CoChat
Sign Up
Cited by 268Nutritional Studies and DietFatty Acid Research and HealthCardiovascular Health and Risk Factors

Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study

Open access
Mente, Andrew, Dehghan, Mahshid, Rangarajan, Sumathy, McQueen, Matthew, Dagenais, Gilles, Wielgosz, Andreas, Lear, Scott, Li, Wei +436 more·2017·The Lancet Diabetes & Endocrinology
DOI 10.1016/s2213-8587(17)30283-8
Open this paper in CoChat — free accountOpen PDF

Abstract

Background The relation between dietary nutrients and cardiovascular disease risk markers in many regions worldwide is unknown. In this study, we investigated the effect of dietary nutrients on blood lipids and blood pressure, two of the most important risk factors for cardiovascular disease, in low-income, middle-income, and high-income countries.Methods We studied 125 287 participants from 18 countries in North America, South America, Europe, Africa, and Asia in the Prospective Urban Rural Epidemiology (PURE) study. Habitual food intake was measured with validated food frequency questionnaires. We assessed the associations between nutrients (total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol) and cardiovascular disease risk markers using multilevel modelling. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intakes by use of nutrient density models. We did simulation modelling in which we assumed that the effects of saturated fatty acids on cardiovascular disease events was solely related to their association through an individual risk marker, and then compared these simulated risk marker-based estimates with directly observed associations of saturated fatty acids with cardiovascular disease events.Findings Participants were enrolled into the study from Jan 1, 2003, to March 31, 2013. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, but also with higher HDL cholesterol and apolipoprotein A1 (ApoA1), and lower triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ratio of apolipoprotein B (ApoB) to ApoA1 (all p trend<0·0001). Higher carbohydrate intake was associated with lower total cholesterol, LDL cholesterol, and ApoB, but also with lower HDL cholesterol and ApoA1, and higher triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ApoB-to-ApoA1 ratio (all p trend<0·0001, apart from ApoB [p trend=0·0014]). Higher intakes of total fat, saturated fatty acids, and carbohydrates were associated with higher blood pressure, whereas higher protein intake was associated with lower blood pressure. Replacement of saturated fatty acids with carbohydrates was associated with the most adverse effects on lipids, whereas replacement of saturated fatty acids with unsaturated fats improved some risk markers (LDL cholesterol and blood pressure), but seemed to worsen others (HDL cholesterol and triglycerides). The observed associations between saturated fatty acids and cardiovascular disease events were approximated by the simulated associations mediated through the effects on the ApoB-to-ApoA1 ratio, but not with other lipid markers including LDL cholesterol.Interpretation Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk.Funding Full funding sources listed at the end of the paper (see Acknowledgments).

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1016/s2213-8587(17)30283-8

Cites

33 of 33 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Emerging evidence suggested the apoB:apoA1 ratio to be the best overall predictor of CVD risk compared with other lipid markers.

    “Emerging evidence suggested the apoB:apoA1 ratio to be the best overall predictor of CVD risk compared with other lipid markers (44, 47, 48).”

    From Eucaloric diets enriched in palm olein, cocoa butter, and soybean oil did not differentially affect liver fat concentration in healthy participants: a 16-week randomized controlled trial. (2021) · cites this paper as [44]

    The Discussion says the apoB-to-apoA1 ratio was the strongest predictor of myocardial infarction and ischaemic stroke in studies it cites. It also calls the ratio the best overall indicator of how saturated fatty acids affect cardiovascular risk compared with other lipid markers. Those findings support the direction of the claim, but not its unqualified assertion that the ratio is the best overall predictor of CVD risk; the paper says no single marker was superior for carbohydrate intake. The supplied copy gives section labels but no page numbers. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Cited by

