Article | Published:

Epidemiology

Comparative ecologic relationships of saturated fat, sucrose, food groups, and a Mediterranean food pattern score to 50-year coronary heart disease mortality rates among 16 cohorts of the Seven Countries Study

European Journal of Clinical Nutritionvolume 72pages11031110 (2018) | Download Citation

Abstract

Background/objectives

We studied the ecologic relationships of food groups, macronutrients, eating patterns, and an a priori food pattern score (Mediterranean Adequacy Index: MAI) with long-term CHD mortality rates in the Seven Countries Study.

Subjects/methods

Sixteen cohorts (12,763 men aged 40–59 years) were enrolled in the 1960s in seven countries (US, Finland, The Netherlands, Italy, Greece, former Yugoslavia: Croatia/Serbia, Japan). Dietary surveys were carried out at baseline and only in a subsample of each cohort. The average food consumption of each cohort was chemically analyzed for individual fatty acids and carbohydrates.

Results

Ecologic correlations of diet were computed across cohorts for 50-year CHD mortality rates; 97% of men had died in cohorts with 50-year follow-up. CHD death rates ranged 6.7-fold among cohorts. At baseline, hard fat was greatest in northern Europe, olive oil in Greece, meat in the US, sweet products in northern Europe and the US, and fish in Japan. The MAI was high in Mediterranean and Japanese cohorts. The 50-year CHD mortality rates of the cohorts were closely positively ecologically correlated (r = 0.68–0.92) with average consumption of hard fat, sweet products, animal foods, saturated fat, and sucrose, but not with naturally occurring sugars. Vegetable foods, starch, and the a priori pattern MAI were inversely correlated (r = −0.59 to −0.91) with CHD mortality rates.

Conclusions

Long-term CHD mortality rates had statistically significant ecologic correlations with several aspects of diet consumed in the 1960s, the traditional Mediterranean and Japanese patterns being rich in vegetable foods, and low in sweet products and animal foods.

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References

  1. 1.

    Den Hartog C, Buzina R, Fidanza F, Keys A, Roine P. Dietary studies and epidemiology of heart diseases. The Hague, The Netherlands: Voeding; 1968. p. 1–157. http://edepot.wur.nl/380320. Accessed 2 Nov 2017.

  2. 2.

    Keys A. Coronary heart disease in seven countries. Circulation. 1970;41(suppl 1):1–211. (Ed)

  3. 3.

    Keys A, Aravanis C, Blackburn H, Buzina R, Djordjevic BS, Dontas AS, et al. Seven Countries Study. A multivariate analysis of death and coronary heart disease. Cambridge, MA: Harvard Univ Press; 1980. p. 1–381.

  4. 4.

    Kromhout D, Menotti A, Blackburn H. Prevention of coronary heart disease. Diet, lifestyle and risk factors in the Seven Countries Study. Norwell, MA: Dordrecht, NL: Kluwer Publ; 2002. p. 1–267.

  5. 5.

    Keys A, Menotti A, Karvonen MJ, Aravanis C, Blackburn H, Buzina R, et al. The diet and 15-year death rate in the Seven Countries Study. Am J Epidemiol. 1986;124:903–915.

  6. 6.

    Menotti A, Keys A, Aravanis C, Blackburn H, Dontas A, Fidanza F, et al. Seven Countries Study. First 20-year mortality data in 12 cohorts of the Seven Countries. Ann Med. 1989;21:175–179.

  7. 7.

    Kromhout D, Menotti A, Bloemberg B, Aravanis C, Blackburn H, Buzina R, et al. Dietary saturated and trans fatty acids and cholesterol and 25-year mortality from coronary heart disease: the Seven Countries Study. Prev Med. 1995;24:308–315.

  8. 8.

    Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort studies and randomised controlled trials. Ann Nutr Metab. 2009;55:173–201.

  9. 9.

    Mozaffarian D, Micha R, Wallace S. Effects of coronary heart disease increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2010;7:e1000252.

  10. 10.

    Ramsden CE, Hibbeln JR, Majchrzak SF, Davis JM. n-6 fatty acid-specific and mixed polyunsaturated dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. Br J Nutr. 2010;104:1586–1600.

  11. 11.

    Hooper L, Summerbell CD, Thompson R, Sills D, Roberts FG, Moore HJ, et al. Reduced or modified dietary fat for preventing cardiovascular disease. Sao Paulo Med J. 2016;134:182–3.

  12. 12.

    Ramsden CE, Zamora D, Leelarthaepin B, Majchrzak-Hong SF, Faurot KR, et al. Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sidney Diet Heart Study an updated meta-analysis. BMJ. 2013;346:e8707.

  13. 13.

    Chowdhury R, Warnakula S, Kunutsor S, Crowe F, Ward HA, Johnson L, et al. Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med. 2014;160:398–406.

  14. 14.

    Hooper L, Martin N, Abdelhamid A, Davy Smith G. Reduction in saturated fat intake for cardiovascular disease. The Cochrane database of systematic reviews. Cochrane Database Syst Rev. 2015;6:CD011737.

  15. 15.

    Howard BV, Van Horn L, Hsia J, Manson JE, Stefanick ML, Wassertheil-Smoller S, et al. Low-fat dietary pattern and risk of cardiovascular disease: the Women´s Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;8:655–666.

  16. 16.

    Atkins RC. Dr. Atkins new diet revolution. New York: Harper Collins; 1992.

  17. 17.

    Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ. 2012;345:e7492.

  18. 18.

    Malik VS, Pan A, Willett WC, Hu HB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084–1102.

  19. 19.

    Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;351:h3576.

  20. 20.

    Malik AH, Akram Y, Shetty S, Malik SS, Njike VY. Impact of sugar-sweetened beverages on blood pressure. Am J Cardiol. 2014;113:1574–1580.

