Berit L. Heitmann

Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies

BACKGROUND Saturated fatty acid (SFA) intake increases plasma LDL-cholesterol concentrations; therefore, intake should be reduced to prevent coronary heart disease (CHD). Lower habitual intakes of SFAs, however, require substitution of other macronutrients to maintain energy balance. OBJECTIVE We investigated associations between energy intake from monounsaturated fatty acids (MUFAs), polyunsaturated fatty acids (PUFAs), and carbohydrates and risk of CHD while assessing the potential effect-modifying role of sex and age. Using substitution models, our aim was to clarify whether energy from unsaturated fatty acids or carbohydrates should replace energy from SFAs to prevent CHD. DESIGN This was a follow-up study in which data from 11 American and European cohort studies were pooled. The outcome measure was incident CHD. RESULTS During 4-10 y of follow-up, 5249 coronary events and 2155 coronary deaths occurred among 344,696 persons. For a 5% lower energy intake from SFAs and a concomitant higher energy intake from PUFAs, there was a significant inverse association between PUFAs and risk of coronary events (hazard ratio: 0.87; 95% CI: 0.77, 0.97); the hazard ratio for coronary deaths was 0.74 (95% CI: 0.61, 0.89). For a 5% lower energy intake from SFAs and a concomitant higher energy intake from carbohydrates, there was a modest significant direct association between carbohydrates and coronary events (hazard ratio: 1.07; 95% CI: 1.01, 1.14); the hazard ratio for coronary deaths was 0.96 (95% CI: 0.82, 1.13). MUFA intake was not associated with CHD. No effect modification by sex or age was found. CONCLUSION The associations suggest that replacing SFAs with PUFAs rather than MUFAs or carbohydrates prevents CHD over a wide range of intakes.

Dietary underreporting by obese individuals--is it specific or non-specific?

Abstract Objective: To examine the distribution of patterns of macronutrient density in relation to obesity. Design: Cross sectional. Setting: Denmark. Subjects: 323 men and women aged 35-65 years, selected randomly from a larger population sample of Danish adults. Main outcome measure: Bias in dietary reporting of energy and protein intake in relation to percentage body fat, assessed by comparison of data from an interview on dietary intake with data estimated from 24 hour nitrogen output, validated by administering p-aminobenzoic acid, and estimated 24 hour energy expenditure. Results: Degree of obesity was positively associated with underreporting of total energy and protein, whereas compared with total energy reported, protein was overreported by the obese subjects. Conclusion: Errors in dietary reporting of protein seem to occur disproportionately with respect to total energy, suggesting a differential reporting pattern of different foods. Although, on average, all subjects showed a greater underreporting of energy than of protein, this was most common in the obese subjects. Snack-type foods may be preferentially forgotten when obese people omit food items in dietary reporting. These results seem to agree with the general assumption that obese people tend to underreport fatty foods and foods rich in carbohydrates rather than underreport their total dietary intake. These results may have implications for the interpretation of studies of diet and comorbidities related to obesity.

Dietary patterns and mortality in Danish men and women: a prospective observational study

The analysis of dietary patterns emerged recently as a possible approach to examining diet-disease relation. We analysed the risk of all-cause and cardiovascular mortality associated with dietary patterns in men and women, while taking a number of potential confounding variables into account. Data were from a prospective cohort study with follow-up of total and cause-specific mortality. A random sample of 3698 men and 3618 women aged 30-70 years and living in Copenhagen County, Denmark, were followed from 1982 to 1998 (median 15 years). Three dietary patterns were identified from a twenty-eight item food frequency questionnaire, collected at baseline: (1) a predefined healthy food index, which reflected daily intakes of fruits, vegetables and wholemeal bread, (2) a prudent and (3) a Western dietary pattern derived by principal component analysis. The prudent pattern was positively associated with frequent intake of wholemeal bread, fruits and vegetables, whereas the Western was characterized by frequent intakes of meat products, potatoes, white bread, butter and lard. Among participants with complete information on all variables, 398 men and 231 women died during follow-up. The healthy food index was associated with reduced all-cause mortality in both men and women, but the relations were attenuated after adjustment for smoking, physical activity, educational level, BMI, and alcohol intake. The prudent pattern was inversely associated with all-cause and cardiovascular mortality after controlling for confounding variables. The Western pattern was not significantly associated with mortality. This study partly supports the assumption that overall dietary patterns can predict mortality, and that the dietary pattern associated with the lowest risk is the one which is in accordance with the current recommendations for a prudent diet.

