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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], 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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Article Info

Publication History

Published: August 29, 2017

Identification

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

Copyright

© 2017 Elsevier Ltd. All rights reserved.

ScienceDirect

Access this article on ScienceDirect

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?
    • As intake of dietary fat remains a topic of intense debate,1,2 both in the scientific field and the media, epidemics of type 2 diabetes and coronary heart disease in some low-income countries threaten to become pandemic.3 Scholars, including the authors of the Prospective Urban Rural Epidemiological (PURE) study,4 warn that guidelines on dietary fat have been made on the basis of observational data, which should not be relied on. In India, clinical and public health professionals trying to prevent and control type 2 diabetes and coronary heart disease have developed guidelines and interventions using risk factors, including diet and fats (especially from cheap, reheated oils).

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • The Prospective Urban Rural Epidemiological (PURE) study1 has attracted considerable attention in both academia and the public domain. The conclusions of the study challenge the dietary advice and guidelines people have adhered to for decades. Scholars have questioned the accuracy of macronutrient distribution data reported in the PURE study for the Chinese population. The study reported that about 77% of the population in China consume at least 60% of energy from carbohydrate and 43% of individuals consume at least 70% of energy from carbohydrate, with a mean of 67·0% energy derived from carbohydrate and 17·7% from fat.

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • In The Lancet, Mahshid Dehghan and colleagues1 reported a positive association between carbohydrate intake and non-cardiovascular mortality, and an unexpected inverse association between non-cardiovascular mortality and saturated fat intake. The authors recommended changes in dietary guidelines on the basis of assumed causality.

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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?
    • The authors of the Prospective Urban Rural Epidemiological (PURE) study (Nov 4, 2017, p 2050)1 suggest that "removing current restrictions on fat intake, but limiting carbohydrate (when high) might improve health" and that global guidelines should be reconsidered in light of their findings.

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • It is better to be rich and healthy than poor and sick: this is the main conclusion from a study1 by Mahshid Dehghan and colleagues published in The Lancet. In the Prospective Urban Rural Epidemiological (PURE) study, investigators examined nutrition and disease in 18 countries, focusing on understudied regions. More than 135 000 participants were enrolled between 2003 and 2013, with a median follow-up of 7·4 years.

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • The Prospective Urban Rural Epidemiological (PURE) investigators previously published ecological analyses showing that total and cardiovascular mortality was substantially higher in low-income countries than in high-income countries (total mortality hazard ratio [HR] 3·66 and cardiovascular mortality HR 6·05).1

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • We congratulate Mahshid Dehghan and colleagues on the Prospective Urban Rural Epidemiological (PURE) study.1 Their results are consistent with evidence suggesting that a diet high in fat might reduce mortality2 and incidence of cardiovascular disease.3

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • The Prospective Urban Rural Epidemiological (PURE) study,1 which included 18 cohorts from low-income, middle-income, and high-income countries worldwide, reported that high carbohydrate intake was associated with an increased risk of total mortality, whereas high intake of total fat and individual types of fat were associated with reduced total mortality. These results contribute valuable evidence to the field of nutrition, but using questionnaires to infer the amount, quality, and composition of intake of fats is error prone because of the complexity of foods and the possibility of implausible questionnaire entries.

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • Much has been said on the results from the Prospective Urban Rural Epidemiological (PURE) study by Mahshid Dehghan and colleagues.1 Data from 18 countries are represented, providing a valuable contribution to the body of prospective observational evidence. PURE is not the largest, most comprehensive, or longest running cohort study; however, the diverse sampling method is a valuable addition to nutrition epidemiology, should the PURE data be found usable.

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  • Associations of fats and carbohydrates with cardiovascular disease and mortality—PURE and simple?
    • The Prospective Urban Rural Epidemiological (PURE) study1 investigators did outstanding work, but we have concerns regarding data presentation and interpretation.

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Sweden High Saturated Fat Diet

Source: https://www.thelancet.com/article/S0140-6736%2817%2932252-3/fulltext