  21. 21.

    Keys A, Keys M. Eat well and stay well. The Mediterranean Way. Garden City, NY: Doubleday & Co, Inc; 1975. p. 1–488.

  22. 22.

    Fidanza F. The Mediterranean Italian diet: keys to contemporary thinking. Proc Nutr Soc. 1991;50:519–526.

  23. 23.

    Kromhout D, Keys A, Aravanis C, Buzina R, Fidanza F, Giampaoli S, et al. Food consumption patterns in the 1960s in Seven Countries. Am J Clin Nutr. 1989;49:889–894.

  24. 24.

    Alberti-Fidanza A, Fidanza F. Mediterranean adequacy Index of Italian diets. Publ Hlth Nutr. 2004;7:937–941.

  25. 25.

    Fidanza F, Alberti A, Lanti M, Menotti A. Mediterranean Adequacy Index: correlation with 25-year mortality from coronary heart disease in the Seven Countries Study. Nutr Metab Cardiovasc Dis. 2004;14:254–258.

  26. 26.

    WHO International Classification of Diseases. Eighth revision. Geneva: World Health Organization; 1965.

  27. 27.

    Pett KD, Kahn J, Willett WC, Katz DL. Ancel Keys and the Seven Countries Study. White paper, 2017, http://www.truehealthinitiative.org/wordpress/wp-content/uploads/2017/07/SCS-White-Paper.THI.8-1-17.pdf. Accessed 2 Nov 2017.

  28. 28.

    Keys A, Anderson JT, Grande F. Serum cholesterol response to changes in diet. IV. Particular saturated fatty acids in the diet. Metabolism. 1965;14:776–787.

  29. 29.

    Sacks FM, Lichtenstein AH, Wu JHY, Appel LJ, Greager MA, Kris-Etherton PM et al. Dietary fats and cardiovascular disease. A presidential advisory from the American Heart Association. Circulation. 2017. https://doi.org/10.1161/CIR.0000000000000510.

  30. 30.

    Keys A. Sucrose in the diet and coronary heart disease. Atherosclerosis. 1971;14:193–202.

  31. 31.

    Guideline: sugars intake for adults and children. Geneva: World Health Organization; 2015, www.who.int/nutrition/publications/guidelines/sugars_intake/en

  32. 32.

    Te Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardio-metabolic risk: systematic review and meta-analysis of randomized controlled trials on blood pressure and lipids. Am J Clin Nutr. 2014;100:65–79.

  33. 33.

    Fattore E, Botta F, Agostini C, Bosetti C. Effects of free sugars on blood pressure and lipids: a systematic review and meta-analysis of nutritional isoenergetic intervention trials. Am J Clin Nutr. 2017;105:42–56.

  34. 34.

    Zock PL, Katan MB. Butter, margarine and lipoproteins. Atherosclerosis. 1997;131:7–16.

  35. 35.

    Ha V, Sievenpiper JL, de Souza RJ, Jayalath VH, Mirrahimi A, Agarwal A, et al. Effect of dietary pulse intake on established therapeutic lipid targets for cardiovascular risk reduction: a systematic review and meta-analysis of randomized controlled trials. CMAJ. 2014;186:E252–E262.

  36. 36.

    Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Publ Health Nutr. 2013;17:2769–2782.

  37. 37.

    Martinez-Gonzalez MA, Bes-Rastrollo M. Dietary patterns, Mediterranean diet, and cardiovascular disease. Curr Opin Lipidol. 2014;25:20–26.

  38. 38.

    Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, et al. Primary prevention of cardiovascular disease with Mediterranean diet. N Engl J Med. 2013;368:1279–1290.

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Acknowledgements

The authors express their gratitude for the role of the late professor Srecko Nedeljkovic from Belgrade, who was for many years the enthusiastic and highly professional principal investigator of the Serbian cohorts in the Seven Countries Study.

Authors contributions

Drs. Menotti and Kromhout had full access to all data of the Seven Countries Study and take responsibility for the integrity of the data and the accuracy of data analysis. Study concept and design: the first generation of investigators lead by the late professor Ancel Keys of the University of Minnesota, Minneapolis conceptualized and designed the Seven Countries Study. Acquisition, analysis, or interpretation of data: all authors Drafting of the manuscript: Kromhout, Menotti, and Jacobs. Critical evaluation of the manuscript for important intellectual content: all authors. Chemical analysis: the first round of chemical analysis from 1959 to 1964 was coordinated by Keys and the second round from 1987 to 1988 by Kromhout. Statistical analysis: Menotti, Puddu, and Jacobs. Obtained funding: Nutrition Council, The Hague; Royal Netherlands Academy of Arts and Sciences, Amsterdam; University of Leiden; National Institute for Public Health and the Environment, Bilthoven; Wageningen University; University of Groningen, all in The Netherlands.

Author information

Affiliations

  1. Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

    • Daan Kromhout
  2. Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands

    • Daan Kromhout
    •  & Peter Hollman
  3. Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA

    • Daan Kromhout
    •  & David R. Jacobs Jr
  4. Association for Cardiac Research, Rome, Italy

    • Alessandro Menotti
  5. Human Nutrition Section, Department of Neurosciences, University of Rome, Rome, Italy

    • Adalberta Alberti-Fidanza
  6. Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Rome, Italy

    • Paolo Emilio Puddu
  7. Department of Social Medicine, Preventive Medicine and Nutrition Clinic, University of Crete, Heraklion, Greece

    • Anthony Kafatos
  8. Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland

    • Hanna Tolonen
  9. Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume University, School of Medicine, Kurume, Japan

    • Hisashi Adachi

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Conflict of interest

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Paolo Emilio Puddu.

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DOI

https://doi.org/10.1038/s41430-018-0183-1

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