1 Dietary patterns and the risk of cardiovascular disease and all-cause mortality in older British men Janice L Atkins 12 , Peter H Whincup 3 , Richard W Morris 4 , Lucy T Lennon 1 , Olia Papacosta 1 , S Goya Wannamethee 1 1 Department of Primary Care and Population Health, University College London, UK 2 Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, EX2 5DW, UK 3 Population Health Research Centre, Division of Population Health Sciences and Education, St George’s, University of London, UK 4 School of Social and Community Medicine, University of Bristol, UK Correspondence: JL Atkins, Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, EX2 5DW, UK . E-mail: [email protected]Running head: Diet patterns, CVD and mortality in older men Key words: a posteriori dietary patterns; Cardiovascular disease; Mortality; Older adults; Principal component analysis 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
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Dietary patterns and the risk of cardiovascular disease and all-cause mortality in older
British men
Janice L Atkins12, Peter H Whincup3, Richard W Morris4, Lucy T Lennon1, Olia Papacosta1, S
Goya Wannamethee1
1Department of Primary Care and Population Health, University College London, UK2Epidemiology and Public Health Group, University of Exeter Medical School, RILD
Building, Barrack Road, Exeter, EX2 5DW, UK3Population Health Research Centre, Division of Population Health Sciences and Education,
St George’s, University of London, UK 4School of Social and Community Medicine, University of Bristol, UK
Correspondence: JL Atkins, Epidemiology and Public Health Group, University of Exeter
Medical School, RILD Building, Barrack Road, Exeter, EX2 5DW, UK . E-mail:
and CVD mortality (SRRE: 0.99, 95% CI: 0.91-1.08). The risk estimates observed in the
present study for the association between a prudent diet and a lower risk of all-cause
mortality and CVD mortality were in the same direction, and of similar magnitudes, as those
in the meta-analysis but statistically non-significant. Also, a significant association was
observed in the present study between higher adherence to an unhealthy diet (the ‘high
fat/low fibre’ diet) and a higher risk of all-cause mortality which was not seen in the meta-
analysis. These discrepancies may have been due to the much bigger sample size in the meta-
analysis giving greater power to detect smaller effects or due to the differences in confounder
adjustments; few studies included in this meta-analysis had such a comprehensive adjustment
for established and emerging cardiovascular risk factors as were included in this study.
This study found no significant association between a ‘high fat/low fibre’ diet or a ‘prudent’
diet and the risk of CVD events or CHD events, but adherence to a ‘high sugar’ diet was
associated with a borderline significant trend for an increased risk of CVD events and CHD
events in fully adjusted models. These results are in keeping with the American Heart
Association recommendation of reducing dietary intake of added sugars in order to lower the
risk of cardiovascular disease41 and the recent suggestion that sugar may be a more important
risk factor than fat for cardiovascular disease42,43. A meta-analysis of 12 prospective studies
involving 409,780 participants examined the association between principal component
analysis defined dietary patterns and CHD risk. Summary relative risks showed an inverse
association between the prudent/healthy diet and CHD risk, but no association with the
Western/unhealthy diet15. The observed association between a healthy diet and CHD events in
this meta-analysis but not in the current study may again possibly be explained by the much
larger sample size in the meta-analysis giving greater power to detect smaller effects. This
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meta-analysis did not identify any studies from the UK specifically and did not mention high
sugar/sweet dietary patterns, as observed in this cohort. Results from this study may therefore
be the first study of principal component analysis defined dietary patterns and CHD risk in
the UK, and this study has shown that a high sugar dietary pattern may increase CHD and
CVD risk in older British men. These analyses should therefore be replicated in other older
adult cohorts.
A major strength of this study is that data are from a moderately large prospective
population-based study, with negligible loss to follow-up and objective ascertainment of
CVD and mortality outcomes20,36. However, the study comprised predominately white
European older male participants so the applicability of findings to women and non-white
ethnic groups is uncertain. Dietary intake was assessed using an FFQ, which has previously
been validated against weighed food intakes in British populations 22,23 and the dietary intake
of participants was broadly comparable with those from the National Diet and Nutrition
Survey44. However, FFQs are more prone to measurement error compared to some other
dietary measures and in older populations non-response to FFQ questions could have
increased the chance of dietary under-reporting45,46. However, no significance difference was
seen in participants with and without complete food group data in terms of diet quality,
assessed by daily fruit and vegetable intake, or the risk of CVD events. Another consideration
in this study is that the FFQ measured dietary intake at baseline only, so whether dietary
patterns of participants changed throughout follow-up was unknown. It is possible reverse
causation may have existed in this study; for example diabetics may have changed their
dietary patterns following diagnosis and this may explain the unexpected inverse association
observed between prevalent diabetes at baseline and the high fat/low fibre dietary pattern.
