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Patrick Sheridan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rajeev Gupta
- Department of Medicine, Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, BC, Canada
| | | | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Patricio Lopez-Jaramillo
- Research Department, Fundacion Oftalmologica de Santander, Medical School, University of Santander, Floridablanca-Santander, Colombia
| | - Prem Mony
- Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore, India
| | - Ravi Prasad Varma
- Faculty of Health Sciences, Achutha Menon Centre for Health Science Studies Health Action by People, Thiruvananthapuram, Kerala, India
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research (PGIMER) School of Public Health, Chandigarh, India
| | - Jephat Chifamba
- College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Aytekin Oguz
- Department of Internal Medicine, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | - Dorota Rozanska
- Department of Dietetics, Wroclaw Medical University, Wroclaw, Poland
| | - Kristina Bengtsson Bostrom
- Närhälsan R&D Centre Skaraborg Primary Care Skövde and Department of Public Health and Community Medicine, Primary Health Care, the Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; Department of Medicine, UCSI University, Cheras, Selangor, Malaysia
| | - Lungiswa P Tsolkile
- School of Public Health, University of the Western Cape, Cape Town, Western Cape Province, South Africa
| | - Antonio Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | - AfzalHussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Paul Poirier
- Institut universitaire de cardiologie et pneumologie de Québec, Université laval, QC, Canada
| | - Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bo Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Yin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ai Deeraili
- Center for Disease Control and Prevention of Xinjiang Hetian, Xinjiang, China
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Rita Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Malaysia
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- School of Life Sciences, Independent University, Bashundhara, Dhaka, Bangladesh
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada.
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; McMaster University, Hamilton, ON, Canada
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Mente A, O'Donnell M, Rangarajan S, McQueen M, Dagenais G, Wielgosz A, Lear S, Ah STL, Wei L, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Mony P, Szuba A, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Yusoff K, Ismail N, Gulec S, Rosengren A, Yusufali A, Kruger L, Tsolekile LP, Chifamba J, Dans A, Alhabib KF, Yeates K, Teo K, Yusuf S. Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. Lancet 2018; 392:496-506. [PMID: 30129465 DOI: 10.1016/s0140-6736(18)31376-x] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 06/04/2018] [Accepted: 06/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND WHO recommends that populations consume less than 2 g/day sodium as a preventive measure against cardiovascular disease, but this target has not been achieved in any country. This recommendation is primarily based on individual-level data from short-term trials of blood pressure (BP) without data relating low sodium intake to reduced cardiovascular events from randomised trials or observational studies. We investigated the associations between community-level mean sodium and potassium intake, cardiovascular disease, and mortality. METHODS The Prospective Urban Rural Epidemiology study is ongoing in 21 countries. Here we report an analysis done in 18 countries with data on clinical outcomes. Eligible participants were adults aged 35-70 years without cardiovascular disease, sampled from the general population. We used morning fasting urine to estimate 24 h sodium and potassium excretion as a surrogate for intake. We assessed community-level associations between sodium and potassium intake and BP in 369 communities (all >50 participants) and cardiovascular disease and mortality in 255 communities (all >100 participants), and used individual-level data to adjust for known confounders. FINDINGS 95 767 participants in 369 communities were assessed for BP and 82 544 in 255 communities for cardiovascular outcomes with follow-up for a median of 8·1 years. 82 (80%) of 103 communities in China had a mean sodium intake greater than 5 g/day, whereas in other countries 224 (84%) of 266 communities had a mean intake of 3-5 g/day. Overall, mean systolic BP increased by 2·86 mm Hg per 1 g increase in mean sodium intake, but positive associations were only seen among the communities in the highest tertile of sodium intake (p<0·0001 for heterogeneity). The association between mean sodium intake and major cardiovascular events showed significant deviations from linearity (p=0·043) due to a significant inverse association in the lowest tertile of sodium intake (lowest tertile <4·43 g/day, mean intake 4·04 g/day, range 3·42-4·43; change -1·00 events per 1000 years, 95% CI -2·00 to -0·01, p=0·0497), no association in the middle tertile (middle tertile 4·43-5·08 g/day, mean intake 4·70 g/day, 4·44-5.05; change 0·24 events per 1000 years, -2·12 to 2·61, p=0·8391), and a positive but non-significant association in the highest tertile (highest tertile >5·08 g/day, mean intake 5·75 g/day, >5·08-7·49; change 0·37 events per 1000 years, -0·03 to 0·78, p=0·0712). A strong association was seen with stroke in China (mean sodium intake 5·58 g/day, 0·42 events per 1000 years, 95% CI 0·16 to 0·67, p=0·0020) compared with in other countries (4·49 g/day, -0·26 events, -0·46 to -0·06, p=0·0124; p<0·0001 for heterogeneity). All major cardiovascular outcomes decreased with increasing potassium intake in all countries. INTERPRETATION Sodium intake was associated with cardiovascular disease and strokes only in communities where mean intake was greater than 5 g/day. A strategy of sodium reduction in these communities and countries but not in others might be appropriate. FUNDING Population Health Research Institute, Canadian Institutes of Health Research, Canadian Institutes of Health Canada Strategy for Patient-Oriented Research, Ontario Ministry of Health and Long-Term Care, Heart and Stroke Foundation of Ontario, and European Research Council.
