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Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies
Open accessAbstract
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.
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In the citing paper
“However, observational studies indicate that there might be no benefits if saturated fat reduction is associated with an increase in carbohydrates,91 which is also supported by the absence of benefits from a low fat diet in the Women’s Health Initiative.192”
In the citing paper
“However, SFA consumption, traditionally considered highly atherogenic, had relatively similar associations with CHD risk as total carbohydrate, the most common (calorically predominant) background macronutrient.142”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [142]
In the citing paper
“PUFA consumption improves levels of blood lipids and lipoproteins, is associated with lower CVD event rates in prospective cohort studies, and reduces clinical events as a replacement for SFA in RCTs.139,142,143”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [142]
In the citing paper
“PUFA consumption improves levels of blood lipids and lipoproteins, is associated with lower CVD event rates in prospective cohort studies, and reduces clinical events as a replacement for SFA in RCTs.139,142,143”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [142]
In the citing paper
“PUFA consumption improves levels of blood lipids and lipoproteins, is associated with lower CVD event rates in prospective cohort studies, and reduces clinical events as a replacement for SFA in RCTs.139,142,143”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [142]
In the citing paper
“In pooled individual-level data from 11 observational cohorts, consumption of PUFA was associated with lower CHD risk than SFA, as would be expected.142”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [142]
In the citing paper
“However, because consumption of monounsaturated fatty acids has been shown to increase atherosclerosis in nonhuman primates150 and has mixed relations with clinical CVD events in long-term cohort studies, some caution is needed.61,142”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [142]
In the citing paper
“While total carbohydrate consumption has little relation to cardiometabolic health, the quality of carbohydrate-rich foods is linked to risk (Figure 6, Figure 7).152-160”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [155]
In the citing paper
“the quality of carbohydrate-rich foods is linked to risk (Figure 6, Figure 7).152-160”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [155]
In the citing paper
“Indeed, when compared with refined carbohydrates, saturated fat appears slightly beneficial.155, 351”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [155]
In the citing paper
“Yet, total monounsaturated fat intake is not associated with lower incidence of diabetes;355 associates with trends toward greater CVD in some cohort studies;155 and increases atherosclerosis in primate experiments, potentially due to enrichment of LDL cholesteryl oleate and increased LDL proteoglycan binding.356”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [155]
In the citing paper
“However, recent prospective cohort meta-analyses suggest an even greater increase in CHD risk when highly refined and readily absorbed carbohydrates replaced SFAs.4,5”
From Associations of Glycemic Index and Load With Coronary Heart Disease Events: A Systematic Review and Meta‐Analysis of Prospective Cohorts (2012) · cites this paper as [4]
In the citing paper
“As a result, SFAs per se no longer appeared to be associated with CHD, emphasizing the potentially deleterious effects of refined, rapidly absorbed carbohydrates.4,5”
From Associations of Glycemic Index and Load With Coronary Heart Disease Events: A Systematic Review and Meta‐Analysis of Prospective Cohorts (2012) · cites this paper as [4]
In the citing paper
“Replacing saturated fat with highly refined carbohydrate is not associated with lower CHD risk, whereas replacing saturated fat with polyunsaturated fat reduces CHD risk (157,158).”
From Food Consumption and its Impact on Cardiovascular Disease: Importance of Solutions Focused on the Globalized Food System (2015) · cites this paper as [158]
In the citing paper
“This benefit of polyunsaturated fat includes the primary n-6 polyunsaturated fatty acid, linoleic acid (158,159).”
From Food Consumption and its Impact on Cardiovascular Disease: Importance of Solutions Focused on the Globalized Food System (2015) · cites this paper as [158]
In the citing paper
“Replacing saturated fat with highly refined carbohydrate is not associated with lower CHD risk, whereas replacing saturated fat with polyunsaturated fat reduces CHD risk (157,158).”
From Food Consumption and its Impact on Cardiovascular Disease: Importance of Solutions Focused on the Globalized Food System (2015) · cites this paper as [158]
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“As a result, SFAs per se no longer appeared to be associated with CHD, emphasizing the potentially deleterious effects of refined, rapidly absorbed carbohydrates.(4,5) In addition, replacement of SFAs with unsaturated fatty acids and complex carbohydrates is associated with favorable changes in CHD risk factors.”
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Metadata
- Authors
- Jakobsen, M. U., O’Reilly, E. J., Heitmann, B. L., Pereira, M. A., Bälter, K., Fraser, G. E., Goldbourt, U., Hallmans, G., Knekt, P., Liu, S., Pietinen, P., Spiegelman, D., Stevens, J., Virtamo, J., Willett, W. C., & Ascherio, A.
- Affiliations
- University of Minnesota (US)
- Corresponding author
- Jakobsen, Marianne U
- ORCID
- Venue
- The American Journal of Clinical Nutrition
- Publisher
- Elsevier BV
- Published
- 2009-05
- Volume
- 89
- Issue
- 5
- Pages
- 1425-1432
- ISSN
- 0002-9165 (ISSN-L)
- PMC
- PMC2676998
- OpenAlex
- W2156924995
- Cited by
- 1,026
- References
- 34
- Citations by year
- 2026: 19 · 2025: 20 · 2024: 28 · 2023: 42 · 2022: 45 · 2021: 60 · 2020: 46 · 2019: 62 · 2018: 78 · 2017: 75 · 2016: 81 · 2015: 94 · 2014: 89 · 2013: 82 · 2012: 75
- FWCI
- 64.38
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- American Journal of Clinical Nutrition (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (publishedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- Funders
- National Heart, Lung, and Blood Institute (R01HL058904)
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK040561)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Fatty Acid Research and Health
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Health Sciences › Nursing › Nutrition and Dietetics › Nuts composition and effects
- Keywords
- coronary artery disease, saturated fatty acids, polyunsaturated fatty acids, monounsaturated fatty acids, dietary fat, carbohydrate intake, LDL cholesterol, macronutrient substitution, coronary events, coronary heart disease mortality
- MeSH terms
- Adult, Aged, Coronary Disease, Dietary Carbohydrates, Dietary Fats, Europe, Fatty Acids, Fatty Acids, Monounsaturated, Humans, Cholesterol, LDL, Middle Aged, Surveys and Questionnaires, United States, Cohort Studies, Proportional Hazards Models
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