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Diet and Risk of Myocardial Infarction: A Community Based Case Control Study
Abstract
To evaluate diet as a risk factor for myocardial infarction.
Community based case-control study.
University Hospital, Oporto.
First time consecutive cases of acute myocardial infarction (n = 100) and 198 community controls, older than 39 years and living in Oporto, were compared.
Data were collected by trained interviewers using a structured questionnaire designed to obtain information on socio-demographic, medical and behavioural aspects, emphasising the description of diet and food habits (using a semi-quantitative food frequency questionnaire). Controls were selected by random digit dialing with a participation rate of 70%. Odds ratios and 95% confidence intervals (CI) according to quartiles of nutrient ingestion were calculated using unconditional logistic regression.
Female controls presented significantly higher mean intakes of protein, omega-3 fatty acids, fiber, cholesterol and vitamin C. Male controls had a significantly higher mean daily intake of fiber, vitamin C, vitamin E, and carotenes. After adjusting for age, sex, education, body mass index, ethanol, smoking and total energy intake, there was a protective effect of vitamin C (OR = 0.2, 95% CI: 0.1-0.6, for the 4th quartile), vitamin E (OR = 0.3, 95% CI: 0.1-0.9 for the 4th quartile) and total fiber (OR = 0.3, 95% CI: 0.1-0.9) for the 4th quartile). No significant effect was found for trans-fatty acids, but there was a higher risk with increased energy intake.
This study showed that diet has an important independent effect on myocardial infarction, a protective independent role for anti-oxidant vitamin C and E was verified.
... Also, the response of capillary vessels to constricting stimuli is attenuated [60,62,63]. The resistance of the walls of capillary vessels to negative pressure is decreased and they break [15,60,[62][63][64]. Obese people tend to develop subcutaneous haematomas, which is a consequence of an increased permeability of capillary walls. ...
... Obesity also causes morphological changes of the heart by increasing its adiposity as well as fat infiltration within the cardiac muscle and its fatty degeneration. A specific obesity cardiomyopathy develops, which initially impairs the systolic, and later also diastolic, activity of the heart, leading to the development of cardiac failure [15,64]. The disease often affects the left ventricle; the hypertrophy is usually asymmetrical and it affects the interventricular septum. ...
The epidemic nature of obesity in industrialized countries is a serious health and social concern. The number of obese people has significantly increased in the past 20 years. In Poland excess weight and obesity are a serious epidemiological concern. In terms of the number of overweight people, Poland is a leader in Europe. Therefore, indicating many serious health concerns that are the natural consequences of this phenomenon has become important from the point of view of public health. This work identifies numerous diseases which are a direct consequence of obesity due to bad eating habits and lack of physical exercise among Poles. It discusses the negative effect of television and food commercials contributing to an increase in obesity, not only among adults but also among children. This is an overview forming grounds for further studies into ways of preventing the development of diseases due to obesity, both in Poland and in the world.
... Foods with similar nutrient composition were grouped together as a single food item. The questionnaire was validated for the adult population by comparison with four 7 d food records (each one in a different season of the year) (17,18) . The FFQ was then adapted for adolescents by including foods more frequently eaten by this age group (19) ; the adolescents' version comprised ninety-one food items or beverage categories and a frequency section with nine possible responses ranging from never to six or more times daily. ...
... In our work we used an FFQ and this method has some limitations in assessing dietary intake, such as using a predetermined food list that might not be representative of foods eaten by a specific population (34) . Nevertheless, we believe that this possible bias had a very low effect, because this FFQ was validated for the adult population (17,18) and furthermore some foods or food groups eaten more frequently by the adolescent age group were included in the questionnaire. Moreover, in an open section, adolescents were also encouraged to list foods eaten at least once weekly that were not in the FFQ. ...
To identify food sources of nutrients in adolescents' diets and to identify differences in food sources according to individual characteristics.
A cross-sectional evaluation was carried out in the 2003/2004 school year. Self-administered questionnaires were used and a physical examination was performed. Diet was evaluated using an FFQ.
Public and private schools in Porto, Portugal.
Adolescents aged 13 years (n 1522) enrolled at school.
The main sources of energy were starchy foods (26·5 %), dairy (12·5 %) and meat (12·0 %). The major contributors to carbohydrate intake were starchy foods (38·2 %) and fruit (13·8 %) and to protein intake were meat (28·0 %), dairy products (20·3 %), starchy foods (15·3 %) and seafood (13·6 %). The main sources of total fat were meat (22·0 %), starchy foods (13·4 %) and dairy products (12·7 %). Sweets and pastries presented important contributions to energy (11·1 %), carbohydrate (12·4 %), total fat (13·3 %) and saturated fat (16·6 %) intakes. Parental education was inversely associated with the contribution of sweets and pastries to energy, carbohydrate and fat intakes and it was positively associated with the seafood contribution to protein intake.
The major sources of carbohydrates were starchy foods, which also accounted for a quarter of energy intake. Dairy products plus meat accounted for another quarter of energy. Meat was a major source of protein and fats. Sweets and pastries contributed more than 10 % to energy, carbohydrates, total and saturated fat. Parental education was the strongest determinant of food sources and was positively associated with a healthier contribution of food groups.
... Although the available evidence in Mediterranean countries is sparse, a recent case -control study (100 cases and 198 unmatched controls) conducted in Portugal found, consis-tently with our results, a relative risk of 0.3 (95% Cl 0.1 -0.9) for the fourth quartile of fibre intake (Lopes et al, 1998). Our findings, together with this Portuguese study (Lopes et al, 1998) may help to explain the advantages of the Mediterranean diet and the lower mortality by CHD in Mediterranean populations. ...
