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Lack of benefit of dietary advice to men with angina: results of a controlled trial


Objective: To see whether mortality among men with angina can be reduced by dietary advice.

Design: A randomized controlled factorial trial.

Setting: Male patients of general practitioners in south Wales.

Subjects: A total of 3114 men under 70 y of age with angina.

Interventions: Subjects were randomly allocated to four groups: (1) advised to eat two portions of oily fish each week, or to take three fish oil capsules daily; (2) advised to eat more fruit, vegetables and oats; (3) given both the above types of advice; and (4) given no specific dietary advice. Mortality was ascertained after 3–9 y.

Results: Compliance was better with the fish advice than with the fruit advice. All-cause mortality was not reduced by either form of advice, and no other effects were attributable to fruit advice. Risk of cardiac death was higher among subjects advised to take oily fish than among those not so advised; the adjusted hazard ratio was 1.26 (95% confidence interval 1.00, 1.58; P=0.047), and even greater for sudden cardiac death (1.54; 95% CI 1.06, 2.23; P=0.025). The excess risk was largely located among the subgroup given fish oil capsules. There was no evidence that it was due to interactions with medication.

Conclusion: Advice to eat more fruit was poorly complied with and had no detectable effect on mortality. Men advised to eat oily fish, and particularly those supplied with fish oil capsules, had a higher risk of cardiac death. This result is unexplained; it may arise from risk compensation or some other effect on patients' or doctors' behaviour.

Sponsorship: British Heart Foundation, Seven Seas Limited, Novex Pharma Limited, The Fish Foundation.

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  • Albert, CM, Hennekens, CH, O'Donnell, CJ, Ajani, UA, Carey, VJ, Willett, WC, Ruskin, JN & Manson, JA (1998). Fish consumption and risk of sudden cardiac death. JAMA, 279, 23–28.

    Article  CAS  Google Scholar 

  • Albert, CM, Campos, H, Stampfer, MJ, Ridker, PM, Manson, JA, Willett, WC & Ma, J (2002). Blood levels of long-chain n-3 fatty acids and the risk of sudden death. New Engl. J. Med., 346, 1113–1118.

    Article  CAS  Google Scholar 

  • Ashfield-Watt, PAL, Clark, ZE, Breay, P, Zotos, PC, Cale, SB, Burr, ML & McDowell, IFW (2002). Nutritional advice to increase soluble fibre intake does not change plasma folate or homocysteine in men with angina: a randomised controlled trial. Publ. Health Nutr., 5, 47–53.

    Article  Google Scholar 

  • Billman, GE, Kang, JX & Leaf, A (1997). Prevention of ischemia-induced cardiac sudden death by n-3 polyunsaturated fatty acids in dogs. Lipids, 32, 1161–1168.

    Article  CAS  Google Scholar 

  • Burr, ML, Fehily, AM, Gilbert, JF, Rogers, S, Holliday, RM, Sweetnam, PM, Elwood, PC & Deadman, NM (1989). Effects of changes in fat, fish and fibre intakes on death and reinfarction: diet and reinfarction trial (DART). Lancet, ii, 757–761.

    Article  Google Scholar 

  • Burr, ML, Sweetnam, PM & Fehily, AM (1994). Diet and reinfarction. Eur. Heart J., 15, 1152–1153.

    Article  CAS  Google Scholar 

  • Charnock, JS (1994). Dietary fats and cardiac arrhythmia in primates. Nutrition, 10, 161–169.

    CAS  PubMed  Google Scholar 

  • Clarke, KW, Gray, D & Hampton, JR (1994). Implication of prescriptions for nitrates: 7 y follow up of patients treated for angina in general practice. Br. Heart J., 71, 38–40.

    Article  CAS  Google Scholar 

  • Daviglus, ML, Stamler, J, Orencia, AJ, Dyer, AR, Liu, K, Greenland, P, Walsh, MK, Morris, D & Shekelle, RB (1997). Fish consumption and the 30 y risk of fatal myocardial infarction. New Engl. J. Med., 336, 1046–1053.

    Article  CAS  Google Scholar 

  • de Lorgeril, M, Renaud, S, Mamelle, N, Salen, P, Martin, J-L, Monjaud, I, Guidollet, J, Touboul, P & Delaye, J (1994). Mediterranean alpha-linoleic acid-rich diet in secondary prevention of coronary heart disease. Lancet, 343, 1454–1459.

    Article  CAS  Google Scholar 

  • Fehily, AM, Butland, BK, Holliday, RM & Yarnell, JWG (1988). Dietary studies in the Caerphilly Heart Disease Survey. Food Sci. Nutr., 42F, 77–78.

    Google Scholar 

  • Food Standards Agency (2001). Food Standards Agency News No. 5, February 2001, London: Food Standards Agency

  • GISSI-Prevenzione Investigators (1999). Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Lancet, 354, 447–455.

  • Key, TJA, Thorogood, M, Appleby, PN & Burr, ML (1996). Dietary habits and mortality in 11 000 vegetarians and health conscious people: results of a 17 y follow up. Br. Med. J., 313, 775–779.

    Article  CAS  Google Scholar 

  • Kromhout, D, Feskens, EJM & Bowles, CH (1995). The protective effect of a small amount of fish on coronary heart disease mortality in an elderly population. Int. J. Epidemiol., 24, 340–345.

    Article  CAS  Google Scholar 

  • Krueger, DE, Rogot, E, Blackwelder, WC & Reid, DD (1970). The predictive value of a postal questionnaire on cardiorespiratory symptoms. J. Chron. Dis., 23, 411–421.

    Article  CAS  Google Scholar 

  • Lampe, FC, Whincup, PH, Wannamethee, SG, Ebrahim, S, Walker, M & Shaper, AG (1998). Chest pain on questionnaire and prediction of major ischaemic heart disease events in men. Eur. Heart J., 19, 63–73.

    Article  CAS  Google Scholar 

  • Liem, AKD & Theelen, RMC (1997). Dioxins, Chemical Analysis, Exposure and Risk Assessment, Bilthoven: National Institute of Public Health and the Environment

    Google Scholar 

  • Lubsen, J & Poole-Wilson, PA (2000). Risk management in cardiology. Eur. Heart J. Suppl., 2, (Suppl D) D39–D44.

    Google Scholar 

  • Marckmann, P & Grønbæk, M (1999). Fish consumption and coronary heart disease mortality. A systematic review of prospective cohort studies. Eur. J. Clin. Nutr., 53, 585–590.

    Article  CAS  Google Scholar 

  • McLennan, PL & Charnock, JS (1988). Dietary fish oil prevents ventricular fibrillation following coronary artery occlusion and reperfusion. Am. Heart J., 116, 709–717.

    Article  CAS  Google Scholar 

  • Ministry of Agriculture, Fisheries and Food (1997). Dioxins and Polychlorinated Biphenyls and Foods and Human Milk, Food Surveillance Information Sheet no. 105 London: MAFF Food Safety Directorate

  • Ness, AR & Powles, JW (1997). Fruit and vegetables and cardiovascular disease: a review. Int. J. Epidemiol., 26, 1–13.

    Article  CAS  Google Scholar 

  • Richens, J, Imrie, J & Copas, A (2000). Condoms and seat belts: the parallels and the lessons. Lancet, 355, 400–403.

    Article  CAS  Google Scholar 

  • Salonen, JT, Seppänen, K, Nyyssönen, K, Korpela, H, Kauhanen, J, Kantola, M, Tuomilehto, J, Esterbauer, H, Tatzber, F & Salonen, R (1995). Intake of mercury from fish, lipid peroxidation, and the risk of myocardial infarction and coronary, cardiovascular, and any death in Eastern Finnish men. Circulation, 91, 645–655.

    Article  CAS  Google Scholar 

  • Singh, RB, Rastogi, SS, Verma, R, Laxmi, B, Singh, R, Ghosh, S & Niaz, MA (1992). Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction: results of one year follow up. Br. Med. J., 304, 1015–1019.

    Article  CAS  Google Scholar 

  • Sterne, JAC & Davey Smith, G (2001). Sifting the evidence—what's wrong with significance tests?. Br. Med. J., 322, 226–231.

    Article  CAS  Google Scholar 

  • Strandberg, TE, Salomaa, VV, Naukkarinen, VA, Vanhanen, HT, Sarna, SJ & Miettinen, TA (1991). Long-term mortality after 5 y multifactorial primary prevention of cardiovascular diseases in middle-aged men. JAMA, 266, 1225–1229.

    Article  CAS  Google Scholar 

  • Woodhill, JM, Palmer, AJ, Leelarthaepin, B, McGilchrist, C & Blacket, RB (1978). Low fat, low cholesterol diet in secondary prevention of coronary heart disease. Adv. Exp. Med. Biol., 109, 317–330.

    Article  CAS  Google Scholar 

  • World Health Organization European Collaborative Group (1983). Multifactorial trial in the prevention of coronary heart disease: 3. Incidence and mortality results. Eur. Heart J., 4, 141–147.

  • Yarnell, JWG, Fehily, AM, Milbank, JE, Sweetnam, PM & Walker, CL (1983). A short dietary questionnaire for use in an epidemiological survey: comparison with weighed dietary records. Hum. Nutr. Appl. Nutr., 37A, 103–112.

    Google Scholar 

  • Zeiner-Henriksen, T (1976). Six year mortality related to cardiorespiratory symptoms and environment risk factors in a sample of the Norwegian population. J. Chron. Dis., 29, 15–23.

    Article  CAS  Google Scholar 

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We gratefully acknowledge financial support by the British Heart Foundation, Seven Seas Limited, Novex Pharma Ltd, and The Fish Foundation. We are also grateful to the following for their help: Elaine Vaughan-Williams, Penny Pritchard-Roberts, Beverley Eldridge, Janie Hughes and Paul Phillips.

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Correspondence to M L Burr.

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Burr, M., Ashfield-Watt, P., Dunstan, F. et al. Lack of benefit of dietary advice to men with angina: results of a controlled trial. Eur J Clin Nutr 57, 193–200 (2003).

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