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[Effect of fats on cardiovascular disease prevention in Denmark.]

Authors:

Abstract

In Denmark death from cardiovascular disease (CVD) has decreased, mainly due to a 72% reduction since 1990 in death from ischaemic heart disease from reduced smoking, elimination of industrial trans fatty acids in the diet, and more effective medical treatment. Replacement of saturated fat by carbohydrate and/or n-6 polyunsaturated fat may increase CVD, but it is reduced by substitution with n-3 fats, monounsaturated fat, or low glycaemic index carbohydrates. Despite a high saturated fat content dark chocolate and cheese may reduce CVD and diabetes risk and eggs may be neutral, and less restrictive dietary recommendations are indicated.
2 VIDENSKAB
1) Institut for Idræt og
Ernæring, Det Natur-
og Biovidenskabelige
Fakultet, Københavns
Universitet
2) Hjertemedicinsk
Afdeling B, Odense
Universitetshospital
3) Klinisk Biokemisk
Afdeling, Gentofte
Hospital
4) Unilabs A/S
Ugeskr Læger
2014;176:V12130740
STATUSARTIKEL
Arne Astrup1, Mogens Lytken Larsen2, Steen Stender3 & Jørn Dyerberg4
Fedtstoffernes betydning for forebyggelse
af hjerte-kar-sygdom i Danmark
I Europa sker 46% af alle dødsfald på grund af kar-
diovaskulær sygdom (CVD), som dermed fortsat er
den største bidragyder til mortalitet. Denne mortali-
tet er overvejende forårsaget af iskæmisk hjertesyg-
dom (IHD). Dødeligheden af IHD er imidlertid faldet
med næsten 50% i mange europæiske lande igennem
de seneste to årtier; men med store forskelle. Faldet
er mindst i Polen og Ungarn (7%) og højest i Dan-
mark (72%) [1, 2]. Faldet i IHD-dødeligheden i Dan-
mark var især markant i 2001-2010 (Figur 1).
Den aldersstandardiserede mortalitet er halveret
for begge køn, og faldet kan tilskrives både et fald i
incidens og forlænget overlevelse [3]. Forebyggelsen
har tilsyneladende haft en stor effekt, især i Danmark,
som nu har den laveste CVD-mortalitet i
Skandinavien [4]. Indsatsen har bestået i råd om en
række effektive behandlinger, rygeophør, øget mo-
tion, råd om hjerterigtig kost og lovgivning om af-
skaffelse af industrielt transfedt (ITF). I de fleste mo-
deller til vurdering af bidrag af de enkelte årsager når
man frem til, at 25-50% af faldet kan forklares med
livsstilsændringer og en tilsvarende del med forbed-
ret behandling [5, 6].
TRANSFEDTSYREELIMINATION I DANMARK
ITF er umættede fedtsyrer, der fremstilles fra plante-
og fiskeolie ved hærdning. Fedt med 10-60% ITF er
velegnet til margarine, friture og i bagværk. Sådanne
fedtstoffer har været anbefalet af både den danske og
den amerikanske hjerteforening. I 1990 opdagede
man imidlertid, at transfedt øgede lavdensitetslipo-
protein- og nedsatte højdensitetslipoproteinkoleste-
rol, hvilket resulterer i en mere aterogen lipidprofil
[7]. I en række observationelle studier har man sam-
stemmende fundet en association mellem transfedt-
indtag og udviklingen af IHD [8]. Også død af alle år-
sager er associeret med øget transfedtindtag [9]. På
baggrund af de observationelle studier og plausible
mekanismer har en lang række sundhedsorganisatio-
ner tilrådet, at indtag af ITF reduceres mest muligt.
Foranlediget af det daværende Ernæringsråd indførte
den danske regering et ITF-forbud i 2003, tilsvarende
synes nu at blive sat i værk også i USA. I EU diskute-
res transfedt fortsat, men i Østrig og Ungarn har man
fulgt Danmarks kurs, og i Sverige er man på vej. Uden
for EU er lovindgreb mod transfedt sket i Schweiz, Is-
land og Norge.
Med eliminationen af ITF fra danskernes kost er
den nok mest aterogene kostkomponent elimineret,
og det store fald i IHD-mortalitet, der helt enestående
har fundet sted især i Danmark, kan formentlig del-
vist tilskrives et nedsat indtag af ITF.