... Although the available evidence in Mediterranean countries is sparse, a recent case -control study (100 cases and 198 unmatched controls) conducted in Portugal found, consis-tently with our results, a relative risk of 0.3 (95% Cl 0.1 -0.9) for the fourth quartile of fibre intake (Lopes et al, 1998). Our findings, together with this Portuguese study (Lopes et al, 1998) may help to explain the advantages of the Mediterranean diet and the lower mortality by CHD in Mediterranean populations. Although the nutritional factors associated with primary and secondary prevention of CHD need not to be the same, our results are also consistent with a randomised trial conducted in France (De Lorgeril et al, 1999), which showed a strong protection associated with an experimental Mediterranean diet on the risk of death and reinfarction among survivors of a first AMI. ...
To assess the association between a first acute myocardial infarction and the consumption of fibre and fruit.
Hospital-based case-control study with incident cases. A validated semi-quantitative food frequency questionnaire (136 items) was used to assess food intake.
Three third-level university hospitals in Pamplona (Spain).
Cases were subjects aged under 80, newly diagnosed with acute myocardial infarction. Each case patient (n=171) was matched to a control subject of the same gender and age (5 y bands) admitted to the same hospital.
An inverse association was apparent for the three upper quintiles of fibre intake. After adjustment for non-dietary and dietary confounders, an inverse linear trend was clearly significant, showing the highest relative reduction of risk (86%) for the fifth quintile (OR=0.14, 95% confidence interval: 0.03-0.67). An inverse association was also apparent for fruit intake, but not for vegetables or legumes.
Our data suggest that a substantial part of the postulated benefits of the Mediterranean diet on coronary risk might be attributed to a high intake of fibre and fruit.
... The frequency of food and beverages intake during the previous month was assessed through a food frequency questionnaire (FFQ), validated for the Portuguese population (17). A single-item was used to assess physical activity during the last week, "In the past week/past month, on how many days have you performed a total of 30 minutes or more of physical activity, enough to raise your breathing rate? ...
ABSTRACT
INTRODUCTION: Several behavioral and lifestyle factors, including disordered eating behaviors, interact in the development and
maintenance of overweight and obesity in adults.
OBJECTIVES: The present study aimed to describe the anthropometric, sociodemographic, and lifestyle characteristics, as well as the disordered eating behaviors of a community sample collected during an Obesity Awareness Campaign. Furthermore, the
association between Body Mass Index, age, gender, food, beverages intake, and disordered eating behaviors is to be explored.
METHODOLOGY: This sample was composed of 109 participants (59% women, aged 39.7 ± 15.5 years; Body Mass Index 24.8 ± 3.6)
who agreed to participate in an Obesity Awareness Campaign promoted in a shopping mall in the north of Portugal. Body Mass Index and disordered eating behaviors (uncontrolled eating, emotional eating, and cognitive restriction) were the main measures evaluated.
RESULTS: Participants with obesity presented significantly more uncontrolled eating and emotional eating levels when compared
to participants with overweight and normal Body Mass Index. No statistically significant differences were found between genders,
age groups (18-28; 29-39; 40-50; 51-61; over 62 years) and disordered eating behaviors.
CONCLUSIONS: The results seem to indicate a positive link between disordered eating behaviors (uncontrolled and emotional eating)
with the intake of unhealthy food/beverages, which can consequently lead to increased caloric intake and difficulties in weight
management. The present findings alert clinicians to the importance of assessing disordered eating behaviors in individuals with
obesity, providing useful information to customize clinical recommendations and intervention strategies, mainly in regard to the
associations between food/beverage consumption and disordered eating behaviors.
... Exclusion criteria for bioimpedance measurements were previously described [27]. Data were collected by applying a semiquantitative food frequency questionnaire, based on a validated FFQ for a Portuguese population [28]. The questionnaire used was composed of a list of food groups with 10 items (red meat, fish, eggs, sweets, dairy products, vegetables, legumes, fruits, oilseeds, and canned food) and one closed section with five categories of frequencies of consumption. ...
Background and Aims
Eating habits may contribute to longevity. We characterized the eating habits and cardiovascular risk (CVR) biomarkers in Portuguese centenarians (CENT) compared to controls.
Methods and Results
Centenarians (n = 253), 100.26 ± 1.98 years, were compared with 268 controls (67.51 ± 3.25), low (LCR) and high (HCR) CVR (QRISK®2-2016). Anthropometric and body composition were evaluated by bioimpedance. Abdominal obesity, BMI, and fat mass (FM) cut-offs were according to the WHO. Sarcopenia was defined by muscle mass index cut-off ≤ 16.7 kg/m². Daily red meat intake, adjusted for age and gender, was sarcopenia protective (OR = 0.25, 95% CI = 0.096–0.670, P = 0.006); however, it contributes for FM excess (OR = 4.946, 95% CI = 1.471–16.626, P = 0.01), overweight, and obesity (OR = 4.804, 95% CI = 1.666–13.851, P = 0.004). This centenarian eating habit (2%) contrasts to HCR (64.3%). The history of red meat (P < 0.0001) and canned/industrialized food intakes (P < 0.0001) was associated with HCR. Basal metabolism was lower in centenarians versus LCR/HCR (CENT = 1176.78 ± 201.98; LCR = 1356.54 ± 170.65; HCR = 1561.33 ± 267.85; P < 0.0001), BMI (CENT = 21.06 ± 3.68; LCR = 28.49 ± 4.69; HCR = 29.56 ± 5.26; P < 0.0001), waist circumference (CENT = 85.29 ± 10.83; LCR = 96.02 ± 11.71; HCR = 104.50 ± 11.84; P < 0.0001), and waist-hip ratio (CENT = 0.88 ± 0.07; LCR = 0.92 ± 0.08; HCR = 1.01 ± 0.08; P < 0.0001). CENT had lower total cholesterol, LDL cholesterol, non-HDL cholesterol, and cholesterol/HDL ratio than controls.