Breastfeeding reduces postpartum weight retention

BACKGROUND Weight gained during pregnancy and not lost postpartum may contribute to obesity in women of childbearing age. OBJECTIVE We aimed to determine whether breastfeeding reduces postpartum weight retention (PPWR) in a population among which full breastfeeding is common and breastfeeding duration is long. DESIGN We selected women from the Danish National Birth Cohort who ever breastfed (>98%), and we conducted the interviews at 6 (n = 36 030) and 18 (n = 26 846) mo postpartum. We used regression analyses to investigate whether breastfeeding (scored to account for duration and intensity) reduced PPWR at 6 and 18 mo after adjustment for maternal prepregnancy body mass index (BMI) and gestational weight gain (GWG). RESULTS GWG was positively (P < 0.0001) associated with PPWR at both 6 and 18 mo postpartum. Breastfeeding was negatively associated with PPWR in all women but those in the heaviest category of prepregnancy BMI at 6 (P < 0.0001) and 18 (P < 0.05) mo postpartum. When modeled together with adjustment for possible confounding, these associations were marginally attenuated. We calculated that, if women exclusively breastfed for 6 mo as recommended, PPWR could be eliminated by that time in women with GWG values of approximately 12 kg, and that the possibility of major weight gain (>or=5 kg) could be reduced in all but the heaviest women. CONCLUSION Breastfeeding was associated with lower PPWR in all categories of prepregnancy BMI. These results suggest that, when combined with GWG values of approximately 12 kg, breastfeeding as recommended could eliminate weight retention by 6 mo postpartum in many women.

Alcohol Intake and Risk of Coronary Heart Disease in Younger, Middle-Aged, and Older Adults

Background— Light to moderate alcohol consumption is associated with a reduced risk of coronary heart disease. This protective effect of alcohol, however, may be confined to middle-aged or older individuals. Coronary heart disease incidence is low in men <40 years of age and in women <50 years of age; for this reason, study cohorts rarely have the power to investigate the effects of alcohol on coronary heart disease risk in younger adults. This study examined whether the beneficial effect of alcohol on coronary heart disease depends on age. Methods and Results— In this pooled analysis of 8 prospective studies from North America and Europe including 192 067 women and 74 919 men free of cardiovascular diseases, diabetes, and cancers at baseline, average daily alcohol intake was assessed at baseline with a food frequency or diet history questionnaire. An inverse association between alcohol and risk of coronary heart disease was observed in all age groups; hazard ratios among moderately drinking men (5.0 to 29.9 g/d) 39 to 50, 50 to 59, and ≥60 years of age were 0.58 (95% confidence interval [CI], 0.36 to 0.93), 0.72 (95% CI, 0.60 to 0.86), and 0.85 (95% CI, 0.75 to 0.97) compared with abstainers. However, the analyses indicated a smaller incidence rate difference between abstainers and moderate consumers in younger adults (incidence rate difference, 45 per 100 000; 90% CI, 8 to 84) than in middle-aged (incidence rate difference, 64 per 100 000; 90% CI, 24 to 102) and older (incidence rate difference, 89 per 100 000; 90% CI, 44 to 140) adults. Similar results were observed in women. Conclusion— Alcohol is also associated with a decreased risk of coronary heart disease in younger adults; however, the absolute risk was small compared with middle-aged and older adults.

Food intake patterns and risk of coronary heart disease: a prospective cohort study examining the use of traditional scoring techniques.

Objective: This study analyses the risk of coronary heart disease (CHD) associated with food intake patterns.Design: A cohort study with follow-up in 1996 for first admission to hospital for a CHD diagnosis or death caused by CHD (280 cases). Three food patterns were identified from a food frequency questionnaire: (1) a predefined healthy food index; (2) a prudent diet (reflecting frequent intakes of wholemeal cereals, fruit and vegetables); and (3) a Western food pattern (reflecting frequent intakes of meat products, butter and white bread) derived by factor analysis. Both factor scores had a mean of zero and a standard deviation of 1.Setting: Copenhagen County, Denmark.Subjects: A random sample of 7316 adults participated in health examinations conducted either in 1982–1984, 1987, or 1991–1992.Results: The healthy food index and the Western pattern were not associated with CHD. The prudent pattern was associated with a decreased risk of CHD (Hazard ratio (HR per score unit increase)=0.85; 95% confidence intervals (CI), 0.75, 0.96), but the association vanished (HR=1.06; 95% CI, 0.93, 1.21) after controlling for confounding. Body mass index (BMI) modified the effect of the prudent and the Western patterns on CHD risk, suggesting an inverse association between both patterns and CHD in persons with low BMI, while the risk of CHD seemed to be positively related to the prudent and the Western pattern in those with high BMIs.Conclusions: This study showed no association between dietary patterns and CHD risk, but suggests that BMI modifies the relation between diet and CHD risk.

Population studies of diet and obesity.

Population-based research on diet, obesity and the metabolic syndrome is faced with accumulating evidence of biases that may profoundly affect results. One potential source of bias, which is often neglected in nutritional epidemiology, arises from self-selected study populations. Subjects who agree to participate in surveys may be at less risk of metabolic syndrome than those who refuse. Analogous to observations in adult populations, studies of schoolchildren have also yielded clear evidence of self-selection. Whether such selection patterns influence analytical results depends on how the biases relate to the dependent and independent variables being studied. Systematic dietary reporting error is another source of bias in studies of nutritional risk factors for disease. While obesity-related under-reporting bias is now well documented, less is known about whether specific foods and nutrients are disproportionately affected. However, two studies employing biomarkers for protein have suggested that obese subjects under-reported the proportion of energy from fat plus carbohydrate. This should alert epidemiologists to the possibility that a dual reporting bias may be present in studies of diet and disease: general under-reporting among obese subjects compounded by food-specific errors. In summary, biases due to self-selection and selective dietary under-reporting may produce consequences in epidemiological studies that are both unpredictable and complex. We conclude this review with recent findings involving dietary fat intake and regional adiposity in a population-based study of women. These preliminary results may have etiological relevance to the development of metabolic syndrome, but multiple biases of the type described previously may also be operating.