MÆTTET FEDT OG ISKÆMISK HJERTESYGDOM
Reduktion af mættet fedt har været en hjørnesten i
forebyggelsen af CVD og byggede initialt på Keys
fund af sammenhængen mellem indtag af mættet fedt
og IHD-mortalitet i forskellige lande [10]. Senere er
det især risikomarkører, som total- og lavdensitet-
slipoproteinkolesterol, der er blevet anvendt, selvom
det er erkendt, at disse er utilstrækkelige [11]. Store
systematiske gennemgange af de observationelle stu-
dier og interventionsstudier med hårde endepunkter
har ikke sikkert underbygget, at en reduktion af mæt-
tet fedt har spillet en væsentlig rolle. Ernæringsrådet
konkluderede i 1995: »I flere årtier har øget indtag af
n-6-flerumættet fedt som erstatning for mættet fedt
været en væsentlig faktor i kostprincipper rettet mod
såvel primær som sekundær forebyggelse af iskæmisk
hjertesygdom. Resultaterne af de i dag tilgængelige
sekundære forebyggelsesundersøgelser støtter ikke
dette kostprincip« [12]. Det var især interventionsstu-
dier, som gav mistanke om en manglende positiv ef-
fekt. I et Cochranereview af studier med hårde ende-
punkter konkluderede man i 2004, at kostændringer
med nedsættelse eller modificering af kostens fedt-
Tidligere tiders kostråd
om, at de kolesterolrige
æg øger blodets koleste-
rolindhold og giver risiko
for hjerte-kar-sygdom, er
der ikke længere viden-
skabeligt belæg for.
VIDENSKAB 3
indhold ser ud til at reducere forekomsten af CVD
[13]. Dette er statistisk signifikant for studierne sam-
let set, men når et studie, hvor man også øgede n-
3-fedtindtaget blev ekskluderet, var det ikke længere
signifikant [13]. I en opdatering af Cochraneanalysen
fra 2012 undersøgte man betydningen af at reducere
kostens totale fedtindhold og udskifte mættet fedt
med flerumættet fedt (PUFA) [14]. Der var ingen ef-
fekt på totaldødeligheden eller CVD, men en reduk-
tion på 14% i CV-hændelser, som primært kunne til-
skrives en effekt hos mænd. Effekten forsvandt
imidlertid, når man ekskluderede studier, hvor der
også var foretaget andre kost- eller omsorgsinterven-
tioner. I en metaanalyse fra 2010 konkluderede man,
FIGUR 
Dødeligheden af hjertesygdom i EU, 2005-2009. A. Aldersstandardiseret dødelighed pr. 100.000, femårsgennemsnitsværdier. B. Procentuelt årligt fald i dødeligheden. (Tal-
lene i figuren stammer fra tabel 2 i [2]).
Litauen
Letland
Estland
Slovakiet
Ungarn
Rumænien
Tjekkiet
Finland
Bulgarien
Malta
Polen
Irland
Østrig
Storbritanniien
Sverige
Tyskland
Grækenland
Danmark
Slovenien
Luxembourg
Belgien
Italien
Spanien
Holland
Portugal
Frankrig
300 300 400 500
n/100.000
200 200100 1000
Danmark
Holland
Storbritannien
Estland
Bulgarien
Irland
Tyskland
Sverige
Slovenien
Polen
Portugal
Italien
Frankrig
Østrig
Spanien
Belgien
Finland
Luxembourg
Grækenland
Malta
Rumænien
Letland
Ungarn
Tjekkiet
Slovakiet
Litauen
10 4 6 10
%/år
8 26 028 8
A
B
MændKvinder
4 VIDENSKAB
at udskiftning af mættet fedt med PUFA ville resul-
tere i en lille reduktion af IHD [15]. I denne analyse
blev der ikke skelnet mellem n-6 og n-3, og resultatet
er derfor ikke i modstrid med det ovennævnte.
NY FORSKNING OM FEDTSTOFFER
Man har tidligere betragtet PUFA som én type fedt og
mættet fedt som en anden, selvom der er solid viden
om, at man bør skelne mellem n-6- og n-3-PUFA og li-
geledes mellem de forskellige mættede fedtsyrer. Fø-
rende eksperter inden for lipidforskning har igennem
de seneste år som følge af nye forskningsresultater
ændret opfattelse af, hvilke fedtstoffer som er hen-
sigtsmæssige for helbredet.