Sorted by citations

Related

Authors
Mente, A., Dehghan, M., Rangarajan, S., McQueen, M., Dagenais, G., Wielgosz, A., Lear, S., Li, W., Chen, H., Yi, S., Wang, Y., Diaz, R., Avezum, A., Lopez-Jaramillo, P., Seron, P., Kumar, R., Gupta, R., Mohan, V., Swaminathan, S., Kutty, R., Zatonska, K., Iqbal, R., Yusuf, R., Mohammadifard, N., Khatib, R., Nasir, N. M., Ismail, N., Oguz, A., Rosengren, A., Yusufali, A., Wentzel-Viljoen, E., Puoane, T., Chifamba, J., Teo, K., Anand, S. S., Yusuf, S., Yusuf, S., Rangarajan, S., Teo, K. K., Chow, C. K., O'Donnell, M., Mente, A., Leong, D., Smyth, A., Joseph, P., Merchant, A., Islam, S., Zhang, M., Hu, W., Ramasundarahettige, C., Wong, G., Bangdiwala, S., Dyal, L., Casanova, A., Dehghan, M., Lewis, G., Aliberti, A., Arshad, A., Reyes, A., Zaki, A., Lewis, B., Zhang, B., Agapay, D., Hari, D., Milazzo, E., Ramezani, E., Hussain, F., Shifaly, F., McAlpine, G., Kay, I., Lindeman, J., Rimac, J., Swallow, J., Heldman, L., Mushtaha, M., Mushtaha, M., Trottier, M., Riggi, M., Aoucheva, N., Kandy, N., Mackie, P., Solano, R., Chin, S., Ramacham, S., Shahrook, S., Trottier, S., Tongana, T., ElSheikh, W., Iyengar, Y., McQueen, M., Hall, K., Keys, J., Wang, X., Keneth, J., Devanath, A., Diaz, R., Orlandini, A., Linetsky, B., Toscanelli, S., Casaccia, G., Cuneo, J. M., Rahman, O., Yusuf, R., Azad, A., Rabbani, K., Cherry, H., Mannan, A., Hassan, I., Talukdar, A., Tooheen, R., Khan, M., Sintaha, M., Choudhury, T., Haque, R., Parvin, S., Avezum, A., Oliveira, G., Marcilio, C., Mattos, A., Teo, K., Yusuf, S., Dejesus, J., Agapay, D., Tongana, T., Solano, R., Kay, I., Trottier, S., Rimac, J., Elsheikh, W., Heldman, L., Ramezani, E., Dagenais, G., Poirier, P., Turbide, G., Auger, D., De Bluts, A. L., Proulx, M., Cayer, M., Bonneville, N., Lear, S., Gasevic, D., Corber, E., de Jong, V, Vukmirovich, I., Wielgosz, A., Fodor, G., Pipe, A., Shane, A., Lanas, F., Seron, P., Martinez, S., Valdebenito, A., Oliveros, M., Wei, L., Lisheng, L., Chunming, C., Xingyu, W., Wenhua, Z., Hongye, Z., Xuan, J., Bo, H., Yi, S., Jian, B., Xiuwen, Z., Xiaohong, C., Tao, C., Hui, C., Xiaohong, C., Qing, D., Xiaoru, C., Qing, D., Xinye, H., Bo, H., Xuan, J., Jian, L., Juan, L., Xu, L., Bing, R., Yi, S., Wei, W., Yang, W., Jun, Y., Yi, Z., Hongye, Z., Xiuwen, Z., Manlu, Z., Fanghong, L., Jianfang, W., Yindong, L., Yan, H., Liangqing, Z., Baoxia, G., Xiaoyang, L., Shiying, Z., Rongwen, B., Xiuzhen, T., Dong, L., Di, C., Jianguo, W., Yize, X., Tianlu, L., Peng, Z., Changlin, D., Ning, L., Xiaolan, M., Yuqing, Y., Rensheng, L., Minfan, F., Jing, H., Yu, L., Xiaojie, X., Qiang, Z., Lopez-Jaramillo, P., Lopez, P. C., Garcia, R., Jurado, L., Gómez-Arbeláez, D., Arguello, J., Dueñas, R., Silva, S., Pradilla, L., Ramirez, F., Molina, D., Cure-Cure, C., Perez, M., Hernandez, E., Arcos, E., Fernandez, S., Narvaez, C., Paez, J., Sotomayor, A., Garcia, H., Sanchez, G., David, T., Rico, A., Mony, P., Vaz, M., Bharathi, A. V., Swaminathan, S., Kurpad, K. S. A., Jayachitra, K., Kumar, N., Hospital, H., Mohan, V, Deepa, M., Parthiban, K., Anitha, M., Hemavathy, S., Rahulashankiruthiyayan, T., Anitha, D., Sridevi, K., Gupta, R., Panwar, R., Mohan, I., Rastogi, P., Rastogi, S., Bhargava, R., Kumar, R., Thakur, J. S., Patro, B., Lakshmi, P., Mahajan, R., Chaudary, P., Kutty, V. R., Vijayakumar, K., Ajayan, K., Rajasree, G., Renjini, A., Deepu, A., Sandhya, B., Asha, S., Soumya, H., Kelishadi, R., Bahonar, A., Mohammadifard, N., Heidari, H., Yusoff, K., Ismail, T., Ng, K., Devi, A., Nasir, N., Yasin, M., Miskan, M., Rahman, E., Arsad, M., Ariffin, F., Razak, S., Majid, F., Bakar, N., Yacob, M., Zainon, N., Salleh, R., Ramli, M., Halim, N., Norlizan, Sr., Ghazali, N., Arshad, M., Razali, R., Ali, S., Othman, H., Hafar, C., Pit, A., Danuri, N., Basir, F., Zahari, S., Abdullah, H., Arippin, M., Zakaria, N., Noorhassim, I., Hasni, M., Azmi, M., Zaleha, M., Hazdi, K., Rizam, A., Sazman, W., Azman, A., Khatib, R., Khammash, U., Khatib, A., Giacaman, R., Iqbal, R., Afridi, A., Khawaja, R., Raza, A., Kazmi, K., Dans, A., Co, H., Sanchez, J., Pudol, L., Zamora-Pudol, C., Palileo-Villanueva, L., Aquino, M., Abaquin, C., Pudol, S., Cabral, M., Zatonski, W., Szuba, A., Zatonska, K., Ilow, R., Ferus, M., Regulska-Ilow, B., Rózanska, D., Wolyniec, M., AlHabib, K., Hersi, A., Kashour, T., Alfaleh, H., Alshamiri, M., Altaradi, H., Alnobani, O., Bafart, A., Alkamel, N., Ali, M., Abdulrahman, M., Nouri, R., Kruger, A., Voster, H. H., Schutte, A. E., Wentzel-Viljoen, E., Eloff, F., de