Dietary Recommendations for Ethiopians on the Basis of Priority Diet-Related Diseases and Causes of Death in Ethiopia: An Umbrella Review

Food-based dietary guidelines (FBDG) need to be evidence-based. As part of the development of Ethiopian FBDG, we conducted an umbrella review to develop dietary recommendations. Protein-energy malnutrition (PEM), deficiencies of vitamin A, zinc, calcium, or folate, cardiovascular diseases (CVD), and type 2 diabetes mellitus (T2DM) were selected as a priority. Systematic reviews were eligible if they investigated the impact of foods, food groups, diet, or dietary patterns on priority diseases. After a search, 1513 articles were identified in PubMed, Scopus, and Google Scholar published from January 2014 to December 2021. The results showed that 19 out of 164 systematic reviews reported the impact of diet on PEM or micronutrient deficiencies. Daily 30-90 g whole-grain consumption reduces risk of CVD and T2DM. Pulses improve protein status, and consuming 50-150 g/d is associated with a reduced incidence of CVD and T2DM. Nuts are a good source of minerals, and consuming 15-35 g/d improves antioxidant status and is inversely associated with CVD risk. A daily intake of 200-300 mL of milk and dairy foods is a good source of calcium and contributes to bone mineral density. Limiting processed meat intake to <50 g/d reduces CVD risk. Fruits and vegetables are good sources of vitamins A and C. CVD and T2DM risks are reduced by consuming 200-300 g of vegetables plus fruits daily. Daily sugar consumption should be below 10% of total energy to lower risk of obesity, CVD, and T2DM. Plant-based fat has favorable nutrient profiles and modest saturated fat content. The association of saturated fatty acids with CVD and T2DM is inconclusive, but intake should be limited because of the low-density lipoprotein cholesterol-raising effect. Plant-based diets lower risk of CVD and T2DM but reduce micronutrient bioavailability. The review concludes with 9 key dietary recommendations proposed to be implemented in the Ethiopian FBDG. This review was registered at PROSPERO (CRD42019125490).

The Role of Diet in Prognosis among Cancer Survivors: A Systematic Review and Meta-Analysis of Dietary Patterns and Diet Interventions

Cancer survival continues to improve in high-income countries, partly explained by advances in screening and treatment. Previous studies have mainly examined the relationship between individual dietary components and cancer prognosis in tumours with good therapeutic response (breast, colon and prostate cancers). The aim of this review is to assess qualitatively (and quantitatively where appropriate) the associations of dietary patterns and cancer prognosis from published prospective cohort studies, as well as the effect of diet interventions by means of randomised controlled trials (RCT). A systematic search was conducted in PubMed, and a total of 35 prospective cohort studies and 14 RCT published between 2011 and 2021 were selected. Better overall diet quality was associated with improved survival among breast and colorectal cancer survivors; adherence to the Mediterranean diet was associated to lower risk of mortality in colorectal and prostate cancer survivors. A meta-analysis using a random-effects model showed that higher versus lower diet quality was associated with a 23% reduction in overall mortality in breast cancer survivors. There was evidence that dietary interventions, generally combined with physical activity, improved overall quality of life, though most studies were in breast cancer survivors. Further cohort and intervention studies in other cancers are needed to make more specific recommendations.

Multiple vitamin co-exposure and mortality risk: A prospective study

BACKGROUND & AIMS

Existing epidemiological studies explored the associations of circulating vitamins and mortality focusing on individual vitamin effects, and controversial findings were obtained. The joint effects of multiple vitamin co-exposure are worth studying. The study aimed to elucidate the associations of circulating vitamins and the joint effects of these vitamins' co-exposure with all-cause and cause-specific mortality risks.

METHODS

We prospectively evaluated the associations of the concentrations of six kinds of vitamins (A, D, E, C, B12 and B9) in serum with risks for all-cause and cause-specific mortalities among U.S. adults. Mortality status and cause of death were determined by NHANES-linked public available files dated up to 31 December 2015. An unsupervised K-means clustering method was used to cluster the participants into several vitamin co-exposure patterns. The Cox proportional hazards model was used for statistical analysis.

RESULTS

A total of 1404 deaths occurred during a median of 10.9 years follow-up among 8295 participants. In multivariable adjustment, increasing levels of vitamin D were associated with reduced all-cause and cause-specific mortality risks. A J-shaped nonlinear exposure-response relationship was observed between all studied vitamins (except for vitamin D) and all-cause mortality risk. Four co-exposure patterns were generated based on the studied vitamins, as follows: low-level exposure (cluster 1), vitamin A/D exposure (cluster 2), water-soluble vitamin exposure (cluster 3) and high-level exposure (cluster 4). Compared with those in cluster 1, participants in cluster 2 had lower all-cause and cancer mortality risks, with hazard ratios (95% confidence intervals [CIs]) of 0.67 (0.53, 0.85) and 0.45 (0.29, 0.71), respectively.

CONCLUSIONS

The findings in this study indicated that high circulating vitamin D levels were associated with reduced mortality risk among U.S. adults. Vitamin co-exposure at moderate levels appropriately contributed to low all-cause and cancer mortality risks. Our findings provided a novel perspective for exploring the joint health effects of multivitamin co-exposure. Future investigations are needed to further unravel the underlying mechanisms of possible vitamin interactions.

Dietary Intake of Advanced Glycation End Products (AGEs) and Mortality among Individuals with Colorectal Cancer

Advanced glycation end-products (AGEs) may promote oxidative stress and inflammation and have been linked to multiple chronic diseases, including cancer. However, the association of AGEs with mortality after colorectal cancer (CRC) diagnosis has not been previously investigated. Multivariable Cox proportional hazards models were used to calculate hazard ratios and corresponding 95% confidence intervals for associations between dietary intake of AGEs with CRC-specific and all-cause mortality among 5801 participant cases diagnosed with CRC in the European Prospective Investigation into Cancer and Nutrition study between 1993 and 2013. Dietary intakes of AGEs were estimated using country-specific dietary questionnaires, linked to an AGE database, that accounted for food preparation and processing. During a median of 58 months of follow-up, 2421 cases died (1841 from CRC). Individually or combined, dietary intakes of AGEs were not associated with all-cause and CRC-specific mortality among cases. However, there was a suggestion for a positive association between AGEs and all-cause or CRC-specific mortality among CRC cases without type II diabetes (all-cause, Pinteraction = 0.05) and CRC cases with the longest follow-up between recruitment and cancer diagnosis (CRC-specific, Pinteraction = 0.003; all-cause, Pinteraction = 0.01). Our study suggests that pre-diagnostic dietary intakes of AGEs were not associated with CRC-specific or all-cause mortality among CRC patients. Further investigations using biomarkers of AGEs and stratifying by sex, diabetes status, and timing of exposure to AGEs are warranted.

