Sweden High Saturated Fat Diet

Summary

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], p_trend=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], p_trend<0·0001; saturated fat, HR 0·86 [0·76–0·99], p_trend=0·0088; monounsaturated fat: HR 0·81 [0·71–0·92], p_trend<0·0001; and polyunsaturated fat: HR 0·80 [0·71–0·89], p_trend<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], p_trend=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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Article Info

Publication History

Published: August 29, 2017

Identification

DOI: https://doi.org/10.1016/S0140-6736(17)32252-3

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Linked Articles

PURE study challenges the definition of a healthy diet: but key questions remain
- The relationships between diet, cardiovascular disease, and death are topics of major public health importance, and subjects of great controversy.^1,2 In European and North American countries, the most enduring and consistent diet advice is to restrict saturated fatty acids, by replacing animal fats with vegetable oils and complex carbohydrates (and more recently whole grains).^1,3 In The Lancet, Mahshid Dehghan and colleagues⁴ echo the views of a growing number of scientists by stating that advice to restrict saturated fatty acids "is largely based on selective emphasis on some observational and clinical data, despite the existence of several randomised trials and observational studies that do not support these conclusions".
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Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
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Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple? – Authors' reply
- We concur with Jim Mann and colleagues that dietary recommendations should be informed with all available evidence, and that ideally large randomised trials on clinical outcomes should be used. In the absence of randomised trials, large, well designed observational studies on clinical outcomes provide the next best type of evidence. Our results are consistent with previous observational studies¹ that showed no harm with high fat intake—even when mean fat intake was higher than in the Prospective Urban Rural Epidemiological (PURE) study.
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Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
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Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
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Sweden High Saturated Fat Diet

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