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, McMaster University, Hamilton, ON, Canada.
| | - Martin O'Donnell
- Department of Medicine, McMaster University, Hamilton, ON, Canada; HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada
| | - Gilles Dagenais
- Department of Cardiology, Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada; Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Vancouver, BC, Canada
| | - Shelly Tse Lap Ah
- Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and 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
| | | | - Fernando Lanas
- Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | - Prem Mony
- Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore, India
| | - Andrzej Szuba
- Department of Internal Medicine, 4th Military Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Khalid Yusoff
- Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; UCSI University, Cheras, Selangor, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Selangor, Malaysia
| | - Sadi Gulec
- Ankara University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | - Lanthe Kruger
- Faculty of Health Science, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | | | - Jephat Chifamba
- Physiology Department, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Antonio Dans
- University of the Philippines, Ermita, Manila, Philippines
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Logan AG, Mente A. Diet Patterns-A Neglected Aspect of Hemodialysis Care. J Am Soc Nephrol 2018; 29:1581-1582. [PMID: 29777020 PMCID: PMC6054338 DOI: 10.1681/asn.2018050459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Alexander G Logan
- Division of Nephrology, Mount Sinai Hospital and University Health Network, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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36
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Dehghan M, Mente A, Yusuf S. Associations of fats and carbohydrates with cardiovascular disease and mortality-PURE and simple? - Authors' reply. Lancet 2018; 391:1681-1682. [PMID: 29726342 DOI: 10.1016/s0140-6736(18)30774-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/19/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada.
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada
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37
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O'Donnell M, Mente A, Yusuf S. Low sodium intake and cardiovascular health: an unanswered question. Response to: Letter from Dr N. Campbell, 'Dissidents and dietary sodium. Concerns about the commentary by O'Donnell et al.'. Int J Epidemiol 2018; 46:367-369. [PMID: 28039380 DOI: 10.1093/ije/dyw297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Martin O'Donnell
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland.,Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
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Graudal N, Mente A. Letter by Graudal and Mente Regarding Article, "Use of a Single Baseline Versus Multiyear 24-Hour Urine Collection for Estimation of Long-Term Sodium Intake and Associated Cardiovascular and Renal Risk". Circulation 2018; 137:1536-1537. [PMID: 29610136 DOI: 10.1161/circulationaha.117.032275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Niels Graudal
- Department 4242, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej, Denmark (N.G.)
| | - Andrew Mente
- McMaster University, Hamilton, Ontario, Canada (A.M.)
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39
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Affiliation(s)
- Martin O'Donnell
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland.,Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
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Dehghan M, Mente A, Zhang X, Swaminathan S, Li W, Mohan V, Iqbal R, Kumar R, Wentzel-Viljoen E, Rosengren A, Amma LI, Avezum A, Chifamba J, Diaz R, Khatib R, Lear S, Lopez-Jaramillo P, Liu X, Gupta R, Mohammadifard N, Gao N, Oguz A, Ramli AS, Seron P, Sun Y, Szuba A, Tsolekile L, Wielgosz A, Yusuf R, Hussein Yusufali A, Teo KK, Rangarajan S, Dagenais G, Bangdiwala SI, Islam S, Anand SS, Yusuf S. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet 2017; 390:2050-2062. [PMID: 28864332 DOI: 10.1016/s0140-6736(17)32252-3] [Citation(s) in RCA: 670] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023]
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).