Unrestrained eating behavior and risk of mortality: A prospective cohort study

BACKGROUND & AIMS

Unrestrained eating behavior has been thought to be a proxy for diet frequency, timing, and caloric intake. We investigated the association of unrestrained eating with mortality risk in the Nurses' Health Study prospectively.

METHODS

During follow-up (1994-2016), 21,953 deaths were documented among 63,999 eligible participants in analyses of eating anything at any time, 22,120 deaths were documented among 65,839 participants in analyses of no concern with figure change. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models.

RESULTS

Eating anything at any time was associated with an increased mortality from cancer (overall HR, 95%CI: 1.07, 1.00-1.13; driven by gastrointestinal tract cancer: 1.30, 1.10-1.54) and respiratory disease (1.16, 1.05-1.29), and decreased cardiovascular disease-specific mortality (0.92, 0.86-0.99), compared to those without this behavior; however, no association was observed between this behavior and all-cause mortality (1.02, 0.99-1.05). Women who reported having no concern with figure change experienced higher risk of mortality from all-cause (1.08, 1.05-1.11), cancer (1.08, 1.02-1.14), and respiratory disease (1.18, 1.08-1.30), compared to those not reporting this behavior. Their combined effect was associated with a higher all-cause (1.09, 1.04-1.14), cancer-specific (overall: 1.18, 1.09-1.28; gastrointestinal tract cancer: 1.36, 1.08-1.71; lung cancer: 1.09; 1.04-1.14), and respiratory disease-specific (1.30, 1.13-1.50) mortality, and was inversely associated with cardiovascular disease-specific mortality (0.88, 0.80-0.98), compared to those exhibiting the opposite.

CONCLUSIONS

Unrestrained eating was associated with increased risk of all-cause, cancer-specific (particularly for gastrointestinal tract cancer and lung cancer), and respiratory disease-specific mortality, and decreased risk of cardiovascular disease-specific mortality.

Association of Walnut Consumption with Total and Cause-Specific Mortality and Life Expectancy in U.S. Adults

Walnut consumption is associated with health benefits. We aimed to (1) examine the association between walnut consumption and mortality and (2) estimate life expectancy in relation to walnut consumption in U.S. adults. We included 67,014 women of the Nurses' Health Study (1998-2018) and 26,326 men of the Health Professionals Follow-up Study (1998-2018) who were free of cancer, heart disease, and stroke at baseline. We used Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). During up to 20 years of follow-up, we documented 30,263 deaths. The hazard ratios for total mortality across categories of walnut intake (servings/week), as compared to non-consumers, were 0.95 (95% confidence interval (CI), 0.91, 0.98) for <1 serving/week, 0.94 (95% CI, 0.89, 0.99) for 1 serving/week, 0.87 (95% CI, 0.82, 0.93) for 2-4 servings/week, and 0.86 (95% CI, 0.79, 0.93) for >=5 servings/week (p for trend <0.0001). A greater life expectancy at age 60 (1.30 years in women and 1.26 years in men) was observed among those who consumed walnuts more than 5 servings/week compared to non-consumers. Higher walnut consumption was associated with a lower risk of total and CVD mortality and a greater gained life expectancy among U.S. elder adults.

Evaluation of Dietary Patterns and All-Cause Mortality: A Systematic Review

Importance

The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)?

Objective

To ascertain the association between dietary patterns consumed and ACM.

Evidence Review

Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements.

Findings

A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings.

Conclusions and Relevance

In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

Coffee Consumption and the Risk of All-Cause and Cause-Specific Mortality in the Korean Population

BACKGROUND

There is a dearth of information regarding the association between coffee consumption and its health effects with respect to mortality among Korean people.

OBJECTIVE

The aim of this study was to examine the association between coffee consumption and all-cause mortality and cause-specific mortality risks in the Korean population.

DESIGN

This prospective cohort study had a median follow-up period of 9.1 years.

PARTICIPANTS/SETTING

In total, 173,209 participants aged 40 years and older from the Health Examinees study were enrolled between 2004 and 2013. The analytic sample included 110,920 participants without diabetes, cardiovascular disease (CVD), or cancer at baseline who could be linked with their death information.

MAIN OUTCOME MEASURES

Deaths of participants until December 31, 2018 were ascertained using the death certificate database of the National Statistical Office. Cause of death was classified according to the International Classification of Diseases, 10th Revision.

STATISTICAL ANALYSES PERFORMED

Participants were categorized according to the amount and type of coffee consumed. Cox proportional hazards regression analysis was performed to estimate the hazard ratio (HR) and 95%CI of all-cause mortality and cause-specific mortality, such as CVD and cancer mortality.

RESULTS

Compared with nonconsumers of coffee, participants who consumed > 3 cups/day had a reduced risk of all-cause mortality (HR 0.79, 95% CI 0.66 to 0.95). Participants who consumed ≤1 cup/day and 1 to 3 cups/day had a reduced risk of CVD mortality (≤1 cup/day: HR 0.58, 95% CI 0.69 to 0.94; 1 to 3 cups/day: HR 0.62, 95% CI 0.41 to 0.96).

CONCLUSIONS

This study provides evidence that greater coffee consumption is associated with a decreased risk of all-cause mortality and moderate coffee consumption (approximately 3 cups/day) is associated with a decreased risk of CVD mortality, regardless of the type of coffee, in a Korean population.

Impact of Inadequate Calorie Intake on Mortality and Hospitalization in Stable Patients with Chronic Heart Failure

Malnutrition is highly prevalent in patients with heart failure (HF), but the precise impact of dietary energy deficiency on HF patients' clinical outcomes is not known. We investigated the associations between inadequate calorie intake and adverse clinical events in 145 stable outpatients with chronic HF who had a history of hospitalization due to worsening HF. To assess the patients' dietary pattern, we used a brief self-administered diet-history questionnaire (BDHQ). Inadequate calorie intake was defined as <60% of the estimated energy requirement. In the total chronic HF cohort, the median calorie intake was 1628 kcal/day. Forty-four patients (30%) were identified as having an inadequate calorie intake. A Kaplan-Meier analysis revealed that the patients with inadequate calorie intake had significantly worse clinical outcomes including all-cause death and HF-related hospitalization during the 1-year follow-up period versus those with adequate calorie intake (20% vs. 5%, p < 0.01). A multivariate logistic regression analysis showed that inadequate calorie intake was an independent predictor of adverse clinical events after adjustment for various factors that may influence patients' calorie intake. Among patients with chronic HF, inadequate calorie intake was associated with an increased risk of all-cause mortality and rehospitalization due to worsening HF. However, our results are preliminary and larger studies with direct measurements of dietary calorie intake and total energy expenditure are needed to clarify the intrinsic nature of this relationship.

White Meat Consumption, All-Cause Mortality, and Cardiovascular Events: A Meta-Analysis of Prospective Cohort Studies

The association of meat consumption with mortality and morbidity for non-communicable diseases has been extensively studied. However, the relation of white meat consumption with health outcomes remains controversial. The present meta-analysis was conducted to comprehensively analyze the available evidence on the consistency and strength of the association between the consumption of white meat, death from any cause and incidence of fatal and non-fatal cardiovascular (CV) events. PubMed, Web of Science, Scopus and Embase databases were searched for articles published up to April 30, 2020. We included prospective cohort studies reporting relative risks and pertinent 95% confidence intervals (CI) for all-cause mortality and/or CV events (fatal or non-fatal). A total of 22 studies were included in the meta-analysis. Eleven studies (14 data sets) reported data on all-cause mortality, 10 studies (15 datasets) on cardiovascular disease (CVD) mortality and 10 studies (11 datasets) on non-fatal CV events. When comparing the highest versus the lowest consumption of white meat, the pooled OR and pertinent 95% CI were 0.94 (0.90, 0.97, p < 0.001) for all-cause mortality, 0.95 (0.89, 1.01, p = 0.13) for CV mortality, and 0.99 (0.95, 1.02, p = 0.48) for non-fatal CV events. In conclusion, the study shows for the first time a robust and inverse association between white meat consumption and all-cause mortality and a neutral association with CV mortality and morbidity. This highlights the importance of differentiating the meat types for what concerns their health effects and suggests that white meat might be a healthier alternative to read and processed meat consumption.

Diet and sedentary behaviour in relation to mortality in US adults with a cardiovascular condition: results from the National Health and Nutrition Examination Survey linked to the US mortality registry

CVD is the most common chronic condition and the highest cause of mortality in the USA. The aim of the present work was to investigate diet and sedentary behaviour in relation to mortality in US CVD survivors. The National Health and Nutrition Examination Surveys conducted between 1999 and 2014 linked to the US mortality registry updated to 2015 were investigated. Multivariate adjusted Cox regression was used to derive mortality hazards in relation to sedentary behaviour and nutrient intake. A multiplicative and additive interaction analysis was conducted to evaluate how sedentariness and diet influence mortality in US CVD survivors. A sample of 2473 participants followed for a median period of 5·6 years resulted in 761 deaths, and 199 deaths were due to CVD. A monotone increasing relationship between time spent in sedentary activities and mortality risk was observed for all-cause and CVD mortality (hazard ratio (HR) = 1·20, 95 % CI 1·09, 1·31 and HR = 1·19, 95 % CI 1·00, 1·67, respectively). Inverse mortality risks in the range of 22-34 % were observed when comparing the highest with the lowest tertile of dietary fibre, vitamin A, carotene, riboflavin and vitamin C. Sedentariness below 360 min/d and dietary fibre and vitamin intake above the median interact on an additive scale influencing positively all-cause and CVD mortality risk. Reduced sedentariness in combination with a varied diet rich in dietary fibre and vitamins appears to be a useful strategy to reduce all-cause and CVD mortality in US CVD survivors.

Diet and sedentary behaviour in relation to cancer survival. A report from the national health and nutrition examination survey linked to the U.S. mortality registry

BACKGROUND & AIMS

Cancer is the second most common chronic disease and cause of death in the United States. Our aim was to evaluate the associations of sedentary behavior and nutrient intakes with total and cancer-specific mortality among US cancer survivors.

METHODS

Data from 2371 cancer survivors collected by the US National Health and Nutrition Examination Survey between 1999 and 2014 were linked to the US mortality registry. Multivariable adjusted Cox proportional hazard models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cancer-specific mortality associated with sedentary time and nutrient intakes. The interaction between time spent on sedentary activities and nutrient intake was evaluated on additive and multiplicative scales.

RESULTS

During a median observational period of 5.7 years, 532 total deaths occurred among cancer survivors, of which 180 were cancer-specific. A monotonic increasing linear relationship between time spent sitting and all-cause mortality was observed (HR = 1.15, 95% CI = 1.03, 1.28 per one standard deviation increment). The highest versus the lowest tertiles of intakes of dietary fiber, carotene, niacin, thiamine, riboflavin, vitamin B6, vitamin B12, and vitamin C were inversely associated with all-cause and cancer-specific mortality (HRs = 0.48 to 0.75). The inverse associations with all-cause mortality were more pronounced for combinations of low sedentary behaviour and high intakes of dietary fiber, carotenoids, vitamin B12, and vitamin C.

CONCLUSION

Our findings support recommendations for cancer survivors to reduce time spent sedentary and to follow a balanced diet with adequate intakes of dietary fiber and micronutrients.

Milk Intake and Stroke Mortality in the Japan Collaborative Cohort Study-A Bayesian Survival Analysis

The aim of this study was to further examine the relationship between milk intake and stroke mortality among the Japanese population. We used data from the Japan Collaborative Cohort (JACC) Study (total number of participants = 110,585, age range: 40–79) to estimate the posterior acceleration factors (AF) as well as the hazard ratios (HR) comparing individuals with different milk intake frequencies against those who never consumed milk at the study baseline. These estimations were computed through a series of Bayesian survival models that employed a Markov Chain Monte Carlo simulation process. In total, 100,000 posterior samples were generated separately through four independent chains after model convergency was confirmed. Posterior probabilites that daily milk consumers had lower hazard or delayed mortality from strokes compared to non-consumers was 99.0% and 78.0% for men and women, respectively. Accordingly, the estimated posterior means of AF and HR for daily milk consumers were 0.88 (95% Credible Interval, CrI: 0.81, 0.96) and 0.80 (95% CrI: 0.69, 0.93) for men and 0.97 (95% CrI: 0.88, 1.10) and 0.95 (95% CrI: 0.80, 1.17) for women. In conclusion, data from the JACC study provided strong evidence that daily milk intake among Japanese men was associated with delayed and lower risk of mortality from stroke especially cerebral infarction.

Breastfeeding and child survival from 0 to 5 years in Côte d'Ivoire

BACKGROUND

One of the main objectives of health policy-makers is to promote children's growth, development, and survival. The current research evaluates the impact of breastfeeding on infant survival and highlights the major socio-economic determinants of child survival from 0 to 5 years old in Côte d'Ivoire.

METHODS

This study uses Probit estimation to evaluate the impact of the type of breastfeeding on the survival of children aged from 0 to 5 years old. The main socio-economic determinants of child survival were identified and analyzed. The sample of the study covers 7776 children under 5 years old drawn from the Côte d'Ivoire Demographic Health Surveys and the Multiple Indicators cluster survey of 2012.

RESULTS

A child is more likely to survive when immediate exclusive breastfeeding was practiced for up to 6 months. The probability of survival increases significantly when the mother lives in a healthy environment, when she has at least a primary school education, and when she plays a leading role in caring for the children. Likewise, when she better controls the market of some breast milk supplement and she chooses the best milk formula to complete feeding for her baby, the child's chances of survival increase significantly.

CONCLUSION

Health policy-makers must strengthen programs to promote exclusive breastfeeding up to 6 months through social campaigns. It should also strengthen the capacity of health workers (midwives, nurses, doctors, etc.) to better guide and provide training to mothers and young women about childbearing age to allow them to practice exclusive breastfeeding for up to 6 months. It is only after 6 months that they have to complete infant feeding by providing some semi-solid food rich in vitamins, proteins, and minerals. Taking into account the time constraint when they are engaged in economic activity, they must choose the best formula milk to supplement breastfeeding. It is also important to educate women to improve hygiene in their housing, in their neighborhood and in their community in order to promote the welfare and health of their children.

Association of soy and fermented soy product intake with total and cause specific mortality: prospective cohort study

OBJECTIVE

To investigate the association between several types of soy products and all cause and cause specific mortality.

DESIGN

Population based cohort study.

SETTING

Japan Public Health Centre-based Prospective Study, which includes 11 public health centre areas in Japan.

PARTICIPANTS

92 915 participants (42 750 men and 50 165 women) aged 45 to 74 years.

EXPOSURES

Intake of total soy products, fermented soy products (natto and miso), non-fermented soy products, and tofu from a five year survey questionnaire.

MAIN OUTCOME MEASURES

All cause and cause specific mortality (cancer, total cardiovascular disease, heart disease, cerebrovascular disease, respiratory disease, and injury) obtained from residential registries and death certificates.

RESULTS

During 14.8 years of follow-up, 13 303 deaths were identified. In the multivariable adjusted models, intake of total soy products was not significantly associated with total mortality. Compared with the lowest fifth of total soy product intake, the hazard ratios in the highest fifth were 0.98 (95% confidence interval 0.91 to 1.06, P_trend=0.43) in men and 0.98 (0.89 to 1.08, P_trend=0.46) in women. Intake of fermented soy products was inversely associated with all cause mortality in both sexes (highest versus lowest fifth: 0.90 (0.83 to 0.97), P_trend=0.05 in men, and 0.89 (0.80 to 0.98), P_trend=0.01 in women). Natto showed significant and inverse associations with total cardiovascular disease related mortality in both sexes.

CONCLUSIONS

In this study a higher intake of fermented soy was associated with a lower risk of mortality. A significant association between intake of total soy products and all cause mortality was not, however, observed. The findings should be interpreted with caution because the significant association of fermented soy products might be attenuated by unadjusted residual confounding.

Relevance of physical function in the association of red and processed meat intake with all-cause, cardiovascular, and cancer mortality

BACKGROUND AND AIMS

Intake of red and processed meat has been associated with a higher risk of morbidity and mortality; it is unknown whether these associations are modified by overall physical health. This study examined the associations of red and processed meat consumption with all-cause, cardiovascular, and cancer mortality and investigated whether markers of physical function modified the associations.

METHODS AND RESULTS

This observational cohort study used UK Biobank data derived from 419,075 participants free from cancer and cardiovascular disease. Cox models assessed the association of red and processed meat consumption (obtained from a baseline food frequency questionnaire) with mortality, adjusted for potential confounders. Objectively measured handgrip strength and self-reported walking pace were used as interaction terms. The median age was 57 (interquartile range, 49-63) years and 54.9% were women. Over 7 years of follow-up, 8586 all-cause, 1660 cardiovascular, and 4812 cancer deaths occurred. Each additional serving per week of red and processed meat was associated with a hazard ratio (HR) of 1.037 (95% CI: 1.028-1.047) for all-cause; 1.030 (1.009-1.051) for cardiovascular; and 1.029 (1.016-1.042) for cancer mortality. The association of red and processed meat consumption was modified by walking pace, with brisk walkers having the lowest risk per additional serving for all-cause and cancer mortality (HR 1.025; 1.006-1.045 and 1.015; 0.990-1.040, respectively); no interaction was observed for handgrip strength.

CONCLUSION

The known risk of mortality associated with red and processed meat consumption may be lower in those with high physical function.

Associations of dairy intake with risk of mortality in women and men: three prospective cohort studies

OBJECTIVE

To examine the association of consumption of dairy foods with risk of total and cause specific mortality in women and men.

DESIGN

Three prospective cohort studies with repeated measures of diet and lifestyle factors.

SETTING

Nurses' Health Study, Nurses' Health Study II, and the Health Professionals Follow-up Study, in the United States.

PARTICIPANTS

168 153 women and 49 602 men without cardiovascular disease or cancer at baseline.

MAIN OUTCOME MEASURE

Death confirmed by state vital records, the national death index, or reported by families and the postal system. During up to 32 years of follow-up, 51 438 deaths were documented, including 12 143 cardiovascular deaths and 15 120 cancer deaths. Multivariable analysis further adjusted for family history of cardiovascular disease and cancer, physical activity, overall dietary pattern (alternate healthy eating index 2010), total energy intake, smoking status, alcohol consumption, menopausal status (women only), and postmenopausal hormone use (women only).

RESULTS

Compared to the lowest category of total dairy consumption (average 0.8 servings/day), the multivariate pooled hazard ratio for total mortality was 0.98 (95% confidence interval 0.96 to 1.01) for the second category of dairy consumption (average 1.5 servings/day), 1.00 (0.97 to 1.03) for the third (average 2.0 servings/day), 1.02 (0.99 to 1.05) for the fourth (average 2.8 servings/day), and 1.07 (1.04 to 1.10) for highest category (average 4.2 servings/day; P for trend <0.001). For the highest compared to the lowest category of total dairy consumption, the hazard ratio was 1.02 (0.95 to 1.08) for cardiovascular mortality and 1.05 (0.99 to 1.11) for cancer mortality. For subtypes of dairy products, whole milk intake was significantly associated with higher risks of total mortality (hazard ratio per 0.5 additional serving/day 1.11, 1.09 to 1.14), cardiovascular mortality (1.09, 1.03 to 1.15), and cancer mortality (1.11, 1.06 to 1.17). In food substitution analyses, consumption of nuts, legumes, or whole grains instead of dairy foods was associated with a lower mortality, whereas consumption of red and processed meat instead of dairy foods was associated with higher mortality.

CONCLUSION

These data from large cohorts do not support an inverse association between high amount of total dairy consumption and risk of mortality. The health effects of dairy could depend on the comparison foods used to replace dairy. Slightly higher cancer mortality was non-significantly associated with dairy consumption, but warrants further investigation.

Diet Quality Affects the Association between Census-Based Neighborhood Deprivation and All-Cause Mortality in Japanese Men and Women: The Japan Public Health Center-Based Prospective Study

Background: Individuals residing in more deprived areas with a lower diet quality might have a higher mortality risk. We aimed to examine the association between deprivation within an area and all-cause mortality risk according to diet quality. Methods: We conducted a population-based prospective study on 27,994 men and 33,273 women aged 45–75 years. Neighborhood deprivation was assessed using the Japanese areal deprivation index (ADI). Dietary intakes were assessed using a validated 147-item food frequency questionnaire. Results: Individuals residing in the most deprived area had the lowest dietary scores. During the 16.7-year follow-up, compared to individuals with a high quality diet residing in the least deprived area, individuals with a low quality diet had a higher risk of mortality according to increment of ADI (p trend = 0.03); the multivariate-adjusted hazard ratio (95% confidence interval) was 1.09 (0.999–1.19), 1.17 (1.08–1.27), and 1.19 (1.08–1.32) in those residing in the lowest through the highest third of ADI, respectively. However, individuals with a high quality diet had no significant association between ADI and mortality. Conclusion: A well-balanced diet may prevent early death associated with neighborhood socioeconomic status among those residing in highly deprived areas.

Soy, Soy Isoflavones, and Protein Intake in Relation to Mortality from All Causes, Cancers, and Cardiovascular Diseases: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

OBJECTIVE

We conducted a systematic review and dose-response meta-analysis of prospective studies to summarize findings on the associations between intakes of soy, soy isoflavones, and soy protein and risk of mortality from all causes, cancers, and cardiovascular diseases.

METHODS

Online databases were systematically searched to identify relevant articles published earlier than May 2018. We applied restricted cubic splines using random-effects analysis to assess dose-response associations. Between-study heterogeneity was assessed by I2 value and Cochrane Q test. Potential publication bias was assessed by visual inspection of funnel plots and Begg regression test.

RESULTS

In total, 23 prospective studies with an overall sample size of 330,826 participants were included in the current systematic review and the meta-analysis. Soy/soy products consumption was inversely associated with deaths from cancers (pooled relative risk 0.88, 95% CI 0.79 to 0.99; P=0.03; I2=47.1%, 95% CI 0.0% to 75.4%) and cardiovascular diseases (pooled effect size: 0.85, 95% CI 0.72 to 0.99; P=0.04; I2=50.0%, 95% CI 0.0% to 77.6%). Such significant associations were also observed for all-cause mortality in some subgroups of the included studies, particularly those with higher quality. In addition, higher intake of soy was associated with decreased risk of mortality from gastric, colorectal, and lung cancers as well as ischemic cardiovascular diseases. Participants in the highest category of dietary soy isoflavones intake had a 10% lower risk of all-cause mortality compared with those in the lowest category. We also found that a 10-mg/day increase in intake of soy isoflavones was associated with 7% and 9% decreased risk of mortality from all cancers and also breast cancer respectively. Furthermore, a 12% reduction in breast cancer death was indicated for each 5-g/day increase in consumption of soy protein. However, intake of soy protein was not significantly associated with all-cause and cardiovascular diseases mortality.

CONCLUSIONS

Soy and its isoflavones may favorably influence risk of mortality. In addition, soy protein intake was associated with a decreased risk in the mortality of breast cancer. Our findings may support the current recommendations to increase intake of soy for greater longevity.

Red and Processed Meat and Mortality in a Low Meat Intake Population

Associations of low-to-moderate consumption of red and processed meat with mortality would add to the evidence of possible adverse effects of these common foods. This study aims to investigate the association of red and processed meat intake with mortality. The Adventist Health Study-2 (AHS-2) is a prospective cohort study of ~96,000 Seventh-day Adventist men and women recruited in the US and Canada between 2002 and 2007. The final analytic sample after exclusions was 72,149. Cox proportional hazards regression was used and hazard ratios (HR) and confidence intervals (CI) were obtained. Diet was assessed by a validated quantitative food frequency questionnaire (FFQ), calibrated using six 24-h dietary recalls. Mortality outcome data were obtained from the National Death Index. During a mean follow-up of 11.8 years, there were 7961 total deaths, of which 2598 were Cardiovascular diseases (CVD) deaths and 1873 were cancer deaths. Unprocessed red meat was associated with risk of all-cause mortality (HR: 1.18; 95% CI: 1.07–1.31) and CVD mortality (HR: 1.26; 95% CI: 1.05–1.50). Processed meat alone was not significantly associated with risk of mortality. The combined intake of red and processed meat was associated with all-cause mortality (HR: 1.23; 95% CI: 1.11–1.36) and CVD mortality (HR: 1.34; 95% CI: 1.12–1.60). These findings suggest moderately higher risks of all-cause and CVD mortality associated with red and processed meat in a low meat intake population.

Dietary Antioxidants, Circulating Antioxidant Concentrations, Total Antioxidant Capacity, and Risk of All-Cause Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Observational Studies

The associations of various dietary or circulating antioxidants with the risk of all-cause mortality in the general population have not been established yet. A systematic search was performed in PubMed and Scopus, from their inception up to October 2017. Prospective observational studies reporting risk estimates of all-cause mortality in relation to dietary intake and/or circulating concentrations of antioxidants were included. Random-effects meta-analyses were conducted. Forty-one prospective observational studies (total n = 507,251) involving 73,965 cases of all-cause mortality were included. The RRs of all-cause mortality for the highest compared with the lowest category of circulating antioxidant concentrations were as follows: total carotenes, 0.60 (95% CI: 0.46, 0.74); vitamin C, 0.61 (95% CI: 0.53, 0.69); selenium, 0.62 (95% CI: 0.45, 0.79); β-carotene, 0.63 (95% CI: 0.57, 0.70); α-carotene, 0.68 (95% CI: 0.58, 0.78); total carotenoids, 0.68 (95% CI: 0.56, 0.80); lycopene, 0.75 (95% CI: 0.54, 0.97); and α-tocopherol, 0.84 (95% CI: 0.77, 0.91). The RRs for dietary intakes were: total carotenoids, 0.76 (95% CI: 0.66, 0.85); total antioxidant capacity, 0.77 (95% CI: 0.73, 0.81); selenium, 0.79 (95% CI: 0.73, 0.85); α-carotene, 0.79 (95% CI: 0.63, 0.94); β-carotene, 0.82 (95% CI: 0.77, 0.86); vitamin C, 0.88 (95% CI: 0.83, 0.94); and total carotenes, 0.89 (95% CI: 0.81, 0.97). A nonsignificant inverse association was found for dietary zinc, zeaxanthin, lutein, and vitamin E. The nonlinear dose-response meta-analyses demonstrated a linear inverse association in the analyses of dietary β-carotene and total antioxidant capacity, as well as in the analyses of circulating α-carotene, β-carotene, selenium, vitamin C, and total carotenoids. The association appeared to be U-shaped in the analyses of serum lycopene and dietary vitamin C. The present study indicates that adherence to a diet with high antioxidant properties may reduce the risk of all-cause mortality. Our results confirm current recommendations that promote higher intake of antioxidant-rich foods such as fruit and vegetables.

Potato Consumption Is not Associated with Higher Risk of Mortality: A Longitudinal Study among Southern Italian Older Adults

OBJECTIVE

The consumption of potatoes is increasing worldwide, but few studies have assessed the association between potato consumption and mortality, particularly in Mediterranean countries. We therefore investigated whether potato consumption is associated with higher risk of death in a large cohort of people living in South Italy.

DESIGN

Longitudinal.

SETTING

Community-dwelling.

MEASUREMENTS

2,442 participants coming from MICOL and NUTRIHEP studies aged more than 50 years at baseline were followed-up for 11 years. Dietary intake was assessed by means of a Food Frequency Questionnaire. Potato consumption was categorized in quintiles according to their daily consumption (< 3.95, 3.96-8.55, 8.56-15.67, 15.68-22.0, and > 22.0 g/day). Mortality was ascertained through validated cases of death. The association between potato consumption and mortality was assessed through Cox's regression models, adjusted for potential confounders, and reporting the data as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

The 2,442 eligible participants were prevalently males (54.6%) and aged a mean of 64.3±9.3 years. During the 11-year follow-up, 396 (=16.2%) participants died. After adjusting for 12 potential baseline confounders, and taking those with the lowest consumption of potatoes as the reference group, participants with the highest consumption of potatoes did not have an increased overall mortality risk (HR=0.75; 95%CI: 0.53-1.07). Modelling the potato consumption as continuous (i.e. as increase in 10 g/day) did not substantially change our findings (fully-adjusted HR=0.93; 95%CI: 0.84-1.02).

CONCLUSION

Overall potato consumption was not associated with higher risk of death in older people living in a Mediterranean area. Future studies are warranted to elucidate the role of potato consumption on all-cause and cause-specific mortality.

Association of Changes in Diet Quality with Total and Cause-Specific Mortality

BACKGROUND

Few studies have evaluated the relationship between changes in diet quality over time and the risk of death.

METHODS

We used Cox proportional-hazards models to calculate adjusted hazard ratios for total and cause-specific mortality among 47,994 women in the Nurses' Health Study and 25,745 men in the Health Professionals Follow-up Study from 1998 through 2010. Changes in diet quality over the preceding 12 years (1986-1998) were assessed with the use of the Alternate Healthy Eating Index-2010 score, the Alternate Mediterranean Diet score, and the Dietary Approaches to Stop Hypertension (DASH) diet score.

RESULTS

The pooled hazard ratios for all-cause mortality among participants who had the greatest improvement in diet quality (13 to 33% improvement), as compared with those who had a relatively stable diet quality (0 to 3% improvement), in the 12-year period were the following: 0.91 (95% confidence interval [CI], 0.85 to 0.97) according to changes in the Alternate Healthy Eating Index score, 0.84 (95 CI%, 0.78 to 0.91) according to changes in the Alternate Mediterranean Diet score, and 0.89 (95% CI, 0.84 to 0.95) according to changes in the DASH score. A 20-percentile increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17% with the use of the three diet indexes and a 7 to 15% reduction in the risk of death from cardiovascular disease with the use of the Alternate Healthy Eating Index and Alternate Mediterranean Diet. Among participants who maintained a high-quality diet over a 12-year period, the risk of death from any cause was significantly lower - by 14% (95% CI, 8 to 19) when assessed with the Alternate Healthy Eating Index score, 11% (95% CI, 5 to 18) when assessed with the Alternate Mediterranean Diet score, and 9% (95% CI, 2 to 15) when assessed with the DASH score - than the risk among participants with consistently low diet scores over time.

CONCLUSIONS

Improved diet quality over 12 years was consistently associated with a decreased risk of death. (Funded by the National Institutes of Health.).

Lifelong vegetarianism and breast cancer risk: a large multicentre case control study in India

BACKGROUND

The lower incidence of breast cancer in Asian populations where the intake of animal products is lower than that of Western populations has led some to suggest that a vegetarian diet might reduce breast cancer risk.

METHODS

Between 2011 and 2014 we conducted a multicentre hospital based case-control study in eight cancer centres in India. Eligible cases were women aged 30-70 years, with newly diagnosed invasive breast cancer (ICD10 C50). Controls were frequency matched to the cases by age and region of residence and chosen from the accompanying attendants of the patients with cancer or those patients in the general hospital without cancer. Information about dietary, lifestyle, reproductive and socio-demographic factors were collected using an interviewer administered structured questionnaire. Multivariate logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals for the risk of breast cancer in relation to lifelong vegetarianism, adjusting for known risk factors for the disease.

RESULTS

The study included 2101 cases and 2255 controls. The mean age at recruitment was similar in cases (49.7 years (SE 9.7)) and controls (49.8 years (SE 9.1)). About a quarter of the population were lifelong vegetarians and the rates varied significantly by region. On multivariate analysis, with adjustment for known risk factors for the disease, the risk of breast cancer was not decreased in lifelong vegetarians (OR 1.09 (95% CI 0.93-1.29)).

CONCLUSIONS

Lifelong exposure to a vegetarian diet appears to have little, if any effect on the risk of breast cancer.

Consumption of whole grains in relation to mortality from all causes, cardiovascular disease, and diabetes: Dose-response meta-analysis of prospective cohort studies

BACKGROUND

To investigate the correlation between consumption of whole grains and the risk of all-cause, cardiovascular disease (CVD), and diabetes-specific mortality according to a dose-response meta-analysis of prospective cohort studies.

METHODS

Observational cohort studies, which reported associations between whole grains and the risk of death outcomes, were identified by searching articles in the MEDLINE, EMBASE, and the reference lists of relevant articles. The search was up to November 30, 2015. Data extraction was performed by 2 independent investigators, and a consensus was reached with involvement of a third.

RESULTS

Ten prospective cohort studies (9 publications) were eligible in this meta-analysis. During follow-up periods ranging from 5.5 to 26 years, there were 92,647 deaths among 782,751 participants. Overall, a diet containing greater amounts of whole grains may be associated with a lower risk of all-cause, CVD-, and coronary heart disease (CHD)-specific mortality. The summary relative risks (RRs) were 0.93 (95% confidence intervals [CIs]: 0.91-0.95; Pheterogeneity < 0.001) for all-cause mortality, 0.95 (95% CIs: 0.92-0.98; Pheterogeneity < 0.001) for CVD-specific mortality, and 0.92 (95% CIs: 0.88-0.97; Pheterogeneity < 0.001) for CHD-specific mortality for an increment of 1 serving (30 g) a day of whole grain intake. The combined estimates were robust across subgroup and sensitivity analyses. Higher consumption of whole grains was not appreciably associated with risk of mortality from stroke and diabetes.

CONCLUSION

Evidence from observational cohort studies indicates inverse associations of intake of whole grains with risk of mortality from all-cause, CVD, and CHD. However, no associations with risk of deaths from stroke and diabetes were observed.

Consumption of spicy foods and total and cause specific mortality: population based cohort study

OBJECTIVE

To examine the associations between the regular consumption of spicy foods and total and cause specific mortality.

DESIGN

Population based prospective cohort study.

SETTING

China Kadoorie Biobank in which participants from 10 geographically diverse areas across China were enrolled between 2004 and 2008.

PARTICIPANTS

199,293 men and 288,082 women aged 30 to 79 years at baseline after excluding participants with cancer, heart disease, and stroke at baseline.

MAIN EXPOSURE MEASURES

Consumption frequency of spicy foods, self reported once at baseline.

MAIN OUTCOME MEASURES

Total and cause specific mortality.

RESULTS

During 3,500,004 person years of follow-up between 2004 and 2013 (median 7.2 years), a total of 11,820 men and 8404 women died. Absolute mortality rates according to spicy food consumption categories were 6.1, 4.4, 4.3, and 5.8 deaths per 1000 person years for participants who ate spicy foods less than once a week, 1 or 2, 3 to 5, and 6 or 7 days a week, respectively. Spicy food consumption showed highly consistent inverse associations with total mortality among both men and women after adjustment for other known or potential risk factors. In the whole cohort, compared with those who ate spicy foods less than once a week, the adjusted hazard ratios for death were 0.90 (95% confidence interval 0.84 to 0.96), 0.86 (0.80 to 0.92), and 0.86 (0.82 to 0.90) for those who ate spicy food 1 or 2, 3 to 5, and 6 or 7 days a week, respectively. Compared with those who ate spicy foods less than once a week, those who consumed spicy foods 6 or 7 days a week showed a 14% relative risk reduction in total mortality. The inverse association between spicy food consumption and total mortality was stronger in those who did not consume alcohol than those who did (P=0.033 for interaction). Inverse associations were also observed for deaths due to cancer, ischemic heart diseases, and respiratory diseases.