FLERUMÆTTET FEDT VERSUS MÆTTET FEDT
I 2013 kom der analyser, hvor man har sammenlignet
effekten af indtaget af hhv. mættet fedt og PUFA på
CVD hos personer, der allerede havde kardiovaskulær
sygdom [16]. I disse studier fandt man ingen sund-
hedsmæssig fordel ved at skifte mættet fedt ud med
PUFA af n-6-typen; snarere var der holdepunkter for,
at en sådan udskiftning vil øge forekomsten af CVD.
Kun hvis mættet fedt udskiftes med PUFA med et væ-
sentligt indhold af n-3-fedtsyrer, er der en sundheds-
mæssig gevinst. Der blev peget på, at ud over det
uhensigtsmæssige i at erstatte mættet fedt med n-
6-PUFA af hensyn til CVD-risikoen, er der holdepunk-
ter for, at et øget indtag af n-6 øger forekomsten af
brystkræft hos kvinder [17]. Det skal bemærkes, at
den nye metaanalyse, hvor man understreger beho-
vet for at vælge PUFA med et højt indhold af n-3-fedt-
syrer ikke indgår i grundlaget for de nye kostråd fra
2013 med den begrundelse, at studierne er udført
med personer med kardiovaskulær sygdom. Resulta-
terne må imidlertid også anses for at gælde den al-
mindelige befolkning, idet der hos en stor del af be-
folkningen udvikles CVD.
Nye analyser giver også belæg for i højere grad at
skelne mellem de forskellige typer mættet fedt [11].
Der er mættet fedt i mørk chokolade, æg, mejeripro-
dukter og kød, men fedtsyresammensætningen er
meget forskellig, og den vides at have meget forskel-
lige biologiske virkninger, ligesom virkningen vil af-
hænge af andre stoffer i fødevaren. Mættet fedt kan
derfor ikke betragtes som én gruppe, men der må fo-
kuseres på de enkelte fødevarer, der er rige på mættet
fedt. Effekten af fedtstoffer kan ikke vurderes alene
ved deres virkning på blodets lipider, den udspilles
også gennem en række andre mekanismer herunder
effekten på arterievæggen.
Langt de fleste studier af fødevarers virkning på
CVD er observationelle. Der er dog to interventions-
studier med hårde endepunkter. Det ene er Lyon diet
heart study, hvor der var en eklatant effekt hos pa-
tienter med IHD af en modificeret middelhavskost
(600 gram frugt og grønt dagligt og tilskud af raps-
olie), uden at effekten kunne forklares gennem virk-
ning på de sædvanlige risikofaktorer for IHD [18,
19]. I det andet studie, PREDIMED, med personer,
der ikke havde haft CV-hændelser, men var i høj ri-
siko herfor, fandt man en 30% reduktion i forekom-
sten af akut myokardieinfarkt og slagtilfælde ved råd
om middelhavskost samt et dagligt indtag af ca. 50
ml olivenolie eller 30 gram trænødder sammenlignet
med forekomsten hos en kontrolgruppe, der alene fik
råd om at reducere kostens fedtindhold [20].
Mørk chokolade har et højt indhold af mættet
fedt (stearinsyre), men der er ingen holdepunkter
for, at indtag af mørk chokolade øger forekomsten af
IHD. Tværtimod er der ret godt belæg for, at mørk
chokolade kan bidrage til at nedsætte forekomsten af
IHD og type 2-diabetes. I en systematisk gennemgang
konkluderede man, at et højt indtag af chokolade kan
nedsætte risikoen for IHD med 39%, slagtilfælde med
27% og diabetes med 31% [21]. Disse gavnlige virk-
ninger skyldes måske ikke fedtindholdet, men andre
aktive stoffer i chokoladen.
Æg er en kilde til mættet fedt, da 32% af fedtind-
holdet er mættet. Danskerne spiser i dag i gennemsnit
en sjettedel æg dagligt, og i en rapport fra
Fødevareinstituttet fra 2011 fandt man, at vi godt
kunne spise seks gange så mange æg uden at få en
øget CVD-risiko [22]. I en metaanalyse fra 2013 be-
kræftes denne konklusion [23]. Der er således belæg
for, at selvom et øget indtag af æg vil øge indtaget af
mættet fedt, er der ikke tegn på, at det vil føre til øget
CVD-risiko. Æg giver samtidig et øget indtag af
D-vitamin og protein.