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Affiliation(s)
- Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Sarjapur Road, Koramangala, Bangalore, Karnataka, India
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | | | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rajesh Kumar
- PGIMER School of Public Health, Chandigarh, India
| | - Edelweiss Wentzel-Viljoen
- Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Leela Itty Amma
- Health Action by People TC 1/1706, Medical College PO, Trivandrum, India
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - Jephat Chifamba
- University of Zimbabwe, College of Health Sciences, Department of Physiology, Harare, Zimbabwe
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, ECLA, Rosario, Argentina
| | - Rasha Khatib
- Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory
| | - Scott Lear
- Faculty of Health Sciences, Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | | | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, 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 Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nan Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Aytekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Goztepe, Istanbul, Turkey
| | | | - Pamela Seron
- Universidad de La Frontera, Temuco, Araucanía, Chile
| | - Yi Sun
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wroclaw, Poland
| | - Lungiswa Tsolekile
- University of the Western Cape, Bellville, Western Province, Cape Town, South Africa
| | | | - 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
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Gilles Dagenais
- Université Laval, Institut Universitaire de Cardiologie, Ville de Québec, QC, Canada
| | | | - Shofiqul Islam
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Miller V, Mente A, Dehghan M, Rangarajan S, Zhang X, Swaminathan S, Dagenais G, Gupta R, Mohan V, Lear S, Bangdiwala SI, Schutte AE, Wentzel-Viljoen E, Avezum A, Altuntas Y, Yusoff K, Ismail N, Peer N, Chifamba J, Diaz R, Rahman O, Mohammadifard N, Lana F, Zatonska K, Wielgosz A, Yusufali A, Iqbal R, Lopez-Jaramillo P, Khatib R, Rosengren A, Kutty VR, Li W, Liu J, Liu X, Yin L, Teo K, Anand S, Yusuf S. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet 2017; 390:2037-2049. [PMID: 28864331 DOI: 10.1016/s0140-6736(17)32253-5] [Citation(s) in RCA: 345] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. METHODS We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. FINDINGS Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5-9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74-1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74-1·31; ptrend=0·2033), stroke (0·92, 0·67-1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53-1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68-1·04; ptrend =0·0038), and total mortality (0·81, 0·68-0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. INTERPRETATION Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day). FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Victoria Miller
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | - Andrew Mente
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Gilles Dagenais
- Institut universitaire de cardiologie et pneumologie de Quebec, Université Laval, QC, Canada
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jaipur, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialties Centre, Chennai, India
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | | | - Aletta E Schutte
- South African Medical Research Council/North-West University, Potchefstroom, South Africa
| | | | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, University Santo Amaro, São Paulo, Brazil
| | - Yuksel Altuntas
- Istanbul Sisli Hamidiye Etfal Health Training and Research Center, Istanbul, Turkey
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University of Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nasheeta Peer
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Jephat Chifamba
- Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosaria, Argentina
| | | | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Katarzyna Zatonska
- Department of Social Medicine, Medical University of Wroclaw, Wroclaw, Poland
| | | | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority and Dubai Medical College, Dubai, United Arab Emirates
| | | | | | - Rasha Khatib
- Public Health Sciences, Stritch School of Medicine, IL, USA
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Őstra, Gőteborg, Sweden
| | | | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jiankang Liu
- Jianshe Road Community Health Center, Chengdu, Sichuan Province, China
| | - Xiaoyun Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Yin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sonia Anand
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Mente A, Dehghan M, Rangarajan S, McQueen M, Dagenais G, Wielgosz A, Lear S, Li W, Chen H, Yi S, Wang Y, Diaz R, Avezum A, Lopez-Jaramillo P, Seron P, Kumar R, Gupta R, Mohan V, Swaminathan S, Kutty R, Zatonska K, Iqbal R, Yusuf R, Mohammadifard N, Khatib R, Nasir NM, Ismail N, Oguz A, Rosengren A, Yusufali A, Wentzel-Viljoen E, Puoane T, Chifamba J, Teo K, Anand SS, Yusuf S. Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study. Lancet Diabetes Endocrinol 2017; 5:774-787. [PMID: 28864143 DOI: 10.1016/s2213-8587(17)30283-8] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 01/21/2023]
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. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada
| | - Gilles Dagenais
- Université Laval Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada
| | - Andreas Wielgosz
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Scott Lear
- Faculty of Health Sciences, and Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Vancouver, BC, Canada
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Sun Yi
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, 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
| | | | - Pamela Seron
- Universidad de La Frontera, Temuco, Araucanía, Chile
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
| | | | - Sumathi Swaminathan
- St John's Research Institute, St John's National Academy of Health Sciences, Koramangala, Bangalore, India
| | - Raman Kutty
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, India
| | - Katarzyna Zatonska
- Department of Social Medicine, Medical University of Wroclaw, Wrocław, Poland
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rita Yusuf
- School of Life Sciences, Independent University, Dhaka, Bangladesh
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasha Khatib
- Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory
| | - Nafiza Mat Nasir
- Faculty of Medicine, Health and Wellbeing, Universiti Teknologi MARA, Shah Alam, Malaysia
| | - Noorhassim Ismail
- Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Goztepe, Istanbul, Turkey
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Östra, Göteborg, Sweden
| | - Afzalhussein Yusufali
- Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Thandi Puoane
- School of Public Health, Faculty of Community and Health, University of the Western Cape, Cape Town, South Africa
| | - Jephat Chifamba
- Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Joseph P, Leong D, McKee M, Anand SS, Schwalm JD, Teo K, Mente A, Yusuf S. Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors. Circ Res 2017; 121:677-694. [PMID: 28860318 DOI: 10.1161/circresaha.117.308903] [Citation(s) in RCA: 538] [Impact Index Per Article: 76.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions.
