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There is evidence that plant-based diets might be associated with a lower risk of IHD; however, previous studies have not reported on intake of subtypes of fruit and vegetables and sources of dietary fibre. This study aims to assess the associations of major plant foods, their subtypes and dietary fibre with risk of ischaemic heart disease (IHD) in the European Prospective Investigation into Cancer and Nutrition (EPIC)-CVD Consortium.
Material and methods
We conducted a prospective analysis of 490,311 men and women in ten European countries without a history of myocardial infarction or stroke at recruitment. Dietary intake was assessed using validated questionnaires and calibrated with 24-hour recall data. Cox regression models, adjusted for IHD risk factors, were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).
During a mean of 12.6 years follow-up, we documented 8504 myocardial infarction cases or deaths from IHD. Participants consuming at least eight portions (80 grams each) of fruits and vegetables a day had a 10% lower risk of IHD (HR 0.90, 95% CI: 0.82–0.98) compared with those consuming fewer than three portions a day. The risk of IHD was 6% (95% CI 0.90–0.99; P-trend = 0.009) lower for a 200 g/day higher intake of fruit and vegetables combined, 3% (0.95–1.00; P-trend = 0.021) lower for a 100 g/ day higher fruit intake, and 8% (0.86–0.97; P-trend = 0.006) lower for a 50 g/ day higher intake of bananas. Moreover, risk of IHD was 9% (0.83–0.99; P-trend = 0.032) lower for a 10g/ day higher intake of nuts and seeds, and 10% (0.82–0.98; P-trend = 0.020) lower for a 10g/ day higher intake of total dietary fibre. No associations were observed between legumes, total vegetables and other subtypes of fruit and vegetables and IHD risk.
The results from this large prospective study suggest that higher intakes of fruit and vegetables combined, total fruit, bananas, nuts and seeds, and total fibre are associated with a lower risk of IHD. Given the observational design of this study, causality and potential mechanisms should be further investigated.
Phenolic acids are secondary plant metabolites that may have protective effects against oxidative stress, inflammation and cancer in experimental studies. To date, limited data exist on the quantitative intake of phenolic acids. We estimated the intake of phenolic acids and their food sources and associated lifestyle factors in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Phenolic acid intakes were estimated for 36 037 subjects aged 35–74 years and recruited between 1992 and 2000 in ten European countries using a standardised 24 h recall software (EPIC-Soft), and their food sources were identified. Dietary data were linked to the Phenol-Explorer database, which contains data on forty-five aglycones of phenolic acids in 452 foods. The total phenolic acid intake was highest in Aarhus, Denmark (1265·5 and 980·7 mg/d in men and women, respectively), while the intake was lowest in Greece (213·2 and 158·6 mg/d in men and women, respectively). The hydroxycinnamic acid subclass was the main contributor to the total phenolic acid intake, accounting for 84·6–95·3 % of intake depending on the region. Hydroxybenzoic acids accounted for 4·6–14·4 %, hydroxyphenylacetic acids 0·1–0·8 % and hydroxyphenylpropanoic acids ≤ 0·1 % for all regions. An increasing south–north gradient of consumption was also found. Coffee was the main food source of phenolic acids and accounted for 55·3–80·7 % of the total phenolic acid intake, followed by fruits, vegetables and nuts. A high heterogeneity in phenolic acid intake was observed across the European countries in the EPIC cohort, which will allow further exploration of the associations with the risk of diseases.
Whether there are differences between countries in the validity of self-reported diet in relation to BMI, as evaluated using recovery biomarkers, is not well understood. We aimed to evaluate BMI-related reporting errors on 24 h dietary recalls (24-HDR) and on dietary questionnaires (DQ) using biomarkers for protein and K intake and whether the BMI effect differs between six European countries. Between 1995 and 1999, 1086 men and women participating in the European Prospective Investigation into Cancer and Nutrition completed a single 24-HDR, a DQ and one 24 h urine collection. In regression analysis, controlling for age, sex, education and country, each unit (1 kg/m2) increase in BMI predicted an approximately 1·7 and 1·3 % increase in protein under-reporting on 24-HDR and DQ, respectively (both P < 0·0001). Exclusion of individuals who probably misreported energy intake attenuated BMI-related bias on both instruments. The BMI effect on protein under-reporting did not differ for men and women and neither between countries on both instruments as tested by interaction (all P>0·15). In women, but not in men, the DQ yielded higher mean intakes of protein that were closer to the biomarker-based measurements across BMI groups when compared with 24-HDR. Results for K were similar to those of protein, although BMI-related under-reporting of K was of a smaller magnitude, suggesting differential misreporting of foods. Under-reporting of protein and K appears to be predicted by BMI, but this effect may be driven by ‘low-energy reporters’. The BMI effect on under-reporting seems to be the same across countries.