Conclusions
Frequent consumption of red meat, cholesterol, and heme iron rich may contribute to obesity and increased CVR. The low frequency of this consumption, observed in centenarians, although associated with sarcopenia, may be one of the keys to longevity.
... Exclusion criteria for bioimpedance measurements were previously described [27]. Data were collected by applying a semiquantitative food frequency questionnaire, based on a validated FFQ for a Portuguese population [28]. The questionnaire used was composed of a list of food groups with 10 items (red meat, fish, eggs, sweets, dairy products, vegetables, legumes, fruits, oilseeds, and canned food) and one closed section with five categories of frequencies of consumption. ...
Introduction
Eating habits may contribute to longevity. Consumption of red meat, source of
saturated fatty acids and cholesterol may be associated with increased risks of
diabetes, cardiovascular disease (CVD), and mortality risk.
Methods
We studied 521 subjects, both genders, 253 centenarians (CENT) (100.26G1.98
age) and 268 controls (67.51G3.25 age), both low (LCR) and high cardiovascular
risk (HCR), calculated based on QRISKw2-2016. Anthropometric and body
composition analysis were evaluated by bioimpedance. The abdominal obesity
(cm), BMI (kg/m2
) and the cut-off for fat mass (FM) by gender, defined according
WHO. Sarcopenia defined by muscle-mass index cut-off%16.7 kg/m2
. Statistical
methods were chi-square test, ANOVA and binary logistic regression.
Results
There were differences in the distribution of food frequency history between
centenarians and controls concerning food groups except oilseeds. The daily
intake of red meat, adjusted for age and gender, was a protective factor for
sarcopenia (ORZ0.25, CI 95%Z0.096–0.670, PZ0.006), but contributes for FM
excess (ORZ4.946, CI 95%Z1.471–16.626, PZ0.01), overweight and obesity
(ORZ4.804, CI 95%Z1.666–13.851, PZ0.004). Only 2% of the centenarians
reported this eating habit unlike the 64.3% of the HCR group. The frequency
history of red meat intake was associated with higher cardiovascular risk
(c2Z239,807; dfZ8, P!0.0001), as well as canned food intake (c2Z225.321;
dfZ8, P!0.0001). Basal metabolism (Kcal) was lower in centenarians and
higher in HCR group (CENTZ1176.78G201.98; LCRZ1356.54G170.65;
HCRZ1561.33G267.85; P!0.0001), in the same way as BMI (CENTZ
21,06G3.68; LCRZ28.49G4.69; HCRZ29.56G5.26; P!0.0001), waist
circumference (CENTZ85.29G10.83; LCRZ96.02G11.71; HCRZ104.50G
11.84; P!0.0001) and hip-waist ratio (CENTZ0.88G0.07; LCRZ0.92G0.08;
HCRZ1.01G0.08; P!0.0001).
Conclusions
Centenarians have different food history than the control population. Frequent
consumption of red meat may contribute to obesity and increased cardiovascular
risk, since the hemic iron of red meat may catalyze oxidations leading to disease
processes. The low frequency of this consumption, observed in centenarians,
although associated with sarcopenia, may be one of the keys to longevity.
... The lack of validation of the FFQ in this adolescent population may also be a limitation. However, the FFQ had been previously validated in the adult population of the same city (46) . ...
Objective:
To quantify short- and long-term associations between dietary patterns defined a priori and bone mineral density (BMD) during adolescence.
Design:
Dietary patterns were defined at 13 years old using a Mediterranean diet (MD) quality index, the Dietary Approaches to Stop Hypertension (DASH) diet index and the Oslo Health Study (OHS) dietary index. Linear regression coefficients were used to estimate associations between dietary patterns and forearm BMD at 13 and 17 years, measured by dual-energy X-ray absorptiometry.
Setting:
Public and private schools of Porto, Portugal.
Subjects:
The EPITeen cohort comprising 1180 adolescents born in 1990, recruited at schools during the 2003/2004 school year and re-evaluated in 2007/2008.
Results:
In girls, at 13 years, mean BMD (g/cm2) in the first and third tertiles was 0·369 and 0·368 for the MD pattern, 0·368 and 0·369 for the DASH diet, and 0·370 and 0·363 for the OHS index. In boys, mean BMD (g/cm2) in the first and third tertiles was 0·338 and 0·347 for the MD pattern, 0·342 and 0·346 for the DASH diet, and 0·344 and 0·342 for the OHS index. None of these differences were significant. Mean BMD at 17 years and prospective variation were also not significantly different between tertiles of adherence to each score. However, a trend of increased BMD at 13 years with greater adherence to the MD pattern was observed in boys (adjusted coefficient = 0·248; 95% CI 0·052, 0·444).
Conclusions:
The selected dietary patterns may not capture truly important dietary differences in determining BMD or diet may not be, beyond nutrient adequacy, a limiting determinant of BMD.
... Dietary intake during the previous year was based on a validated semiquantitative food-frequency questionnaire (FFQ). 26,27 The questionnaire comprised 82 food and beverage-item categories, as well as a frequency section with 9 possible options, which ranged from "never" to "6 or more times per day." Participants were asked to indicate the average frequency of consumption during the preceding year, as well as the portion size based on a photograph manual with 3 size options (small, medium, large) for each food item. ...
Evaluate the role of different types of physical activity (PA) and diet on overall and central obesity incidence.
A cohort study with 1621 adults was conducted in an urban Portuguese population. Anthropometrics were objectively obtained during 1999-2003 and 2005-2008. Overall, obesity was defined by a body mass index (BMI) ≥ 30.0 kg/m2 and central obesity by a waist circumference (WC) > 88.0 cm in women and >102.0 cm in men. Usual PA and dietary intake were assessed using validated questionnaires. Analyses of obesity incidence were conducted through different types of PA and a "healthy" dietary score.