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Affiliation(s)
- Philip Joseph
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.).
| | - Darryl Leong
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Martin McKee
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Sonia S Anand
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Jon-David Schwalm
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Koon Teo
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Andrew Mente
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Salim Yusuf
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (P.J., D.L., S.S.A., J.-D.S., K.T., A.M., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
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Zulyniak MA, de Souza RJ, Mente A, Kandasamy S, Nundy M, Desai D, Raman K, Hasso R, Pare G, Beyene J, Anand SS. A randomized controlled trial of the effects of a prudent diet on cardiovascular risk factors, gene expression, and DNA methylation - the Diet and Genetic Intervention (DIGEST) Pilot study. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0074-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8S 4L8, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON L8S 4L8, Canada.
| | - Martin J O'Donnell
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8S 4L8, Canada; Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada; HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8S 4L8, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON L8S 4L8, Canada; Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
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Mente A, O’Donnell MJ, Yusuf S. How Robust Is the Evidence for Recommending Very Low Salt Intake in Entire Populations? ∗. J Am Coll Cardiol 2016; 68:1618-1621. [DOI: 10.1016/j.jacc.2016.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/11/2016] [Indexed: 11/28/2022]
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Miller V, Yusuf S, Chow CK, Dehghan M, Corsi DJ, Lock K, Popkin B, Rangarajan S, Khatib R, Lear SA, Mony P, Kaur M, Mohan V, Vijayakumar K, Gupta R, Kruger A, Tsolekile L, Mohammadifard N, Rahman O, Rosengren A, Avezum A, Orlandini A, Ismail N, Lopez-Jaramillo P, Yusufali A, Karsidag K, Iqbal R, Chifamba J, Oakley SM, Ariffin F, Zatonska K, Poirier P, Wei L, Jian B, Hui C, Xu L, Xiulin B, Teo K, Mente A. Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet Glob Health 2016; 4:e695-703. [PMID: 27567348 DOI: 10.1016/s2214-109x(16)30186-3] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 06/13/2016] [Accepted: 07/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability. METHODS We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. FINDINGS Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040). INTERPRETATION The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables. FUNDING Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
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Affiliation(s)
- Victoria Miller
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Clara K Chow
- Westmead Hospital and the George Institute for Global Health, Sydney University, Sydney, NSW, Australia
| | - Mahshid Dehghan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | | | - Karen Lock
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Barry Popkin
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA; Institute of Community and Public Health, Birzeit University, Ramallah, Occupied Palestinian Territory
| | - Scott A Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Prem Mony
- St John's Medical College & Research Institute, Bangalore, India
| | - Manmeet Kaur
- School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Rajeev Gupta
- Department of Medicine, Fortis Escorts Hospital, Jaipur, India
| | - Annamarie Kruger
- Faculty of Health Science North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | | | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omar Rahman
- Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
| | - Annika Rosengren
- Sahlgrenska Academy and Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur Malaysia
| | - Patricio Lopez-Jaramillo
- Grupo Investigaciones FOSCAL, Fundacion Oftalmologica de Santander and Medical School, Universidad de Santander, Bucaramanga, Colombia