Mejeriprodukter især smør, fløde og ost er vig-
FAKTABOKS
I Danmark er forekomsten og død af iskæmisk hjertesygdom reduce-
ret med 72% siden 1985.
Udviklingen tilskrives tobaksophør, forbud mod transfedt og forbed-
ret behandling.
Yderligere reduktion kan opnås gennem kosten, men erstatning af
mættet fedt med lavglykæmiske kulhydrat eller n-6-planteolier kan
øge forekomsten.
En sikker reduktion kan opnås ved at erstatte mættet fedt med n-3,
enkeltumættet fedt og lavglykæmiske, fiberrige og fuldkornsholdige
kulhydrater.
Trods højt indhold af mættet fedt kan øget indtag af mørk chokolade
og ost bidrage til forebyggelse af hjerte-kar-sygdom, og et øget ind-
tag af æg anses ikke for at have en negativ virkning. Fede fisk har en
positiv virkning, men uforarbejdet kød synes at være neutralt.
VIDENSKAB 5
tige kilder til mættet fedt. For de fede mejeriproduk-
ter gælder, at indholdet af fedtsyrer er speciel, og at
virkningen på kroppen også afhænger af andre næ-
ringsstoffer i fødevarerne. Der er foretaget en omfat-
tende forskning i virkningen af de forskellige mejeri-
produkter. Generelt finder man, at et højt indtag af
mejeriprodukter ikke er forbundet med øget CVD,
tværtimod viser to metaanalyser af befolkningsstu-
dier, at et højt indtag af mejeriprodukter er forbundet
med en vis nedsat risiko for CVD [24] og udvikling af
type 2-diabetes [25].
Der er endvidere god dokumentation for, at fede
fisk gennem et højt indhold af n-3-fedtsyrer også bi-
drager til forebyggelse af CVD.
Kød er også en vigtig kilde til mættet fedt, og det
tyder på, at et højt indtag af kød kan øge risikoen for
CVD. I et observationalt studie har man sammenlig-
net kød og mejeriprodukter og fundet, at et højere
indtag af mejeriprodukter var forbundet med en 21%
lavere risiko for CVD, mens det samme indtag af mæt-
tet fedt fra kødprodukter viste en 26% øget risiko
[26]. En udskiftning af mættet fedt fra kød med fedt
fra mejeriprodukter svarende til 2% af kostens energi
var forbundet med en 25% lavere risiko for CVD [22].
Det er uklart, om der er tale om kausale sammen-
hænge, da der dels kan være andre faktorer i kød el-
ler forhold i kødspiseres adfærd, som er årsag.
Poolede observationelle studier fra Asien kunne tyde
herpå [27].
KONKLUSION
Den hidtidige kostvejledning sammen med andre til-
tag har medført en betydelig reduktion i forekomsten
af CVD. Ny forskning peger dog på, at yderligere ge-
vinster kan opnås blandt andet ved ikke at udskifte
mættet fedt alene med n-6-PUFA, som synes at øge
forekomsten af CVD. Mættet fedt fra forskellige føde-
varer har forskellig fedtsyresammensætning og en
virkning på CVD afhænger både heraf og af andre
stoffer i fødevaren. Nye analyser viser, at fedtstoffer
med et højt indhold af n-3-flerumættet fedt (rapsolie,
nødder og fede fisk) samt olivenolie, der ikke inde-
holder n-3-flerumættet fedt, er at foretrække frem for
fedtstoffer med højt indhold af mættet fedt (smør) og
planteolier med lavt n-3-indhold.
KORRESpONDANcE: Arne Astrup, Institut for Idræt og Ernæring,
Det Natur- og Biovidenskabelige Fakultet, Københavns Universitet, Rolighedsvej ,
 Frederiksberg. E-mail-adresse: ast@life.ku.dk
ANTAGET: . januar 
pUBLIcERET på UGESKRIFTET.DK: . maj 
INTERESSEKONFLIKTER: Forfatternes ICMJE-formularer er tilgængelige sammen
med artiklen på Ugeskriftet.dk
TAKSIGELSE: Arbejdet er støttet af Nordea Fonden.