Significant inverse associations were found between leisure-time PA and obesity incidence, namely among subjects classified into the last tertile of energy expenditure, who had approximately a 40% lower risk of developing the disease. Despite higher energy intakes, individuals with a high Physical Activity Level (PAL > 1.60) were significantly protected against obesity incidence, relative risks (RR) = 0.25 (0.09-0.72) and RR = 0.47(0.27-0.94), for overall and central obesity, respectively. No significant associations were found between dietary score and obesity incidence rates.
In our population, leisure-time PA played a significant role in preventing obesity. In both overall and central obesity, PAL above 60% of the resting metabolic rate and moderate energy intake seem to strike the right balance to prevent obesity.
... The Nutritional evaluation. In order to quantify folate, vitamin B6 and vitamin B12 intake, we used a Food Frequency Questionnaire validated for a Portuguese population (32). Participants were asked to recall their habits in the year before CRC diagnosis (patients), or in the year prior to the interview (controls). ...
Thymidylate synthase, as a rate-limiting step in DNA synthesis, catalyses the conversion of dUMP into dTMP using 5,10-methylenotetrahydrofolate as the methyl donor. Two polymorphisms have been described in this gene: a repeat polymorphism in the 5' promoter enhancer region (3R versus 2R) and a 6 bp deletion in the 3' unstranslated region. Both of these may affect protein levels. The present case control study was aimed at investigating the influence of these two polymorphisms on the development of colorectal cancer (CRC), as well as their potential interaction with folate, vitamin B6 and vitamin B12 intake. A total of 196 cases and 200 controls, matched for age and sex distribution, were included in the study. No association was found between CRC and the 28 bp repeat polymorphism, but it was observed that individuals with the 6 bp/del and del/del genotypes had a significantly lower risk of developing the disease (OR=0.47; 95% CI 0.30-0.72). A combined genotype (2R/2R; 6 bp/del+del/del) was also found, which was associated with an even lower risk of developing of the disease (OR=0.42; 95% CI 0.26-0.69). No significant interaction between these polymorphisms and vitamin intake was observed. These results indicate for the first time that the 6 bp/del allele might be a protective factor in the development of CRC, independent of the intake of methyl group donors.
... This study was part of a previously described populationbased case-control investigation on risk factors for myocardial infarction, the EPIcardis study (10,11), assessing persons older than 39 years. Cases and controls were permanent residents in the catchments area of Hospital de S. João, Porto. ...
To characterize non-participants in a population-based study on cardiovascular diseases and investigate the effect of non-participation on risk estimates for myocardial infarction.
Using random digit dialing we obtained full information for 1054 adults (60.8% female), while 345 eligible individuals (72.5% female) declined the invitation to participate, but answered a limited set of questions by telephone. Risk of myocardial infarction was estimated using 474 cases (19.4% females) admitted with a first acute myocardial infarction.
Participation proportion was 99.0% for cases and 70.0% for population controls. Population non-participants were older (61.6 vs. 58.5 years, for males, and 62.9 vs. 57.7 years for females) and more frequently women (66.3% vs. 74.7%, p < 0.001); males tended to be non-drinkers and to have had a blood test during the previous year; females were additionally more often non-smokers. Crude and adjusted risk estimates for myocardial infarction were generally similar regardless of considering the information provided by non-participants.
In this South European population, demographic and social characteristics associated with the decision to participate in a community investigation were different from those usually described in Northern European or American populations. However, their characteristics did not influence the direction or the magnitude of myocardial infarction risk estimates.
... As part of an ongoing health and nutrition survey, 23 residents in Porto, Portugal, were selected using random digit dialing. In every identified household, residents were characterized according to age and sex. ...
Introduction:
Traditional cardiovascular risk factors such as central obesity, high blood pressure and insulin resistance, all constituents of metabolic syndrome, have been associated with increased levels of C-reactive protein (CRP). Therefore, this marker of low-grade inflammation may play a major role in the pathogenesis of cardiovascular diseases. In this study, data from a representative sample of urban adults was used to evaluate the association between CRP and metabolic syndrome, accounting for the type and number of its constituents.
Methods:
Using random digit dialing, 1022 participants, aged 18-92 y, were selected. All participants completed a structured questionnaire comprising of information on social, demographic, behavioral and clinical aspects. Anthropometrics and blood pressure were recorded and a fasting blood sample collected. Metabolic syndrome was defined, according to the Third Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, as the presence of three or more of the following characteristics: waist circumference greater than 102 cm in men and 88 cm in women; triglyceride levels > or = 150 mg/dl; high-density lipoprotein cholesterol levels < 40 mg/dl in men and < 50 mg/dl in women; blood pressure > or = 130/85 mm Hg; and serum glucose > or = 110 mg/dl. High-sensitivity CRP was assessed by immunonephelometric assay. After excluding 65 participants with CRP > or = 10 mg/l, 957 subjects (599 women and 358 men) remained for analysis. Geometric means were compared after adjustment for age, sex, alcohol consumption and smoking.
Results:
Higher mean levels of CRP (2.34 vs 1.36, P < 0.001) were observed when metabolic syndrome was present. Also, mean CRP levels were significantly higher in the presence of central obesity (2.45 vs 1.24, P < 0.001), high blood pressure (1.76 vs 1.12, P < 0.001), hypertriglyceridemia (2.17 vs 1.32, P < 0.001) and high fasting glucose (1.96 vs 1.46, P = 0.032). We found a significant increasing trend (P < 0.001) in mean levels of CRP as the number of features of metabolic syndrome increased. The major contributing features for high CRP levels were central obesity and high blood pressure.
Conclusions:
Present data show that increasing severity of metabolic syndrome is associated with increasing CRP. Additionally, we found that central obesity and high blood pressure are the most important determinants of the low-grade chronic inflammation present in metabolic syndrome.