Ridder, H., Moss, H., Potgieter, J., Roux, A., Watson, M., de Wet, G., Olckers, A., Jerling, J., Pieters, M., Hoekstra, T., Puoane, T., Igumbor, E., Tsolekile, L., Sanders, D., Naidoo, P., Steyn, N., Peer, N., Mayosi, B., Rayner, B., Lambert, V, Levitt, N., Kolbe-Alexander, T., Ntyintyane, L., Hughes, G., Swart, R., Fourie, J., Muzigaba, M., Xapa, S., Gobile, N., Ndayi, K., Jwili, B., Ndibaza, K., Egbujie, B., Rosengren, A., Bengtsson Boström, K., Gustavsson, A., Andreasson, M., Snällman, M., Wirdemann, L., Yeates, K., Sleeth, J., Kilonzo, K., Oguz, A., Imeryuz, N., Altuntas, Y., Gulec, S., Temizhan, A., Karsidag, K., Calik, K., Akalin, A., Caklili, O., Keskinler, M., Erbakan, A., Yusufali, A., Almahmeed, W., Swidan, H., Darwish, E., Hashemi, A., Al-Khaja, N., Muscat-Baron, J., Ahmed, S., Mamdouh, T., Darwish, W., Abdelmotagali, M., Awed, S. O., Movahedi, G., Hussain, F., Al Shaibani, H., Gharabou, R., Youssef, D., Nawati, A., Salah, Z. A., Abdalla, R., Al Shuwaihi, S., Al Omairi, M., Cadigal, O., Alejandrino, R. S., Chifamba, J., Gwaunza, L., Terera, G., Mahachi, C., Murambiwa, P., Machiweni, T., & Mapanga, R.
Affiliations
  • Population Health Research Institute (CA)
  • University of Ottawa (CA)
  • Simon Fraser University (CA)
  • Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
  • Post Graduate Institute of Medical Education and Research (IN)
  • Eternal Hospital (IN)
  • Madras Diabetes Research Foundation (IN)
  • St. John's National Academy of Health Sciences (IN)
  • Sree Chitra Thirunal Institute for Medical Sciences and Technology (IN)
  • Aga Khan University (PK)
  • Independent University, Bangladesh (BD)
  • Isfahan University of Medical Sciences (IR)
  • Universiti Teknologi MARA System (MY)
  • Istanbul Medeniyet University (TR)
  • Sahlgrenska University Hospital (SE)
  • Dubai Health Authority (AE)
  • North-West University (ZA)
  • University of the Western Cape (ZA)
  • University of Zimbabwe (ZW)
  • Instituto Dante Pazzanese de Cardiologia (BR)
  • Universidad de La Frontera (CL)
  • Foscal Hospital (CO)
  • University of Wrocław (PL)
Corresponding author
  • Mente, Andrew
  • Mente, A
ORCID
Venue
The Lancet Diabetes & Endocrinology
Publisher
Elsevier BV
Published
2017-10
Volume
5
Issue
10
Pages
774-787
ISSN
2213-8587 (ISSN-L)
DOI
10.1016/s2213-8587(17)30283-8
OpenAlex
W2752623014
Cited by
268
References
33
Citations by year
2026: 11 · 2025: 19 · 2024: 20 · 2023: 33 · 2022: 30 · 2021: 36 · 2020: 35 · 2019: 43 · 2018: 33 · 2017: 8
FWCI
30.44
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Diabetes & Endocrinology (publishedVersion)
  • PubMed (publishedVersion)
  • eCommons - AKU (Aga Khan University) (submittedVersion, cc-by-nc-nd)
  • Omeka S (Universidad de La Frontera) (submittedVersion, cc-by-nc-nd)
Funders
  • Heart and Stroke Foundation of Canada
  • Ontario Ministry of Health and Long-Term Care
  • Svenska Forskningsrådet Formas
  • Vetenskapsrådet
  • Canadian Institutes of Health Research
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
  • Health Sciences › Nursing › Nutrition and Dietetics › Fatty Acid Research and Health
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
Keywords
dietary nutrients, serum lipids, blood pressure, cardiovascular risk factors, saturated fatty acids, unsaturated fatty acids, dietary cholesterol, dietary carbohydrates, dietary protein, total fat intake, LDL cholesterol, HDL cholesterol, apolipoprotein A-I, apolipoprotein B, triglycerides, nutrient density, PURE study, cross-national comparison, low- and middle-income countries
MeSH terms
Blood Pressure, Cardiovascular Diseases, Cross-Sectional Studies, Diet, Dietary Carbohydrates, Dietary Fats, Female, Humans, Lipids, Male, Risk Factors, Biomarkers

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review