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SUMMARY
Arne Astrup, Mogens Lytken Larsen, Steen Stender & Jørn Dyerberg:
Effect of fats on cardiovascular disease prevention in Denmark
Ugeskr Læger ;:V
In Denmark death from cardiovascular disease (CVD) has
decreased, mainly due to a % reduction since  in death
from ischaemic heart disease from reduced smoking,
elimination of industrial trans fatty acids in the diet, and more
effective medical treatment. Replacement of saturated fat by
carbohydrate and/or n- polyunsaturated fat may increase CVD,
but it is reduced by substitution with n- fats, monounsaturated
fat, or low glycaemic index carbohydrates. Despite a high
saturated fat content dark chocolate and cheese may reduce
CVD and diabetes risk and eggs may be neutral, and less
restrictive dietary recommendations are indicated.
6 VIDENSKAB
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... Although the cause of PCOS is still unclear, the genetic and environmental factors, as well as their interactions, may be implicated in etiology of this syndrome (Norman et al. 2007;Astrup et al. 2014). One of the most important causes of PCOS related to contribution of intrinsic and extrinsic insulin resistance in the pathophysiology of PCOS (Stepto et al. 2013). ...
... Elevated insulin levels resulted in reduced production of Sex hormone-binding globulin (SHBG) and hyperandrogenism. Hyperandrogenism disrupted the hypothalamicpituitary-ovarian axis (HPO axis) function and subsequently resulted in disruption of ovulation which is involved in PCOS pathophysiology (Dunaif 1997;Norman et al. 2007;Astrup et al. 2014). Additionally, high intakes of saturated fatty acids and low intakes of fiber directly resulted in low concentration of SHBG and hyperandrogenism (Lima et al. 2013). ...
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Objective: Polycystic ovary syndrome (PCOS) is a multifactorial endocrine disorder in women. Change in lifestyle, especially dietary pattern, might have a role in prevalence of PCOS. The limited number of studies has made it difficult to draw any conclusion about the dietary patterns with PCOS. This study aimed to investigate the association between dietary patterns with PCOS. Methods: This case-control study was performed on 225 new diagnosed patients and 345 healthy women in Isfahan, Iran. The presence of PCOS was confirmed by the expert gynecologists based on Rotterdam criteria. Usual dietary intake was assessed by a 168-items food frequency questionnaire. Dietary patterns were identified by principal component analysis. Results: Three major dietary patterns including western, plant-based, and mixed were identified that explained 53.93% of the variance of food intake. Top tertile of western dietary pattern significantly increased the odds of PCOS (OR, 2.03; 95%CI, 1.12-3.67), either before or after adjustments for covariates. After adjustments for potential confounders, the highest tertile of plant-based dietary pattern was related to higher odds of PCOS than the lowest one (OR, 2.32; 95%CI, 1.23-4.37). In addition, those in the second tertile of mixed dietary pattern were 66% less likely to have PCOS compared with the lowest one (OR, 0.34; 95%CI, 0.18-0.61). Conclusions: We found that western and plant-based dietary patterns were associated with an increased risk of PCOS. Also, moderate adherence to the mixed dietary pattern was associated with reduced risk of PCOS. To confirm our findings more studies with longitudinal design are required.
... According to nutritional and public health recommendations, dairy products are recommended as part of a healthy diet. They are in effect associated with lower risk of cardiovascular disease (Huth and Park, 2012) and obesity (Astrup et al., 2014). Furthermore, recent works suggest an inverse dose-response relationship between dairy product consumption and risk of metabolic syndrome (Chen et al., 2015;Thorning et al., 2017). ...
... Until now, studies of the health effects of dairy products consist mainly in epidemiological studies or in randomized controlled trial comparing the consumption of different dairy matrixes (e.g., cheese vs. butter, calcium content; Lamarche, 2008;Astrup et al., 2014), but data on the metabolic effect of UHT heat treatments of milk and cream are still lacking. Our study hence focuses on the short-term effect of UHT process type (direct and indirect heat treatments of cream) on metabolic parameters in mice. ...