Purpose:
To evaluate the association between dietary fat intake and the presence of AMD.
Methods:
Cross-sectional, observational study with cohorts prospectively recruited from the United States and Portugal. AMD was diagnosed based on color fundus photographs with the AREDS classification. A validated food frequency questionnaire was used to calculate the percent energy intake of trans fat, saturated fat, monounsaturated fatty acid (MUFA), and polyunsaturated fatty acid (PUFA). Odds ratio (OR) and 95% confidence intervals for quintile of amount of FA were calculated. Multiple logistic regression was used to estimate the OR.
Results:
We included 483 participants, 386 patients with AMD and 97 controls. Higher intake of trans fat was associated with a 2.3-fold higher odds of presence of AMD (P for trend = 0.0156), whereas a higher intake of PUFA (OR, 0.25; P for trend = 0.006) and MUFA (OR, 0.24; P for trend < 0.0001) presented an inverse association. Subgroup analysis showed that higher quintile of trans fat was associated with increased odds of having intermediate AMD (OR, 2.26; P for trend = 0.02); and higher quintile of PUFA and MUFA were inversely associated with intermediate AMD (OR, 0.2 [P for trend = 0.0013]; OR, 0.17 [P for trend < 0.0001]) and advanced AMD (OR, 0.13 [P for trend = 0.02]; OR, 0.26 [P for trend = 0.004]). Additionally, a statistically significant effect modification by country was noted with inverse association between MUFA and AMD being significant (OR, 0.04; P for trend < 0.0001) for the Portugal population only.
Conclusions:
Our study shows that higher dietary intake of trans fat is associated with the presence of AMD, and a higher intake of PUFA and MUFA is inversely associated with AMD.
The period of adolescence presents enormous challenges. Food choices often deviate from the concept of healthy eating, a situation aggravated by unfavorable socio-economic or cultural contexts. The relevant prevalence of obesity in teenagers is a reality. The consumption of fast food has been related to this prevalence and to the distancing of the consumption of healthy foods, such as fruits and vegetables. Food and nutritional education, conducted in a systematic way, in diverse contexts such as school, is an important strategy to support adolescents to make decisions that ensure the maintenance of their health in the present and in the future. This review aims to establish a critical and reflexive interconnection between nutrition and the role of food education, especially in a school context, focused on the adolescent.
Among the behaviors associated with food intake, exposure to television is particularly important given the number of adolescents exposed. Also, increased time spent watching television has been associated with physical inactivity and with less desirable dietary intake among adolescents. The aim of this study was to examine the association between television viewing and dietary intake among 13-y-old adolescents.
A cross-sectional evaluation was carried out in the 2003-2004 school year, including adolescents born in 1990 and enrolled in the schools of Porto, Portugal. Time spent watching TV was collected by self-administered questionnaires and dietary intake was evaluated using a food frequency questionnaire. Included in the analysis were 1436 adolescents.
Spending more than 120 min per day watching TV was significantly associated with higher intake of total fat and polyunsaturated fat and with lower intake of magnesium, in both sexes. Additionally, in girls, spending more than 120 min per day watching TV was associated with lower intake of complex carbohydrates, fiber, total vitamin A, folate, vitamin C, calcium, iron, phosphorus, and potassium. In boys, higher intake of saturated fat and cholesterol was found among those spending more time watching TV.
We found that television viewing is associated with higher consumption of foods containing more fats and sugars and a lower consumption of fruits and vegetables. Consequently, adolescents who watched more television had a higher intake of total fat and polyunsaturated fat and a lower intake of minerals and vitamins. This dietary behavior among adolescents may have long-term health implications, not only limited to obesity.
To assess the impact of academic life on health status of university students.
Longitudinal study including 154 undergraduate students from the Universidade de Aveiro, Portugal, with at least two years of follow-up observations. Sociodemographic and behavioral characteristics were collected using questionnaires. Students' weight, height, blood pressure, serum glucose, serum lipids and serum homocysteine levels were measured. Regression analysis was performed using linear mixed-effect models, allowing for random effects at the participant level.
A higher rate of dyslipidemia (44.0% vs. 28.6%), overweight (16.3% vs. 12.5%) and smoking (19.3% vs. 0.0%) was found among students exposed to the academic life when compared to freshmen. Physical inactivity was about 80%. Total cholesterol, high density lipoprotein-cholesterol (HDL-C), triglycerides, systolic blood pressure, and physical activity levels were significantly associated with gender (p<0.001). Academic exposure was associated with increased low density lipoprotein-cholesterol (LDL-C) levels (about 1.12 times), and marginally with total cholesterol levels (p = 0.041).
High education level does not seem to have a protective effect favoring a healthier lifestyle and being enrolled in health-related areas does not seem either to positively affect students' behaviors. Increased risk factors for non-transmissible diseases in university students raise concerns about their well-being. These results should support the implementation of health promotion and prevention programs at universities.
To evaluate the prevalence and the determinants of obesity, and the associated cardiovascular risk factors in a random sample of non-institutionalised adults.
Cross-sectional study.
A random sample of 1436 habitants of Porto (873 women and 563 men) aged 18-90 years.
All participants answered a structured questionnaire comprising information on social, demographic, behavioural and clinical aspects. Anthropometric measures, blood pressure and fasting blood samples were obtained. Diet was assessed using a semi-quantitative food-frequency questionnaire, and physical activity was evaluated using a questionnaire exploring all professional, domestic and leisure-time activities. When the body mass index was > or =30 kg/m2, the subject was considered as 'obese'. Proportions were age adjusted for the European population. Odds ratios and 95% confidence intervals were computed using unconditional logistic regression.
