부산대학교 도서관

To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1016/S0140-6736(17)32252-3 Byline: Dr Mahshid Dehghan, PhD [mahshid.dehghan@phri.ca] (a,*), Andrew Mente, PhD (a,b), Xiaohe Zhang, MSc (a), Sumathi Swaminathan, PhD (c), Prof Wei Li, PhD (d), Prof Viswanathan Mohan, MD (e), Romaina Iqbal, PhD (f), Prof Rajesh Kumar, MD (g), Edelweiss Wentzel-Viljoen, PhD (h), Prof Annika Rosengren, MD (i), Leela Itty Amma, MD (j), Prof Alvaro Avezum, MD (k), Jephat Chifamba, DPhil (l), Rafael Diaz, MD (m), Rasha Khatib, PhD (n), Prof Scott Lear, PhD (o), Prof Patricio Lopez-Jaramillo, MD (p), Xiaoyun Liu, PhD (d), Prof Rajeev Gupta, MD (q), Noushin Mohammadifard, PhD (r), Nan Gao, BSc (d), Aytekin Oguz, MD (s), Anis Safura Ramli, MD (t), Pamela Seron, PhD (u), Yi Sun, MSc (d), Prof Andrzej Szuba, MD (v), Lungiswa Tsolekile, MPH (w), Prof Andreas Wielgosz, MD (x), Rita Yusuf, PhD (y), Afzal Hussein Yusufali, MD (z), Prof Koon K Teo, MD (a), Sumathy Rangarajan, MSc (a), Gilles Dagenais, MD (aa), Shrikant I Bangdiwala, PhD (a), Shofiqul Islam, MSc (a), Prof Sonia S Anand (ab), Prof Salim Yusuf, DPhil (a), R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, S Yusuf, J Dejesus, D Agapay, T Tongana, R Solano, I Kay, S Trottier, J Rimac, W Elsheikh, L Heldman, E Ramezani, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, Jia Xuan, Hu Bo, Sun Yi, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Chang Xiaohong, Deng Qing, Cheng Xiaoru, Deng Qing, He Xinye, Hu Bo, Jia Xuan, Li Jian, Li Juan, Liu Xu, Ren Bing, Sun Yi, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhang Hongye, Zhao Xiuwen, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, Bian Rongwen, Tian Xiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gomez-Arbelaez, JF Arguello, R Duenas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, W Zatonski, A Szuba, K Zatonska, R Ilow, M Ferus, B Regulska-Ilow, D Rozanska, M Wolyniec, Alkamel, M Ali, M A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Bostrom, A Gustavsson, M Andreasson, M Snallman, L Wirdemann, A Oguz, N Imeryuz, Y Altuntas, S Gulec, A Temizhan, K Karsidag, KBT Calik, AAK Akalin, OT Caklili, MV Keskinler, AN Erbakan, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, F Hussain, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, R Mapanga Summary Background The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear. Methods The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35--70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7*4 years (IQR 5*3--9*3). Dietary intake of 135,335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. Findings During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1*28 [95% CI 1*12--1*46], p.sub.trend=0*0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0*77 [95% CI 0*67--0*87], p.sub.trend Interpretation High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings. Funding Full funding sources listed at the end of the paper (see Acknowledgments). Author Affiliation: (a) Population Health Research Institute, McMaster University, Hamilton, ON, Canada (b) Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada (c) St John's Research Institute, St John's National Academy of Health Sciences, Sarjapur Road, Koramangala, Bangalore, Karnataka, India (d) State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China (e) Madras Diabetes Research Foundation, Chennai, India (f) Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan (g) PGIMER School of Public Health, Chandigarh, India (h) Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa (i) Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (j) Health Action by People TC 1/1706, Medical College PO, Trivandrum, India (k) Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil (l) University of Zimbabwe, College of Health Sciences, Department of Physiology, Harare, Zimbabwe (m) Estudios Clinicos Latinoamerica, ECLA, Rosario, Argentina (n) Institute of Community and Public Health, Birzeit University, Birzeit, occupied Palestinian territory (o) Faculty of Health Sciences, Department of Biomedical Physiology & Kinesiology, Simon Fraser University, Burnaby, BC, Canada (p) Fundacion Oftalmologica de Santander-FOSCAL, Floridablanca-Santander, Colombia (q) Eternal Heart Care Centre and Research Institute, Jaipur, India (r) Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (s) Istanbul Medeniyet University, Faculty of Medicine, Department of Internal Medicine, Goztepe, Istanbul, Turkey (t) Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia (u) Universidad de La Frontera, Temuco, Araucania, Chile (v) Division of Angiology, Wroclaw Medical University, Wroclaw, Poland (w) University of the Western Cape, Bellville, Western Province, Cape Town, South Africa (x) University of Ottawa Department of Medicine, Ottawa, ON, Canada (y) Independent University, Bangladesh, Dhaka, Bangladesh (z) Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates (aa) Universite Laval, Institut Universitaire de Cardiologie, Ville de Quebec, QC, Canada (ab) Department of Medicine, McMaster University, Hamilton, ON, Canada * Correspondence to: Dr Mahshid Dehghan, Population Health Research Institute, DBCVS Research Institute, McMaster University, Room C1-102, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada (footnote)[Dagger] Investigators listed in the