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Although UHT heat treatment is being optimized to improve the stability and functional properties of dairy products, its metabolic effects remain scarcely known. As such, we studied the effect of the type of UHT process on lipid metabolism, intestinal barrier, and inflammation in mice. Nine-week-old male C57Bl/6J mice were fed a diet composed of nonlipidic powder mixed with different UHT dairy creams (final: 13% milkfat) for 1 or 4 wk. All creams contained 0.02% of thickener (carrageenan) and were treated via either (1) classical indirect heating process (Th), (2) indirect process at higher temperature (Th+), or (3) direct process by steam injection (ThD). Plasma, epididymal adipose tissue (EAT), and intestine were analyzed. Multivariate principal component analyses were used to identify differential effects of processes. Th+ differed by a globally higher liver damage score compared with that of the other creams. After 4 wk, the duodenal expression of lipid absorption genes fatty acid binding protein 4 (Fatp4) and microsomal triglycerides transfer protein (Mttp) was lower in the Th+ versus Th group. Expression in the colon of tight junction protein zonula occludens 1 (Zo-1) and of some endoplasmic reticulum stress markers was lower in both Th+ and ThD versus the Th group. In EAT, ThD had lower gene expression of several inflammatory markers after 4 wk. Some differential effects may be related to heat-induced physicochemical changes of creams. The type of cream UHT process differentially affected metabolic parameters in mice after a 4-wk fat-rich diet, partly due to cream structure. Altogether, direct steam injection process induced the lowest early markers of high-fat-induced metabolic inflammation in EAT.
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Background Polycystic Ovary Syndrome (PCOS) is defined as a common metabolic and endocrine abnormality in reproductive-aged women. This study aimed to investigate the relevance between major dietary patterns and PCOS. Methods This is a case-control study of 108 newly diagnosed women with PCOS and 108 age-, and BMI-matched women without PCOS, as a control group, in Yazd, Iran. The PCOS was diagnosed based on Rotterdam criteria. Subsequently, the validated 168-item food frequency questionnaire was used to evaluate the usual dietary intake. Moreover, the Principal Component Analysis (PCA) was used for driving dietary patterns, and logistic regression assessed the relationship between dietary patterns and PCOS. Results Three major dietary patterns were identified, namely a high glycemic index (high fat), a low glycemic index (low fat), and an anti-inflammatory dietary pattern. After adjustment for potential confounders, the high glycemic index (high fat) dietary pattern significantly increased the odds of PCOS (OR for the highest and. lowest quartile = 3.94; 95% CI: 1.65, 9.38), and demonstrated a significant increase in body mass index (BMI), waist circumference (WC), fasting blood sugar (FBS), and visceral fat. Then, having adjusted the potential confounders, the moderate adherence to the anti-inflammatory dietary pattern had a protective effect on the odds of PCOS (OR = 0.38; 95% CI = 0.15, 0.95). However, no significant relation was found between low glycemic index (low fat) dietary pattern and the odds of PCOS. Conclusions The results indicated that the high glycemic index (high fat) dietary pattern had an incremental effect on the odds of PCOS. Moreover, the anti-inflammatory dietary pattern had a reduction effect on the risk of PCOS. It's worth noting that more prospective studies are required to confirm the findings of this study.
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Recent decades have seen very large declines in coronary heart disease (CHD) mortality across most of Europe, partly due to declines in risk factors such as smoking. Cardiovascular diseases (predominantly CHD and stroke), remain, however, the main cause of death in most European countries, and many risk factors for CHD, particularly obesity, have been increasing substantially over the same period. It is hypothesized that observed reductions in CHD mortality have occurred largely within older age groups, and that rates in younger groups may be plateauing or increasing as the gains from reduced smoking rates are increasingly cancelled out by increasing rates of obesity and diabetes. The aim of this study was to examine sex-specific trends in CHD mortality between 1980 and 2009 in the European Union (EU) and compare trends between adult age groups. Sex-specific data from the WHO global mortality database were analysed using the joinpoint software to examine trends and significant changes in trends in age-standardized mortality rates. Specific age groups analysed were: under 45, 45-54, 55-64, and 65 years and over. The number and location of significant joinpoints for each country by sex and age group was determined (maximum of 3) using a log-linear model, and the annual percentage change within each segment calculated. Average annual percentage change overall (1980-2009) and separately for each decade were calculated with respect to the underlying joinpoint model. Recent CHD rates are now less than half what they were in the early 1980s in many countries, in younger adult age groups as well as in the population overall. Trends in mortality rates vary markedly between EU countries, but less so between age groups and sexes within countries. Fifteen countries showed evidence of a recent plateauing of trends in at least one age group for men, as did 12 countries for women. This did not, however, appear to be any more common in younger age groups compared with older adults. There was little evidence to support the hypothesis that mortality rates have recently begun to plateau in younger age groups in the EU as a whole, although such plateaus and even a small number of increases in CHD mortality in younger subpopulations were observed in a minority of countries. There is limited evidence to support the hypothesis that CHD mortality rates in younger age groups in the member states of the EU have been more likely to plateau than in older age groups. There are, however, substantial and persistent inequalities between countries. It remains vitally important for the whole EU to monitor and work towards reducing preventable risk factors for CHD and other chronic conditions to promote wellbeing and equity across the region.