However, such effects are only likely to have biased prospective associations between dietary
patterns and outcomes towards the null.
A posteriori methods of defining dietary patterns have the advantage over using a priori
methods, of making no prior assumptions about dietary patterns, instead using an empirical,
data-driven approach to derive typical patterns of dietary intake9. However, data on the
reproducibility and validity of principal component method is limited47-49 and subjectivity
was introduced at various points in the analysis, such as the grouping of dietary variables and
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the choice of how many components to retain, which may have influenced the observed
associations with disease risk9,29,30. However the food groups used here were comparable to
those used previously for a national representative dietary survey of British adults 27 and
criteria for deciding how many components to retain was decided in advance of the analysis,
both of which helped to reduce this bias.
Dietary patterns persist as an important risk factor for CVD and all-cause mortality in the
elderly, with higher adherence to a ‘high fat/low fibre’ dietary pattern being associated with
an increased risk of all-cause mortality, and higher adherence to a ‘high sugar’ diet being
associated with a modest increase in risk of CVD events and CHD events, which could not be
explained by adjustment for cardiovascular risk factors. The ‘prudent’ diet was not
significantly associated with cardiovascular outcomes or mortality. Adopting a diet which
avoids ‘high fat/low fibre’ and ‘high sugar’ components may reduce the risk of
cardiovascular events and all-cause mortality in older adults.
FINANCIAL SUPPORT
The British Regional Heart Study is a British Heart Foundation Research Group. This work
was carried out by JLA whilst at University College London, funded by a PhD studentship
from the National Institute for Health Research School for Primary Care Research (NIHR
SPCR). The views expressed in this study are those of the authors and not necessarily those
of the funding bodies.
CONFLICT OF INTEREST
None.
AUTHORSHIP
JLA and SGW conceived the study concept and design; JLA performed statistical analysis
and drafted the manuscript; PHW and LTL planned the data collection and OP contributed to
the analysis of the data; PHW, RWM and SGW contributed to the interpretation of the data
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and writing the manuscript; PHW, RWM, LTL, OP and SGW critically reviewed and agreed the final content of the manuscript.
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SBP, systolic blood pressure; HDL, high density lipoprotein; CRP, C-reactive protein; vWF, von Willebrand factor.aValues presented as mean ± SD unless otherwise stated.*Log transformed - geometric mean and interquartile range presented.
561562
563564565566
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Table 2 Baseline characteristics of British Regional Heart Study Participants by quartiles of a ‘prudent’ dietary pattern, in 1998-2000a
SBP, systolic blood pressure; HDL, high density lipoprotein; CRP, C-reactive protein; vWF, von Willebrand factor.aValues presented as mean ± SD unless otherwise stated. *Log transformed - geometric mean and interquartile range presented.
567568
569
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21
Table 3 Baseline characteristics of British Regional Heart Study Participants by quartiles of a ‘high sugar’ dietary pattern, in 1998-2000a
SBP, systolic blood pressure; HDL, high density lipoprotein; CRP, C-reactive protein; vWF, von Willebrand factor.aValues presented as mean ± SD unless otherwise stated. *Log transformed - geometric mean and interquartile range presented.