Flavonols, flavanones and flavones (FLAV) are sub-classes of flavonoids that exert cardioprotective and anti-carcinogenic properties in vitro and in vivo. We aimed to estimate the FLAV dietary intake, their food sources and associated lifestyle factors in ten European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. FLAV intake and their food sources for 36 037 subjects, aged between 35 and 74 years, in twenty-seven study centres were obtained using standardised 24 h dietary recall software (EPIC-SOFT). An ad hoc food composition database on FLAV was compiled using data from US Department of Agriculture and Phenol-Explorer databases and was expanded using recipes, estimations and flavonoid retention factors in order to increase its correspondence with the 24 h dietary recall. Our results showed that the highest FLAV-consuming centre was the UK health-conscious group, with 130·9 and 97·0 mg/d for men and women, respectively. The lowest FLAV intakes were 36·8 mg/d in men from Umeå and 37·2 mg/d in women from Malmö (Sweden). The flavanone sub-class was the main contributor to the total FLAV intake ranging from 46·6 to 52·9 % depending on the region. Flavonols ranged from 38·5 to 47·3 % and flavones from 5·8 to 8·6 %. FLAV intake was higher in women, non-smokers, increased with level of education and physical activity. The major food sources were citrus fruits and citrus-based juices (especially for flavanones), tea, wine, other fruits and some vegetables. We concluded that the present study shows heterogeneity in intake of these three sub-classes of flavonoids across European regions and highlights differences by sex and other sociodemographic and lifestyle factors.
To describe the development of the Oxford WebQ, a web-based 24 h dietary assessment tool developed for repeated administration in large prospective studies; and to report the preliminary assessment of its performance for estimating nutrient intakes.
We developed the Oxford WebQ by repeated testing until it was sufficiently comprehensive and easy to use. For the latest version, we compared nutrient intakes from volunteers who completed both the Oxford WebQ and an interviewer-administered 24 h dietary recall on the same day.
A total of 116 men and women.
The WebQ took a median of 12·5 (interquartile range: 10·8–16·3) min to self-complete and nutrient intakes were estimated automatically. By contrast, the interviewer-administered 24 h dietary recall took 30 min to complete and 30 min to code. Compared with the 24 h dietary recall, the mean Spearman's correlation for the 21 nutrients obtained from the WebQ was 0·6, with the majority between 0·5 and 0·9. The mean differences in intake were less than ±10 % for all nutrients except for carotene and vitamins B12 and D. On rare occasions a food item was reported in only one assessment method, but this was not more frequent or systematically different between the methods.
Compared with an interviewer-based 24 h dietary recall, the WebQ captures similar food items and estimates similar nutrient intakes for a single day's dietary intake. The WebQ is self-administered and nutrients are estimated automatically, providing a low-cost method for measuring dietary intake in large-scale studies.
Vegetarians and vegans exclude certain food sources of vitamin D from their diet, but it is not clear to what extent this affects plasma concentrations of 25-hydroxyvitamin D (25(OH)D). The objective was to investigate differences in vitamin D intake and plasma concentrations of 25(OH)D among meat eaters, fish eaters, vegetarians and vegans.
A cross-sectional analysis.
Plasma 25(OH)D concentrations were measured in 2107 white men and women (1388 meat eaters, 210 fish eaters, 420 vegetarians and eighty-nine vegans) aged 20–76 years from the European Prospective Investigation into Cancer and Nutrition (EPIC)–Oxford cohort.
Plasma 25(OH)D concentrations reflected the degree of animal product exclusion and, hence, dietary intake of vitamin D; meat eaters had the highest mean intake of vitamin D (3·1 (95 % CI 3·0, 3·2) μg/d) and mean plasma 25(OH)D concentrations (77·0 (95 % CI 75·4, 78·8) nmol/l) and vegans the lowest (0·7 (95 % CI 0·6, 0·8) μg/d and 55·8 (95 % CI 51·0, 61·0) nmol/l, respectively). The magnitude of difference in 25(OH)D concentrations between meat eaters and vegans was smaller (20 %) among those participants who had a blood sample collected during the summer months (July–September) compared with the winter months (38 %; January–March). The prevalence of low plasma concentrations of 25(OH)D (<25 nmol/l) during the winter and spring ranged from <1 % to 8 % across the diet groups.
Plasma 25(OH)D concentrations were lower in vegetarians and vegans than in meat and fish eaters; diet is an important determinant of plasma 25(OH)D in this British population.
A higher proportion of n-3 long-chain PUFA in tissue lipids has been associated with a lower risk of CVD and some cancers. Diet is an important predictor of n-3 long-chain PUFA composition; however, the importance of non-dietary factors such as sex and age is unclear. We measured the proportion of n-3 long-chain PUFA in serum phospholipid, cholesterol ester and TAG of 2793 New Zealanders 15 years or older who participated in the 1997 National Nutrition Survey to determine differences by sex and age. Women had lower proportions of EPA and docosapentaenoic acid in phospholipid, by 0·07 (P = 0·004) and 0·10 (P < 0·001) mol%, respectively, and a higher proportion of DHA by 0·16 mol% (P = 0·001) compared with men. Intake of fish fat did not differ between men and women. There was a positive association between age and the proportion of EPA and DHA in phospholipid (P < 0·001). The sex differences in EPA and DHA were similar at all ages. Similar sex and age differences in serum cholesterol ester n-3 long-chain PUFA were found; only age differences were found in serum TAG. Sex and age differences in n-3 long-chain PUFA occur in the general population. Men and women may need to be considered separately when examining the association between disease risk and biomarkers of n-3 fatty acids.
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