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To investigate and quantify the potential dose-response association between egg consumption and risk of coronary heart disease and stroke. Dose-response meta-analysis of prospective cohort studies. PubMed and Embase prior to June 2012 and references of relevant original papers and review articles. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Prospective cohort studies with relative risks and 95% confidence intervals of coronary heart disease or stroke for three or more categories of egg consumption. Eight articles with 17 reports (nine for coronary heart disease, eight for stroke) were eligible for inclusion in the meta-analysis (3 081 269 person years and 5847 incident cases for coronary heart disease, and 4 148 095 person years and 7579 incident cases for stroke). No evidence of a curve linear association was seen between egg consumption and risk of coronary heart disease or stroke (P=0.67 and P=0.27 for non-linearity, respectively). The summary relative risk of coronary heart disease for an increase of one egg consumed per day was 0.99 (95% confidence interval 0.85 to 1.15; P=0.88 for linear trend) without heterogeneity among studies (P=0.97, I(2)=0%). For stroke, the combined relative risk for an increase of one egg consumed per day was 0.91 (0.81 to 1.02; P=0.10 for linear trend) without heterogeneity among studies (P=0.46, I(2)=0%). In a subgroup analysis of diabetic populations, the relative risk of coronary heart disease comparing the highest with the lowest egg consumption was 1.54 (1.14 to 2.09; P=0.01). In addition, people with higher egg consumption had a 25% (0.57 to 0.99; P=0.04) lower risk of developing hemorrhagic stroke. Higher consumption of eggs (up to one egg per day) is not associated with increased risk of coronary heart disease or stroke. The increased risk of coronary heart disease among diabetic patients and reduced risk of hemorrhagic stroke associated with higher egg consumption in subgroup analyses warrant further studies.
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Reduction or modification of dietary fat can improve total cholesterol levels, but may also have a variety of effects, both positive and negative, on other cardiovascular risk factors. OBJECTIVES: The aim of this systematic review was to assess the effect of reduction or modification of dietary fats on total and cardiovascular mortality and cardiovascular morbidity over at least 6 months, using all available randomized clinical trials. SEARCH STRATEGY: The Cochrane Library, MEDLINE, EMBASE, CAB Abstracts, CVRCT registry and related Cochrane Groups' trial registers were searched through spring 1998, SIGLE to January 1999. Trials known to experts in the field and biographies were included through May 1999. SELECTION CRITERIA: Trials fulfilled the following criteria: 1) randomized with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) healthy adult humans, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available. Inclusion decisions were duplicated, disagreement resolved by discussion or a third party. DATA COLLECTION AND ANALYSIS: Rate data were extracted by two independent reviewers and meta-analysis performed using random effects methodology. Meta-regression and funnel plots were used. MAIN RESULTS: Twenty seven studies were included (40 intervention arms, 30,901 person-years). There was no significant effect on total mortality (rate ratio 0.98, 95% CI 0.86 to 1.12), a trend towards protection form cardiovascular mortality (rate ratio 0.91, 95% CI 0.77 to 1.07), and significant protection from cardiovascular events (rate ratio 0.84, 95% CI 0.72 to 0.99). The latter became non-significant on sensitivity analysis. Trials where participants were involved for more than 2 years showed significant reductions in the rate of cardiovascular events and a suggestion of protection from total mortality. The degree of protection from cardiovascular events appeared similar in high and low risk groups, but was statistically significant only in the former. REVIEWER'S CONCLUSIONS: The findings are suggestive of a small but potentially important reduction in cardiovascular risk in trials longer than two years. Lifestyle advice to all those at high risk of cardiovascular disease (especially where statins are unavailable or rationed), and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates.