M.-L. Hellénius

Low prevalence of the metabolic syndrome in wine drinkers: is it the alcohol beverage or the lifestyle?

Objective: To study how the intake of alcohol and the choice of wine, beer, and spirits is related to lifestyle factors and the metabolic syndrome in 60-y-old men and women.Design: Cross-sectional population based study.Setting: Stockholm County, Sweden.Subjects: Sixty-year-old men and women (n=4232).Results: Moderate intake of wine (10–30 g/day) was associated with a lifestyle characterized by being married, having a university education, being employed, being Swedish-born, having a good quality of life according to economy, leisure time and health, compared with a group with low alcohol intake. The opposite characteristics were seen among the non-drinkers. Drinkers of spirits were more often smokers and also reported higher intake of sausage and fried potatoes compared with a group with low alcohol intake. In women, the metabolic syndrome was significantly more common in non-drinkers (20%), P<0.05, and less common among wine drinkers (8%), P<0.01, compared with a group with low alcohol intake. After adjustments, a significant lower odds ratio for the metabolic syndrome were seen in wine drinkers in women (OR=0.60, P<0.05).Conclusion: Compared with low alcohol drinkers, moderate wine drinkers exhibited a more favorable pattern according to both lifestyle factors and metabolic parameters. The close link between alcohol drinking behaviour and lifestyle habits illustrate the complex relationship between alcohol and health.Sponsorship: Swedish Heart-Lung Foundation, the Stockholm City County Council, the Swedish Society for Medicine, and the Swedish Medical Research Council.

Associations between the intake of dairy fat and calcium and abdominal obesity

OBJECTIVE: This study evaluates the association between abdominal obesity and the intake of dairy fat and calcium using information from dietary data and the relative content of the fatty acids 14:0, 15:0, and 17 : 0 in serum phospholipids (PL) and adipose tissue (AT), which are suggested biological markers for dairy fat intake. This study also explores how the associations were affected when under-reporters (URs) were separated from the analyses.DESIGN: Cross-sectional study.SUBJECTS: In all, 301 healthy 63-y-old men with different degrees of fasting-insulin concentrations.METHODS: Sagittal abdominal obesity (SAD), dietary intake assessed by a 7-day food registration, and the fatty acid composition in serum PL and AT were measured. URs (n=88) and non-under-reporters (non-URs, n=213) were identified by Goldbergs equation, which compares energy intake with energy expenditure, both expressed as multiples of the basal metabolic rate.RESULTS: The intake of dairy fat, expressed as g/100 g fat, was inversely correlated with SAD; however, this association was only observed in the URs (r=−0.36, P=0.001) and not in the non-URs (r=−0.04, P=0.59). The intake of calcium was inversely correlated with SAD in both groups, although the association was weaker in the non-URs. The intake of dairy fat was related to the relative content of the fatty acids 14:0, 15:0, and 17 : 0 in serum PL and AT (r ranging between 0.32 and 0.55). When these fatty acids were correlated to SAD, inverse associations were seen except for 14:0 in PL (r ranging between −0.17 and −0.29.CONCLUSION: If there is a true inverse association between the intake of dairy fat and SAD, it remains to explain why this association was not seen in the non-URs. The data gave some indications of an inverse association between SAD and the intake of calcium. The diverse findings observed when the URs and non-URs were separated highlight the question of how to use and interpret dietary data in URs when diet–disease relationships are investigated.

Sagittal Abdominal Diameter as a Screening Tool in Clinical Research: Cutoffs for Cardiometabolic Risk

Background. Waist girth and BMI are commonly used as markers of cardiometabolic risk. Accumulating data however suggest that sagittal abdominal diameter (SAD) or “abdominal height” may be a better marker of intra-abdominal adiposity and cardiometabolic risk. We aimed to identify cutoffs for SAD using a cardiometabolic risk score. Design. A population-based cross-sectional study. Methods. In 4032 subjects (1936 men and 2096 women) at age 60, different anthropometric variables (SAD, BMI, waist girth, and waist-to-hip ratio) were measured and cardiometabolic risk score calculated. ROC curves were used to assess cutoffs. Results. Among men SAD showed the strongest correlations to the majority of the individual risk factors; whereas in women SAD was equal to that of waist girth. In the whole sample, the area under the ROC curve was highest for SAD. The optimal SAD cutoff for an elevated cardiometabolic risk score in men was ∼22 cm (95%CI; 21.6 to 22.8) and in women ∼20 cm (95%CI; 19.4 to 20.8). These cutoffs were similar if the Framingham risk score was used. Conclusions. These cutoffs may be used in research and screening to identify “metabolically obese” men who would benefit from lifestyle and pharmacological interventions. These results need to be verified in younger age groups.

Novel and established anthropometric measures and the prediction of incident cardiovascular disease: a cohort study

Objectives:The aim of this study was to compare novel and established anthropometrical measures in their ability to predict cardiovascular disease (CVD), and to determine whether they improve risk prediction beyond classical risk factors in a cohort study of 60-year-old men and women. We also stratified the results according to gender to identify possible differences between men and women. Furthermore, we aimed to replicate our findings in a large independent cohort (The Malmö Diet and Cancer study—cardiovascular cohort).Methods:This was a population-based study of 1751 men and 1990 women, aged 60 years and without CVD at baseline, with 375 incident cases of CVD during 11 years of follow-up. Weight, height, waist circumference (WC), hip circumference and sagittal abdominal diameter (SAD) were measured at baseline. Body mass index (BMI), waist–hip ratio (WHR), waist–hip-height ratio (WHHR), WC-to-height ratio (WCHR) and SAD-to-height ratio (SADHR) were calculated.Results:All anthropometric measures predicted CVD in unadjusted Cox regression models per s.d. increment (hazard ratios, 95% confidence interval), while significant associations after adjustments for established risk CVD factors were noted for WHHR 1.20 (1.08–1.33), WHR 1.14 (1.02–1.28), SAD 1.13 (1.02–1.25) and SADHR 1.17 (1.06–1.28). WHHR had higher increases in C-statistics, and model improvements (likelihood ratio tests (P<0.001)). In the replication study (MDC-CC, n=5180), WHHR was the only measure that improved Cox regression models in men (P=0.01).Conclusion:WHHR, a new measure reflecting body fat distribution, showed the highest risk estimates after adjustments for established CVD risk factors. These findings were verified in men but not women in an independent cohort.

Fatty acid handling protein expression in adipose tissue, fatty acid composition of adipose tissue and serum, and markers of insulin resistance

Objective:Proteins involved in cellular fatty acid (FA) uptake and metabolism may be of relevance in the context of disturbed FA metabolism associated with insulin resistance. Therefore this study investigated relationships between FA handling protein mRNA expression in adipose tissue, FA composition of adipose tissue and serum, and markers of insulin resistance.Subjects:75 subjects with a range of insulin sensitivities recruited from a cohort of 294 healthy 63-year-old Swedish men.Measurements:Anthropometric and biochemical variables (e.g. waist-hip-ratio (WHR) and homeostasis model assessment (HOMA) index of insulin sensitivity), FA composition of the subcutaneous (s.c.) gluteal adipose tissue, serum nonesterified FA (NEFA) and serum phospholipid compartments (by gas–liquid chromatography; n=294), and mRNA levels of FA handling proteins (adipocyte and keratinocyte lipid binding proteins, fatty acid transport protein (FATP) −1 and −4, CD36/fatty acid translocase, plasma membrane fatty acid binding protein, and acyl-CoA synthase-1 (ACS1)) in s.c. gluteal adipose tissue (by quantitative real-time polymerase chain reaction; n=75).Results:ACS1 expression was negatively correlated with measures of insulin resistance and central obesity (ACS1 versus HOMA: r=−0.28, P<0.05; ACS1 versus WHR: r=−0.23, P<0.05), with an opposite trend for FATP4. Further analysis of ACS1 expression levels revealed correlations with adipose tissue 16:0 (r=−0.27, P<0.05) and NEFA 16:1 (r=0.29, P<0.05), FA composition variables which in turn correlated with HOMA index (r=0.39, P<0.001 and r=−0.23, P<0.05, respectively, n=75). Moreover, NEFA 16:1 predicted ACS1 expression independently of HOMA, WHR and adipose tissue 16:0 in multiple regression analysis (standardized coefficient=0.27, P<0.05).Conclusion:Significant associations were found between measures of insulin sensitivity, adipose tissue FA handling protein expression, and specific FA composition variables. Although causal relationships could not be identified these findings suggest a role of FA handling proteins in relation to insulin sensitivity, via their involvement in FA trafficking and metabolism. In particular they indicate links between ACS1 activity, the distribution of 16:0 and 16:1, and insulin sensitivity, which may be of physiological relevance.

Quality of life is not negatively affected by diet and exercise intervention in healthy men with cardiovascular risk factors.

Health-related quality of life was assessed in a diet and exercise intervention study among 157 healthy men aged 35–60 years (mean ± s.d.; 46.2 ± 5.0) with moderately raised cardiovascular risk factors. The men were randomized to four groups, diet (D, n=40), exercise (E, n=39), diet plus exercise (DE, n=39), and no active intervention (controls (C) n=39). Quality of life was measured with two self-administered questionnaires; Subjective Symptoms Assessment Profile and Minor Symptom Evaluation Profile, at baseline and after 1.5, 3 and 6 months. Cardiovascular risk factors were investigated at baseline and after 6 months. As a result of changes in dietary habits and physical exercise in the three intervention groups, several important cardiovascular risk factors were significantly reduced. The quality of life/well-being did not differ between the four groups and did not change significantly in any of the groups during the study. There was, however, a tendency towards fewer gastrointestinal symptoms in group D and fewer cardiac symptoms in group DE. We conclude that advice on lifestyle changes in the form of diet and exercise reduce risk factors in middle-aged men without negative effects on their quality of life.

Simple advice on lifestyle habits and long-term changes in biomarkers of inflammation and vascular adhesion in healthy middle-aged men

Background/Objectives:Lifestyle habits, vascular function and inflammation are components in the development of cardiovascular disease (CVD). We investigated whether simple advice on dietary and exercise habits given (at a single time point) to hypercholesterolemic men affects circulating biomarkers of inflammation and vascular adhesion.Subjects/Methods:In total, 157 men (age 46±5 years) with mild hypercholesterolemia were randomized to four intervention groups, diet (D, n=40), exercise (E, n=39), diet and exercise (DE, n=39) or controls (C, n=39) and serum concentrations of C-reactive protein (CRP), interleukin-6 (IL-6), soluble intercellular adhesion molecule 1 (sICAM-1), soluble vascular cell adhesion molecule 1 (sVCAM-1) and soluble E-selectin (sE-selectin) were quantified at baseline and after a 6-month intervention period.Results:The intervention applied in this study, that is, simple advice on lifestyle changes given at a single time point, had a modest effect on inflammatory biomarkers and soluble vascular adhesion molecules. The most apparent alterations were found for individuals in group DE, who responded with significant reductions in sICAM-1, −28 (−41 to −14 μg/l) and sE-selectin, −3.6 (−6.9 to −0.3 μg/l) after 6 months. None of the groups had altered their concentrations of sVCAM-1, CRP or IL-6 significantly after the intervention. In all individuals combined, we found changes in apolipoprotein B (apoB) to predict alterations in sICAM-1 (β=0.21) and sE-selectin (β=0.26), independently of changes in inflammation and other adhesion molecules.Conclusions:These observations indicate that even small efforts to improve diet and physical activity can influence biomarkers of vascular function in individuals at increased risk for CVD. ApoB was identified as an important determinant of this improvement, which adds further support to the notion of apoB as a critical target in cardiovascular prevention.

Effect of diet and physical exercise intervention programmes on coronary heart disease risk in smoking and non-smoking men in Sweden.

STUDY OBJECTIVE: To investigate differences between smokers and non-smokers in health behaviour, cardiovascular risk factors, coronary heart disease (CHD) risks, health knowledge, health attitudes, and compliance with a CHD prevention programme. DESIGN: Differences between smokers and non-smokers were studied via medical examinations, questionnaires, physical exercise activity logs, and food record sheets. Data were analysed using univariate and multivariate analyses. The five and 10 year CHD risks were assessed using the Framingham CHD risk estimate. SETTING: The Karolinska Hospital, Stockholm, and Sollentuna Primary Health Centre, Sollentuna, Sweden. PARTICIPANTS: The analyses were based on 158 healthy smoking and non-smoking men aged 35-60 years with raised cardiovascular risk factors who enrolled in controlled, randomised six month diet and exercise programmes. MAIN RESULTS: Discriminant analysis suggested that smokers, compared with non-smokers, were characterised by a higher alcohol energy percent, lower HDL cholesterol concentration, lower systolic blood pressure, and a higher plasminogen activator inhibitor-1 (PAI-1) value. Knowledge of the risk factors for CHD was not a discriminating factor. Both smokers and non-smokers increased the exercise taken, improved their diet, and lowered their CHD risk. Before, as well as after the intervention, smokers had a higher CHD risk than non-smokers. CONCLUSIONS: The best CHD prevention action that could be taken by smokers would of course be to quit smoking. Those who cannot stop should be encouraged to improve their diet and increase the amount of physical exercise they take in order to reduce the health hazards of their smoking behaviour.

Prediction of cardiovascular disease by abdominal obesity measures is dependent on body weight and sex - Results from two community based cohort studies

AIM To study waist-hip ratio (WHR), waist circumference (WC), sagittal abdominal diameter (SAD), and waist-hip-height ratio (WHHR) as predictors of CVD, in men and women stratified by BMI (cut-off ≥25). METHODS AND RESULTS A cohort of n = 3741 (53% women) 60-year old individuals without CVD was followed for 11-years (375 CVD cases). To replicate the results, we also assessed another large independent cohort; The Malmö Diet and Cancer study - cardiovascular cohort (MDCC, (n = 5180, 60% women, 602 CVD cases during 16-years). After adjustment for established risk factors in normal-weight women, the hazard ratio (HR) per one standard deviation (SD) were; WHR; 1.91 (95% confidence interval (CI) 1.35-2.70), WC; 1.81 (95% CI 1.02-3.20), SAD; 1.25 (95% CI 0.74-2.11), and WHHR; 1.97 (95% CI 1.40-2.78). In men the association with WHR, WHHR and WC were not significant, whereas SAD was the only measure that significantly predicted CVD in men (HR 1.19 (95% CI 1.04-1.35). After adjustments for established risk factors in overweight/obese women, none of the measures were significantly associated with CVD risk. In men, however, all measures were significant predictors; WHR; 1.24 (955 CI 1.04-1.47), WC 1.19 (95% CI 1.00-1.42), SAD 1.21 (95% CI 1.00-1.46), and WHHR; 1.23 (95% CI 1.05-1.44). Only the findings in men with BMI ≥ 25 were verified in MDCC. CONCLUSION In normal weight individuals, WHHR and WHR were the best predictors in women, whereas SAD was the only independent predictor in men. Among overweight/obese individuals all measures failed to predict CVD in women, whereas WHHR was the strongest predictor after adjustments for CVD risk factors in men.

The relation between alcohol intake and physical activity and the fatty acids 14 : 0, 15 : 0 and 17 : 0 in serum phospholipids and adipose tissue used as markers for dairy fat intake.

The relative contents of the fatty acids 14 : 0, 15 : 0 and 17 : 0 in serum and adipose tissue may be used as biological markers of dairy fat intake. However, the determinants of these fatty acids are not fully understood. This study investigates the relationship between these fatty acids and the intake of macronutrients and physical activity in a cross-sectional study of 301 healthy men aged 61-64 years. Dietary intake was assessed using a pre-coded 7 d food record, and physical activity during the previous year was recorded in an interview. Under-reporters of energy intake were identified by the Goldberg cut-off. Fatty acid composition was determined in serum phospholipids (PL) and subcutaneous adipose tissue (AT) from the upper buttock. The relative content of each of 14 : 0, 15 : 0 and 17 : 0 in PL and AT was positively associated with the intake of dairy fat. In addition, all three fatty acids were inversely correlated with alcohol intake, R ranging from -0.28 to -0.53 (P<0.001). The results were not markedly affected when under-reporters (n 88) were excluded from the analyses. In both PL and AT, the relative content of the fatty acids was approximately 5% higher in a group of high physical activity compared with a group of low physical activity, although significant trends were only seen for 14 : 0 in PL and 17 : 0 in AT. The findings suggest that adjustments should be made for alcohol intake when the fatty acids 14 : 0, 15 : 0 and 17 : 0 are applied as markers for dairy fat intake.