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Dietary Nutrients and CV Risk Factors
Study Questions:
What is the association between diet nutrients and cardiovascular disease (CVD) risk factors such as blood lipids and blood pressure in a large globally diverse cohort?
Methods:
Data were used from the PURE (Prospective Urban Rural Epidemiology) study, a large epidemiological cohort of adults, residing in 18 countries from five continents (North America, South America, Europe, Africa, and Asia). Diet was assessed using validated food frequency questionnaires. Nutrient groups included total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intake by use of nutrient density models. Risk markers examined included fasting lipids (total cholesterol, low-density lipoprotein [LDL] and high-density lipoprotein [HDL] cholesterol, triglycerides, and apolipoprotein A1 [ApoA1] and apolipoprotein B [ApoB]) levels and resting systolic and diastolic blood pressure.
Results:
A total of 125,287 participants, free of CVD at baseline, were included in this analysis. Intake of total fat, saturated fatty acids, monounsaturated fatty acids, and total protein decreased as country income level decreased, whereas carbohydrate and polyunsaturated fatty acid intake was highest in low-income countries, intermediate in middle-income countries, and lowest in high-income countries. Consumption of total fat (mainly from saturated fatty acids and monounsaturated fatty acids) was highest in North America, Europe, and the Middle East, whereas carbohydrate intake was highest in south Asia, China, and Africa. Protein intake was lower in south Asia than in other regions. Generally, carbohydrates and fats had stronger associations with risk markers, in comparison with the associations of protein and dietary cholesterol with risk markers. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, and higher HDL cholesterol and ApoA1. Intake of total fat and each type of fat was also associated with lower triglycerides, and lower ratios (including total cholesterol to HDL cholesterol; triglycerides to HDL cholesterol; and ApoB to ApoA1). Intakes of saturated fatty acids and polyunsaturated fatty acids were also associated with higher ApoB concentration. Higher carbohydrate intake was associated with lower total cholesterol, LDL cholesterol, ApoB, HDL cholesterol, and ApoA1, but also with higher triglycerides, and lower ratios (including total cholesterol to HDL cholesterol; triglycerides to HDL cholesterol; and ApoB-to-ApoA1). Higher intake of protein was associated with higher total cholesterol and LDL cholesterol, and HDL cholesterol and ApoA1, while associated with lower ApoB-to-ApoA1 ratio. 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 CVD 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.
Conclusions:
The investigators concluded that reducing saturated fatty acid intake and replacing it with carbohydrates 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 CVD risk among the markers tested, and that focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on CV risk.
Perspective:
Data from this large global cohort suggest that intake of dietary fats and carbohydrates has more complex associations with blood lipid markers and blood pressure. Given these are important CV risk factors, improving our current understanding regarding fat and carbohydrate intake is important. Healthy protein sources and reductions of refined carbohydrates may be important advice for patients.
Keywords: Apolipoprotein A-I, Apolipoproteins B, Blood Pressure, Carbohydrates, Cholesterol, HDL, Cholesterol, LDL, Cholesterol, Dietary, Diabetes Mellitus, Diet, Dietary Fats, ESC Congress, ESC2017, Fatty Acids, Fats, Unsaturated, Fatty Acids, Monounsaturated, Primary Prevention, Risk Factors, Triglycerides
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