The prevalence of obesity was significantly higher in women (26.1%) than men (13.9%). Regardless of gender, obesity increased with age, decreased with education, and was more frequent in married blue-collar workers and unemployed subjects. Smoking was more prevalent in subjects of normal weight, and a higher proportion of those reporting no regular exercise were obese. In men, obesity prevalence increased with increasing quartiles of energy intake, but no such changes were found in women. Compared with subjects of normal weight, obese men showed a significantly higher prevalence of hypertension (53.3 vs 26.1%) and hypertriglyceridaemia (23.4 vs 9.0%). Also, hypertension (43.7 vs 30.7%), diabetes (7.6 vs 2.7%), hypertriglyceridaemia (27.1 vs 5.0%), and abnormal low-density lipoprotein (30.4 vs 21.4%) and high-density lipoprotein cholesterol concentration (15.0 vs 5.3%) were more frequent in obese women.
Obesity is a major public health issue in urban Portuguese populations, and obese individuals have many features of metabolic syndrome. Education and relative deprivation are modifiable factors that are significantly associated with obesity. However, no clear-cut relationship was found between physical activity and energy intake.
A few international studies suggest an inverse association of the intake of fat with risk of ischemic stroke. On the contrary of coronary heart disease, only 10% a 15% of ischemic strokes are associated to large vessels atherosclerosis. This suggests different mechanisms for these two pathologies. So, we design a study whose aim is to quantify the ischemic stroke risk associated to dietary fat.
A case-control study, that included two hundred ninety seven individuals of both sexes, hospitalized in the S. João Hospital in Oporto, with a first episode of ischemic stroke. Six hundred and seventy one controls of both sexes were also evaluated, selected by random digit dialing. The target population was Caucasian adults aged 44 years or older, living in the area served by the above named hospital, without cognitive abnormalities and who had not changed their dietary habits in the past year. The information was obtained by a structured questionnaire, by interview that included socio-demographic, medical and behavioural aspects (physical activity, tobacco use, food habits). Food intake in the past year was evaluated by a validated, semi-quantitative food frequency questionnaire. Logistic regression was used to evaluate the relative risk (odds ratio) and their 95% confidence intervals, with separate models fitted for men and women.
Lipids accounted for less than 30% of the total energy and less than 10% were saturated fatty acids and polyunsaturated fatty acids but the cholesterol ingestion in men were higher than 300 mg. The increasing quartiles of total lipids, monounsaturated, polyunsaturated and saturated fatty acids and cholesterol were independent protective risk factors. However, the intake of trans fatty acids increases the risk. Intake of oleic and linolenic fatty acids only had significant protection in women while intake of all n-3 fatty acids, dodecohexanoic acid in particular, had a significant protective effect in both sexes. All the n-6 fatty acids and arachidonic fatty acids also had an inverse association in women but they showed a tendency to be directly associated with ischemic stroke in men.
The total intakes of fat, saturated fat, monounsaturated fat and polyunsaturated fat were associated with reduced risk of ischemic stroke of both sexes.
As a result of the Seven Countries Study, the Mediterranean diet has been popularized as a healthy diet. Nevertheless, it has not replaced the prudent diet commonly prescribed to coronary patients. Recently, we completed a secondary, randomized, prospective prevention trial in 605 patients recovering from myocardial infarction in which we compared an adaptation of the Cretan Mediterranean diet with the usual prescribed diet. After a mean follow-up period of 27 mo, recurrent myocardial infarction, all cardiovascular events, and cardiac and total death were significantly decreased by > 70% in the group consuming the Mediterranean diet. These protective effects were not related to serum concentrations of total, low-density-lipoprotein (LDL), or high-density-lipoprotein (HDL) cholesterol. In contrast, protective effects were related to changes observed in plasma fatty acids: an increase in n-3 fatty acids and oleic acid and a decrease in linoleic acid that resulted from higher intakes of linolenic and oleic acids, but lower intakes of saturated fatty acids and linoleic acid. In addition, higher plasma concentrations of antioxidant vitamins C and E were observed. We conclude that a Cretan Mediterranean diet adapted to a Western population protected against coronary heart disease much more efficiently than did the prudent diet. Thus, it appears that the favorable life expectancy of the Cretans could be largely due to their diet.
Several sources of information suggest that man evolved on a diet with a ratio of ω6 to ω3 fatty acids of ∼ 1 whereas today this ratio is ∼10:1 to 20–25:1, indicating that Western diets are deficient in ω3 fatty acids compared with the diet on which humans evolved and their genetic patterns were established. Omega-3 fatty acids increase bleeding time; decrease platelet aggregation, blood viscosity, and fibrinogen; and increase erythrocyte deformability, thus decreasing the tendency to thrombus formation. In no clinical trial, including coronary artery graft surgery, has there been any evidence of increased blood loss due to ingestion of ω3 fatty acids. Many studies show that the effects of ω3 fatty acids on serum lipids depend on the type of patient and whether the amount of saturated fatty acids in the diet is held constant. In patients with hyperlipidemia, ω3 fatty acids decrease low-density-lipoprotein (LDL) cholesterol if the saturated fatty acid content is decreased, otherwise there is a slight increase, but at high doses (32 g) they lower LDL cholesterol; furthermore, they consistently lower serum triglycerides in normal subjects and in patients with hypertriglyceridemia whereas the effect on high-density lipoprotein (HDL) varies from no effect to slight increases. The discrepancies between animal and human studies most likely are due to differences between animal and human metabolism. In clinical trials eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in the form of fish oils along with antirheumatic drugs improve joint pain in patients with rheumatoid arthritis; have a beneficial effect in patients with ulcerative colitis; and in combination with drugs, improve the skin lesions, lower the hyperlipidemia from etretinates, and decrease the toxicity of cyclosporin in patients with psoriasis. In various animal models ω3 fatty acids decrease the number and size of tumors and increase the time elapsed before appearance of tumors. Studies with nonhuman primates and human newborns indicate that DHA is essential for the normal functional development of the retina and brain, particularly in premature infants. Because ω3 fatty acids are essential in growth and development throughout the life cycle, they should be included in the diets of all humans. Omega-3 and ω6 fatty acids are not interconvertible in the human body and are important components of practically all cell membranes. Whereas cellular proteins are genetically determined, the polyunsaturated fatty acid (PUFA) composition of cell membranes is to a great extent dependent on the dietary intake. Therefore appropriate amounts of dietary ω6 and ω3 fatty acids need to be considered in making dietary recommendations, and these two classes of PUFAs should be distinguished because they are metabolically and functionally distinct and have opposing physiological functions. Their balance is important for homeostasis and normal development. Canada is the first country to provide separate dietary recommendations for ω6 and ω3 fatty acids.