| | | | - Kubilay Karsidag
- Department of Internal Medicine, Istanbul University, Istanbul, Turkey
| | - Romaina Iqbal
- Department of Community Health Sciences and Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Jephat Chifamba
- Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Farnaza Ariffin
- Faculty of Medicine, UiTM Sungai Buloh Campus, Selangor, Malaysia
| | - Katarzyna Zatonska
- Department of Social Medicine, Medical University in Wroclaw, Wroclaw, Poland
| | - Paul Poirier
- Laval University Heart and Lungs Institute, Quebec City, QC, Canada
| | - Li Wei
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bo Jian
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Chen Hui
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Liu Xu
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bai Xiulin
- National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
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Mente A, O'Donnell M, Rangarajan S, Dagenais G, Lear S, McQueen M, Diaz R, Avezum A, Lopez-Jaramillo P, Lanas F, Li W, Lu Y, Yi S, Rensheng L, Iqbal R, Mony P, Yusuf R, Yusoff K, Szuba A, Oguz A, Rosengren A, Bahonar A, Yusufali A, Schutte AE, Chifamba J, Mann JFE, Anand SS, Teo K, Yusuf S. Associations of urinary sodium excretion with cardiovascular events in individuals with and without hypertension: a pooled analysis of data from four studies. Lancet 2016; 388:465-75. [PMID: 27216139 DOI: 10.1016/s0140-6736(16)30467-6] [Citation(s) in RCA: 325] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several studies reported a U-shaped association between urinary sodium excretion and cardiovascular disease events and mortality. Whether these associations vary between those individuals with and without hypertension is uncertain. We aimed to explore whether the association between sodium intake and cardiovascular disease events and all-cause mortality is modified by hypertension status. METHODS In this pooled analysis, we studied 133,118 individuals (63,559 with hypertension and 69,559 without hypertension), median age of 55 years (IQR 45-63), from 49 countries in four large prospective studies and estimated 24-h urinary sodium excretion (as group-level measure of intake). We related this to the composite outcome of death and major cardiovascular disease events over a median of 4.2 years (IQR 3.0-5.0) and blood pressure. FINDINGS Increased sodium intake was associated with greater increases in systolic blood pressure in individuals with hypertension (2.08 mm Hg change per g sodium increase) compared with individuals without hypertension (1.22 mm Hg change per g; pinteraction<0.0001). In those individuals with hypertension (6835 events), sodium excretion of 7 g/day or more (7060 [11%] of population with hypertension: hazard ratio [HR] 1.23 [95% CI 1.11-1.37]; p<0.0001) and less than 3 g/day (7006 [11%] of population with hypertension: 1.34 [1.23-1.47]; p<0.0001) were both associated with increased risk compared with sodium excretion of 4-5 g/day (reference 25% of the population with hypertension). In those individuals without hypertension (3021 events), compared with 4-5 g/day (18,508 [27%] of the population without hypertension), higher sodium excretion was not associated with risk of the primary composite outcome (≥ 7 g/day in 6271 [9%] of the population without hypertension; HR 0.90 [95% CI 0.76-1.08]; p=0.2547), whereas an excretion of less than 3 g/day was associated with a significantly increased risk (7547 [11%] of the population without hypertension; HR 1.26 [95% CI 1.10-1.45]; p=0.0009). INTERPRETATION Compared with moderate sodium intake, high sodium intake is associated with an increased risk of cardiovascular events and death in hypertensive populations (no association in normotensive population), while the association of low sodium intake with increased risk of cardiovascular events and death is observed in those with or without hypertension. These data suggest that lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets. FUNDING Full funding sources listed at end of paper (see Acknowledgments).
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Affiliation(s)
- Andrew Mente
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada.