High dietary intake of saturated fat is associated with reduced semen quality among 701 young Danish men from the general population

BACKGROUND Saturated fat intake has been associated with both cardiovascular disease and cancer risk, and a newly published study found an association between saturated fat intake and a lower sperm concentration in infertile men. OBJECTIVE The objective was to examine the association between dietary fat intake and semen quality among 701 young Danish men from the general population. DESIGN In this cross-sectional study, men were recruited when they were examined to determine their fitness for military service from 2008 to 2010. They delivered a semen sample, underwent a physical examination, and answered a questionnaire comprising a quantitative food-frequency questionnaire to assess food and nutrient intakes. Multiple linear regression analyses were performed with semen variables as outcomes and dietary fat intakes as exposure variables, adjusted for confounders. RESULTS A lower sperm concentration and total sperm count in men with a high intake of saturated fat was found. A significant dose-response association was found, and men in the highest quartile of saturated fat intake had a 38% (95% CI: 0.1%, 61%) lower sperm concentration and a 41% (95% CI: 4%, 64%) lower total sperm count than did men in the lowest quartile. No association between semen quality and intake of other types of fat was found. CONCLUSIONS Our findings are of potentially great public interest, because changes in diet over the past decades may be part of the explanation for the recently reported high frequency of subnormal human sperm counts. A reduction in saturated fat intake may be beneficial for both general and reproductive health.

The relation between drinking pattern and body mass index and waist and hip circumference

OBJECTIVES:To study the association between alcohol drinking pattern and obesity.DESIGN:Cross-sectional population study with assessment of quantity and frequency of alcohol intake, waist and hip circumference, height, weight, and lifestyle factors including diet.SUBJECTS:In all, 25 325 men and 24 552 women aged 50–65 y from the Diet, Cancer and Health Study, Denmark, 1993–1997 participated in the study.MEASUREMENTS:Drinking frequency, total alcohol intake, body mass index (BMI), and waist and hip circumference.RESULTS:Among men, total alcohol intake was positively associated with high BMI (≥30 kg/m2), large waist circumference (≥102 cm) and inversely associated with small hip circumference (<100 cm). Among women, the total alcohol was associated with high BMI, large waist (≥88 cm), and small hips only for the highest intake (28+ drinks/week). The most frequent drinkers had the lowest odds ratios (OR) for being obese. Among men, OR for having a high BMI were 1.39 (95% confidence interval: 1.36–1.64), 1.17 (1.02–1.34), 1.00 (reference), 0.87 (0.77–0.98), and 0.73 (0.65–0.82) for drinking 1–3 days/month, 1 day/week, 2–4 days/week, 5–6 days/week, and 7 days/week, respectively. Similar estimates were found for waist circumference. Corresponding results were found for women.CONCLUSION:For a given level of total alcohol intake, obesity was inversely associated with drinking frequency, whereas the amount of alcohol intake was positively associated with obesity. These results indicate that frequent drinking of small amounts of alcohol is the optimal drinking pattern in this relation.

Association Between Periodontal Disease and Overweight and Obesity: A Systematic Review

BACKGROUND Periodontitis and obesity are among the most common chronic disorders affecting the worlds populations, and recent reviews suggest a potential link between overweight/obesity and periodontitis. However, because of the scarcity of prospective evidence, previous reviews were primarily based on cross-sectional studies, with only a few longitudinal or intervention studies included. This studys objective is to examine the time-dependent association between obesity and periodontitis and how weight changes may affect the development of periodontitis in the general population. Therefore, longitudinal and experimental studies that assessed the association among overweight, obesity, weight gain, waist circumference, and periodontitis are reviewed. METHODS Intervention and longitudinal studies with overweight or obesity as exposure and periodontitis as outcome were searched through the platforms PubMed/Medline and Web of Knowledge. RESULTS Eight longitudinal and five intervention studies were included. Two of the longitudinal studies found a direct association between degree of overweight at baseline and subsequent risk of developing periodontitis, and a further three studies found a direct association between obesity and development of periodontitis among adults. Two intervention studies on the influence of obesity on periodontal treatment effects found that the response to non-surgical periodontal treatment was better among lean than obese patients; the remaining three studies did not report treatment differences between obese and lean participants. Among the eight longitudinal studies, one study adjusted for C-reactive protein (CRP) and biologic markers of inflammation such as CRP, interleukin-6, and tumor necrosis factor-α, and inflammation markers were analyzed separately in three of the five intervention studies. CONCLUSION This systematic review suggests that overweight, obesity, weight gain, and increased waist circumference may be risk factors for development of periodontitis or worsening of periodontal measures.