All three large epidemiologic cohort studies of vitamin E noted that high-level vitamin E intake or supplementation was associated with a significant reduction in cardiovascular disease (RRR range, 31% to 65%), as measured by various fatal and nonfatal cardiovascular end points. To obtain these reductions, vitamin E supplementation must last at least 2 years. Less consistent reductions were seen in studies of β-carotene (RRR range, −2% to 46%) and vitamin C (RRR range, −25% to 51%). Considerable biases in observational studies, such as different health behaviors of persons using antioxidants, may account for the observed benefit. By contrast, none of the completed randomized trials showed any clear reduction in cardiovascular disease with vitamin E, vitamin C, or β-carotene supplementation. The trials were not specifically designed to assess cardiovascular disease, did not provide data on nonfatal cardiovascular end points, may have had insufficient treatment durations, and used suboptimal vitamin E doses. The completed trials were of adequate size to indicate that the true therapeutic benefit of vitamin E and other antioxidants in reducing fatal cardiovascular disease (a survival benefit as long as 5 years) is probably more modest than the epidemiologic data suggest.
There are inherent difficulties in the use of indirect observations in the epidemiology of a chronic ubiquitous disease such as atherosclerosis. Such difficulties do not condone basic errors in epidemiological methodology, the use of low quality data, a lack of precision in measurements, invalid extrapolations and inappropriate use of terminology and coronary heart disease as a surrogate or synonym of coronary atherosclerosis and bias in the interpretation of data. These errors reveal a lack of rigorous and scientific standards in the epidemiology of coronary heart disease. Analysis cannot launder such data. Independent scientists must evaluate the data in respect of precision, logic and truth.
The authors examined the relation between 24-hour dietary fiber intake at baseline survey in 1972-1974 and subsequent 12-year ischemic heart disease mortality in a southern Californian population-based cohort of 859 men and women aged 50-79 years. Relative risks of ischemic heart disease mortality in those with dietary fiber intake of 16 gm/24 hours or more compared with those with intake less than 16 gm/24 hours were 0.33 in men and 0.37 in women. A 6 gm increment in daily fiber intake was associated with a 25% reduction in ischemic heart disease mortality (p less than 0.01). This effect was independent of other dietary variables, including calories, fat, cholesterol, protein, carbohydrate, alcohol, calcium, and potassium. Some, but not all, of this effect appears to be mediated through the known cardiovascular risk factors: after multivariate adjustment for age, sex, blood pressure, plasma cholesterol, obesity, fasting plasma glucose, and cigarette smoking habit, the magnitude of the protective effect of fiber was reduced but still significant in both sexes combined. These findings support the hypothesis that high dietary fiber intake is protective for ischemic heart disease mortality.
Fish oil supplements are currently being nationally advertised, and many physicians are being queried about their clinical utility. Epidemiologic studies reveal a low incidence of cardiovascular disease in people, such as the Eskimos, who eat large amounts of seafood. Cardiovascular health may be improved because fish and fish oil supplements lower plasma lipid levels (especially triglycerides), inhibit platelet aggregation, and may decrease blood pressure and viscosity and increase high-density lipoprotein (HDL) levels. Preliminary observations also suggest a potential future role for fish oils in the treatment of some autoimmune diseases, such as atopic dermatitis, psoriasis, and rheumatoid arthritis. Patients with serum triglyceride levels greater than 5.64 mmol/L and/or cholesterol levels greater than 7.75 mmol/L refractory to dietary management may benefit from a medically supervised trial of fish oil supplements. Data currently available are insufficient to recommend fish oil supplements for the general public, or for patients with other diseases, and side effects must also be considered. These include occasional adverse lipid changes, potential for bleeding and vitamin E deficiency, and, with some preparations, vitamin A and D toxicity.
(JAMA 1988;260:665-670)
In 1960, 871 middle-aged men in the town of Zutphen, The Netherlands, participated in a survey of risk indicators (including diet) for coronary heart disease (CHD). Information was collected about the usual food intake for the 6--12 months before the interview by the cross-check dietary history method. During 10 years of follow-up, 107 men died from all causes, 37 from CHD, and 44 from cancer. Mortality from CHD was about four times higher for men in the lowest quintile of dietary-fibre intake than for those in the highest quintile, but this inverse relation disappeared after multivariate analyses. Rates of death from cancer and from all causes were about three times higher for men in the lowest quintile of dietary-fibre intake than for those in the highest quintile, and these relations persisted after multivariate analyses. A diet containing at least 37 g dietary fibre per day may be protective against chronic diseases in Western societies.
Results are described from four epidemiologic studies in the United States which used random digit dialing in over 30,000
households to identify controls from the general population for use in case-control studies. Methods and problems in telephone
sampling are discussed. It Is concluded that if complete population rosters are unavailable and if the population to be sampled
has the high rates of telephone ownership typical of much of the United States, telephone-based sampling can yield a nearly
random sample of the individuals in a population, often at much less expense than can dwelling-based sampling.
When used in a loose manner to indicate distortive effects on associations among hospitalized patients, the term Berkson's bias denotes a special case of Simpson's paradox. If, however, Berkson's independence assumption is introduced, Berkson's bias affects only the "selected" subjects and not those "left behind" and tends to decrease the odds-ratio. Generally speaking, the model is valid not only for case-control studies but also for prospective and other investigations. By introducing a time dimension the model allows for the study of changes over time in Berkson's bias.
Variable amounts of olive oil rather than hard fats were used in classic Mediterranean diets. We review the effects of replacing hard fats with olive oils or starchy foods on blood lipoprotein concentrations. The saturated fatty acids lauric, myristic, and palmitic acids raise both low-density lipoprotein (LDL) and high-density lipoprotein (HDL) somewhat compared with oleic acid. If any fat is replaced by carbohydrates, fasting triglyceride values rise and HDL concentrations fall; effects on LDL depend on the type of fat that is being replaced. Trans isomers of oleic acid lower HDL and raise LDL and lipoprotein(a). The fatty acids in unhydrogenated fish oil potently lower triglycerides but may raise LDL somewhat. When body weight is forcibly kept constant, substitution of unsaturated oils such as olive oil for hard fats rich in saturated or trans fatty acids will produce a more favorable lipoprotein profile than replacement of fat by carbohydrates. However, high-oil diets might lead to obesity, which would undo their favorable effects.
The epidemic of coronary heart disease in the western world followed the introduction of partially hydrogenated fats in food. Exposure to trans fatty acids (TFA) in those foods can explain the observed sex and age differences in serum cholesterol concentrations and coronary heart disease (CHD), the cholesterolaemic response to pregnancy, and national differences in rates of CHD. There is evidence that TFA can be innocuously used for muscular work. I propose that the TFA in partially hydrogenated fats impair lipoprotein receptors during energy surfeit, leading to hypercholesterolaemia, atherogenesis, obesity, and insulin resistance. A series of feasible experiments is proposed to examine this hypothesis.
Trans isomers of fatty acids, formed by the partial hydrogenation of vegetable oils to produce margarine and vegetable shortening, increase the ratio of plasma low-density-lipoprotein to high-density-lipoprotein cholesterol, so it is possible that they adversely influence risk of coronary heart disease (CHD). To investigate this possibility, we studied dietary data from participants in the Nurses' Health Study. We calculated intake of trans fatty acids from dietary questionnaires completed by 85,095 women without diagnosed CHD, stroke, diabetes, or hypercholesterolaemia in 1980. During 8 years of follow-up, there were 431 cases of new CHD (non-fatal myocardial infarction or death from CHD). After adjustment for age and total energy intake, intake of trans isomers was directly related to risk of CHD (relative risk for highest vs lowest quintile 1.50 [95% Cl 1.12-2.00], p for trend = 0.001). Additional control for established CHD risk factors, multivitamin use, and intakes of saturated fat, monounsaturated fat, and linoleic acid, dietary cholesterol, vitamins E or C, carotene, or fibre did not change the relative risk substantially. The association was stronger for the 69,181 women whose margarine consumption over the previous 10 years had been stable (1.67 [1.05-2.66], p for trend = 0.002). Intakes of foods that are major sources of trans isomers (margarine, cookies [biscuits], cake, and white bread) were each significantly associated with higher risks of CHD. These findings support the hypothesis that consumption of partially hydrogenated vegetable oils may contribute to occurrence of CHD.
We conducted a case-control study in Athens, Greece, bepositively related to coronary heart disease, and total carbo-tween January 1990 and April 1991 to examine the associa-hydrates were negatively related to coronary heart disease, tion between diet and coronary heart disease. The case seriesthe nutrient-specific relative risks for a quintile increase being comprised 329 patients with electrocardiographically con1.19 (95% confidence interval = 0.96-1.48) and 0.81 (95% confidence interval = 0.96-1.48) and 0.81 (95% confidence interval =-0.67-0 97),-respectively.-Major fat components (saturated, monounsaturated, and polyunsaturated fat) did not appear to have differential risk implications for coronary heart disease; however, cooking with margarine was associated with an increased relative risk (1.87; 95% confidence interval = 0.82-4.28). Dietary proteins, cholesterol, and vitamin C were not associated with coronary heart disease. (Epidemiology 1993, 4:511-516)
(C) Lippincott-Raven Publishers.
To examine prospectively the relationship between dietary fiber and risk of coronary heart disease.
Cohort study.
In 1986, a total of 43,757 US male health professionals 40 to 75 years of age and free from diagnosed cardiovascular disease and diabetes completed a detailed 131-item dietary questionnaire used to measure usual intake of total dietary fiber and specific food sources of fiber.
Fatal and nonfatal myocardial infarction (MI).
During 6 years of follow-up, we documented 734 cases of MI (229 were fatal coronary heart disease). The age-adjusted relative risk (RR) for total MI was 0.59 (95% confidence interval [CI], 0.46 to 0.76) among men in the highest quintile of total dietary fiber intake (median, 28.9 g/d) compared with men in the lowest quartile (median, 12.4 g/d). The inverse association was strongest for fatal coronary disease (RR, 0.45; 95% CI, 0.28 to 0.72). After controlling for smoking, physical activity and other known nondietary cardiovascular risk factors, dietary saturated fat, vitamin E, total energy intake, and alcohol intake, the RRs were only modestly attenuated. A 10-g increase in total dietary fiber corresponded to an RR for total MI of 0.81 (95% CI, 0.70 to 0.93). Within the three main food contributors to total fiber intake (vegetable, fruit, and cereal), cereal fiber was most strongly associated with a reduced risk of total MI (RR, 0.71; 95% CI, 0.55 to 0.91 for each 10-g increase in cereal fiber per day).
Our results suggest an inverse association between fiber intake and MI. These results support current national dietary guidelines to increase dietary fiber intake and suggest that fiber, independent of fat intake, is an important dietary component for the prevention of coronary disease.
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