| | - Martin O'Donnell
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada; HRB-Clinical Research Facility, NUI Galway, Ireland
| | - Sumathy Rangarajan
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Gilles Dagenais
- Laval University Heart and Lungs Institute, Quebec City, QC, Canada
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, BC, Canada; Division of Cardiology, Providence Health Care, BC, Canada
| | - Matthew McQueen
- Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, SP, Brazil
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-FOSCAL, Medical School, Universidad de Santander Floridablanca-Santander, Colombia
| | | | - Wei Li
- National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yin Lu
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China
| | - Sun Yi
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, FuWai Hospital, Beijing, China
| | - Lei Rensheng
- Center for Disease Control & Prevention Nanchang County, Nanchang City, Jiangxi Province, China
| | - Romaina Iqbal
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Prem Mony
- Community Health & Epidemiology, St John's Research Institute, Bangalore, India
| | - Rita Yusuf
- The School of Life Sciences and The Centre for Health, Population, and Development, Independent University, Bangladesh
| | - Khalid Yusoff
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Andrzej Szuba
- Division of Angiology, Wroclaw Medical University, Wrocław, Poland; Department of Internal Medicine, 4th Military Hospital in Wroclaw, Poland
| | - Aytekin Oguz
- Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Istanbul, Turkey
| | - Annika Rosengren
- Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Ahmad Bahonar
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Aletta Elisabeth Schutte
- MRC Unit for Hypertension and CVD/Hypertension in Africa Research Team, North-West University, Potchefstroom, North West Province, South Africa
| | - Jephat Chifamba
- University of Zimbabwe, College of Health Sciences, Physiology Department, Harare, Zimbabwe
| | - Johannes F E Mann
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Nephrology, University of Erlangen-Nurnberg and Munich General Hospitals, Munich, Germany
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - S Yusuf
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada; Department of Medicine, Hamilton, ON, Canada
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Lamelas PM, Mente A, Diaz R, Orlandini A, Avezum A, Oliveira G, Lanas F, Seron P, Lopez-Jaramillo P, Camacho-Lopez P, O Donnell MJ, Rangarajan S, Teo K, Yusuf S. Association of Urinary Sodium Excretion With Blood Pressure and Cardiovascular Clinical Events in 17,033 Latin Americans. Am J Hypertens 2016; 29:796-805. [PMID: 26683344 DOI: 10.1093/ajh/hpv195] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/23/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Information on actual sodium intake and its relationships with blood pressure (BP) and clinical events in South America is limited. The aim of this cohort study was to assess the relationship of sodium intake with BP, cardiovascular (CV) events, and mortality in South America. METHODS We studied 17,033 individuals, aged 35-70 years, from 4 South American countries (Argentina, Brazil, Chile, and Colombia). Measures of sodium excretion, estimated from morning fasting urine, were used as a surrogate for daily sodium intake. We measured BP and monitored the composite outcome of death and major CV events. RESULTS Overall mean sodium excretion was 4.70±1.43g/day. A positive, nonuniform association between sodium and BP was detected, with a significant steeper slope for the relationship at higher sodium excretion levels (P < 0.001 for interaction). With a median follow-up of 4.7 years, the primary composite outcome (all-cause death, myocardial infarction, stroke, or heart failure) occurred in 568 participants (3.4%). Compared with sodium excretion of 5-6g/day (reference group), participants who excreted >7g/day had increased risks of the primary outcome (odds ratio (OR) 1.73; 95% confidence interval (CI) 1.24 to 2.40; P < 0.001), as well as death from any cause (OR 1.87; 95% CI 1.23 to 2.83; P = 0.003) and major CV disease (OR 1.77; 95% CI 1.12 to 2.81; P = 0.014). Sodium excretion of <3g/day was associated with a statistically nonsignificant increased risk of the primary outcome (OR 1.20; 95% CI 0.86 to 1.65; P = 0.26) and death from any cause (OR 1.25; 95% CI 0.81 to 1.93; P = 0.29), and a significant increased risk of major CV disease (OR 1.50; 95% CI 1.01 to 2.24; P = 0.048), as compared to the reference group. CONCLUSIONS Our results support a positive, nonuniform association between estimated urinary sodium excretion and BP, and a possible J-shaped pattern of association between sodium excretion over the entire range and clinical outcomes.
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Affiliation(s)
- Pablo M Lamelas
- The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada;
| | - Andrew Mente
- The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Rafael Diaz
- Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada; Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Andres Orlandini
- Department of Laboratory Medicine, McMaster University, Hamilton, ON, Canada; Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | | | | | - Patricio Lopez-Jaramillo
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Fundación Oftalmológica de Santander Medical School, Universidad de Santander, Floridablanca, Colombia
| | - Paul Camacho-Lopez
- Fundación Oftalmológica de Santander Medical School, Universidad de Santander, Floridablanca, Colombia
| | - Martin J O Donnell
- The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Koon Teo
- The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- The Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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50
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Dehghan M, Anand S, Mente A, Yusuf S. OC06_01 Association of Nutrients With Blood Lipids in 19 Countries and 5 Continents: The Pure Study. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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