573574
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576
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Table 4 Hazard ratios (95% CI) for CHD events, CVD events, CVD mortality and all-cause mortality by quartiles of a ‘high fat/low fibre’ dietary pattern in British Regional Heart Study participants from baseline (1998-2000) to 2010a
‘High fat/low fibre’ diet quartiles
Cases (n) Rate (per 1,000 person years) Model 1 Model 2 Model 3 Model 4
P-trend 0.10 0.69 0.80 0.72CVD, cardiovascular disease. CHD, coronary heart disease.aModel 1: Age adjusted. Model 2: Adjusted for model 1 + energy intake, smoking, alcohol, physical activity, social class and BMI. Model 3: Adjusted for model 2 + HDL, SBP and diabetes. Model 4. Adjusted for model 3 + CRP and vWF. *P < 0.05
580581582
583584585586
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Table 5 Hazard ratios (95% CI) for CHD events, CVD events, CVD mortality and all-cause mortality by quartiles of a ‘prudent’ dietary pattern in British Regional Heart Study participants from baseline (1998-2000) to 2010a
P-trend 0.06 0.26 0.27 0.40CVD, cardiovascular disease. CHD, coronary heart disease.aModel 1: Age adjusted. Model 2: Adjusted for model 1 + energy intake, smoking, alcohol, physical activity, social class and BMI. Model 3: Adjusted for model 2 + HDL, SBP and diabetes. Model 4. Adjusted for model 3 + CRP and vWF. *P < 0.05
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Table 6 Hazard ratios (95% CI) for CHD events, CVD events, CVD mortality and all-cause mortality by quartiles of a ‘high sugar’ dietary pattern in British Regional Heart Study participants from baseline (1998-2000) to 2010a
CVD, cardiovascular disease. CHD, coronary heart disease.aModel 1: Age adjusted. Model 2: Adjusted for model 1 + energy intake, smoking, alcohol, physical activity, social class and BMI. Model 3: Adjusted for model 2 + HDL, SBP and diabetes. Model 4. Adjusted for model 3 + CRP and vWF. *P < 0.05
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ONLINE SUPPLEMENTARY MATERIAL
SUPPLEMENTAL TABLE 1 List of 34 food groups derived from items in the food frequency questionnaire, used in British Regional Heart Study participants in1998-2000
Fish White fish (cod, haddock, hake, plaice, fish fingers, etc.); kippers, herrings, pilchards, tuna, sardines, salmon, mackerel (including tinned); shellfish
days/week 0-7
Potatoes Boiled, baked, mashed days/week 0-7Fried potatoes Chips or fried (from shop); chips or fried (cooked at home); roast potatoes days/week 0-7Vegetables Green vegetables, salad; carrots; parsnips, swedes, turnips, beetroot, other
root vegetables; onions; tomatoesdays/week 0-7
Legumes Baked or butter beans, lentils, peas, chickpeas, sweetcorn days/week 0-7Fruit Apples; pears; oranges; bananas; other fruits pieces/week 0-60Pasta and rice Spaghetti and other pasta; rice (all types except pudding rice) days/week 0-7Breakfast cereal Grapenuts, porridge Ready Brek, Special K, Sugar Puffs, Rice Crispies;
Cornflakes, muesli, Shredded Wheat, Sultana Bran, Weetabix; Bran Flakes, Puffed Wheat; All Bran, Wheat Bran; other cereal
days/week0-7
White bread White bread days/week 0-7Wholemeal bread Brown bread; wholemeal bread days/week 0-7Full-fat cheese e.g. cheddar, Leicester, stilton, brie, soft cheeses days/week 0-7Low-fat cheese e.g. edam, cottage cheese, reduced fat cheeses days/week 0-7Full-fat milk Full-fat milk None; ≤0.5 pint; 0.5-1 pint; >1 pint/day
ice-cream, sweet yoghurts, trifle; fruit cake, fruit bread, plum pudding; fruit tart, jam tart, fruit crumble; milk puddings (rice, tapioca); tinned fruit, jellies; sweet sauces (chocolate, custard)
Fruit juice Natural fruit juices (including tomato juice) days/week 0-7Soft drinks Fizzy drinks, non-diet squashes; low calorie (diet) squashes and fizzy drinks days/week 0-7Tea and coffee Tea; coffee; other hot drinks (hot chocolate, malted milk, Horlicks) cups/day 0-34Nuts Nuts (e.g. salted or unsalted peanuts), nut butter days/week 0-7Savoury snacks Potato crisps, corn chips, crackers days/week 0-7Sweet spreads Jam, honey, marmalade, chocolate spread days/week 0-7Sauces and soups Chutney, brown sauce, tomato sauce; soups (all kinds, home-made, tinned,
packet)days/week 0-7
Wine Wine single glasses/week 0-44Beer Beer, Lager, Shandy pints/week 0-70Spirits Spirits single glasses/week 0-84Olive oil Olive oil mls/week 0-500Butter Butter grams/week 0-1134*Units of measurements based on the available frequency measures from the food frequency questionnaire.606
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SUPPLEMENTAL TABLE 2 Food group factor loadings for ‘high fat/low fibre’, ‘prudent’ and ‘high sugar’ dietary patterns, in British Regional Heart Study participants in 1998-2000a