CONCLUSION

In this large prospective study, the habitual consumption of spicy foods was inversely associated with total and certain cause specific mortality, independent of other risk factors of death.

Nutrition: The whole cereal grain is more informative than cereal fibre

A massive prospective study that assessed the association between consumption of cereals and mortality has concluded that cereal fibre is a component of whole grains that is potentially protective. This focus on cereal fibre is not fully consonant with plant and human biology and might distract from the aspect of most importance in prediction of chronic disease—the whole grain and its myriad bioactive phytochemical constituents.

Red meat and processed meat consumption and all-cause mortality: a meta-analysis

High consumption of red meat and processed meat has been associated with increased risk of several chronic diseases. We conducted a meta-analysis to summarize the evidence from prospective studies on red meat and processed meat consumption in relationship to all-cause mortality. Pertinent studies were identified by searching PubMed through May 2013 and by reviewing the reference lists of retrieved articles. Prospective studies that reported relative risks with 95% confidence intervals for the association of red meat or processed meat consumption with all-cause mortality were eligible. Study-specific results were combined by using a random-effects model. Nine prospective studies were included in the meta-analysis. The summary relative risks of all-cause mortality for the highest versus the lowest category of consumption were 1.10 (95% confidence interval (CI): 0.98, 1.22; n = 6 studies) for unprocessed red meat, 1.23 (95% CI: 1.17, 1.28; n = 6 studies) for processed meat, and 1.29 (95% CI: 1.24, 1.35; n = 5 studies) for total red meat. In a dose-response meta-analysis, consumption of processed meat and total red meat, but not unprocessed red meat, was statistically significantly positively associated with all-cause mortality in a nonlinear fashion. These results indicate that high consumption of red meat, especially processed meat, may increase all-cause mortality.

Fruit and vegetable intake and mortality from ischaemic heart disease: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study

AIMS

A higher intake of fruits and vegetables has been associated with a lower risk of ischaemic heart disease (IHD), but there is some uncertainty about the interpretation of this association. The objective was to assess the relation between fruit and vegetable intake and risk of mortality from IHD in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study.

METHODS AND RESULTS

After an average of 8.4 years of follow-up, there were 1636 deaths from IHD among 313 074 men and women without previous myocardial infarction or stroke from eight European countries. Participants consuming at least eight portions (80 g each) of fruits and vegetables a day had a 22% lower risk of fatal IHD [relative risk (RR) = 0.78, 95% confidence interval (CI): 0.65-0.95] compared with those consuming fewer than three portions a day. After calibration of fruit and vegetable intake to account for differences in dietary assessment between the participating centres, a one portion (80 g) increment in fruit and vegetable intake was associated with a 4% lower risk of fatal IHD (RR = 0.96, 95% CI: 0.92-1.00, P for trend = 0.033).

CONCLUSION

Results from this large observational study suggest that a higher intake of fruits and vegetables is associated with a reduced risk of IHD mortality. Whether this association is causal and, if so, the biological mechanism(s) by which fruits and vegetables operate to lower IHD risks remains unclear.

Effect of Larrea tridentata (creosote bush) on cholesterol gallstones and bile secretion in hamsters

Larrea tridentata (Sesse and Moc. ex DC.) Coville is used for the treatment of gallstones in traditional Mexican medicine. The possible prevention or elimination of gallstones by ethanolic and aqueous extracts of the leaves and twigs of L. tridentata was tested in hamsters fed a rich carbohydrate, fat-free diet. In addition, the effects of the ethanolic extract and its main metabolite, nordihydroguaiaretic acid, on bile secretion in the perfused liver were tested. In the experiment on prevention of gallstones, the dry ethanolic extract at a level of 0.5% of diet completely inhibited gallstone formation, lowered biliary moles percent cholesterol and increased the proportion of chenodeoxycholic acid of hepatic bile. The dry aqueous extract at a level of 1% of diet did not affect gallstone frequency or biliary parameters. In the experiment on elimination of gallstones, the ethanolic extract significantly reduced gallstone frequency, gallbladder bile cholesterol concentration and moles percent cholesterol. Both the ethanolic extract and nordihydroguaiaretic acid had cholestatic effects in the perfused liver, with an EC50 of 34 and 28 mg dL-1, respectively, when perfused for 10 min. This effect was reversible with concentrations up to 40 mg dL-1. The results indicate that L. tridentata could be useful in the treatment of gallstone disease, however care must be taken due to its hepatotoxicity.

Does diet matter for survival in long-lived cultures?

In 1987, the International Union of Nutritional Sciences (IUNS) subcommittee on Nutrition and Ageing, in conjunction with the World Health Organization (WHO) global program for the elderly, embarked on the 'Food Habits in Later Life' (FHILL): a cross-cultural study to determine to what extent health, social and lifestyle variables, especially food intake, collectively predict survival amongst long-lived cultures. A total of 818 participants aged 70 years and over were recruited from five IUNS centres. Mortality data were collected after five to seven years. The cohorts included Swedes in Sweden (SWD), Greeks in Greece (GRS) and in Melbourne, Australia (GRM), Anglo-Celts in Australia (ACS) and Japanese in Japan (JPN). Information was obtained on health, lifestyle and diet at baseline. A Cox Proportional Hazard model containing ten potential predictors of survival, adjusted to age at enrollment and ethnicity/locality, was developed to analyse the survival data. Based on up to seven years survival data, it was found that being an elderly Greek in Australia conferred the lowest mortality risk and being an elderly Greek in Greece conferred the highest mortality risk. When the ten potential predictors of survival were entered into the Cox model, the memory score, the Mediterranean diet score, Activities of Daily Living (ADL) and general health status scores showed the greatest effects in significantly reducing mortality hazard ratios by 22%, 13%, 4% and 4%, respectively. For diet score, a one-unit change predicted a significant 13% difference in survival. Of the lifestyle (modifiable) variables entered in the multivariate model, exercise and social activity were not significant predictors of survival suggesting that diet is a more important predictor of survival than these variables. Another lifestyle variable, smoking, significantly increased mortality hazard ratios by 67%, making it a more important predictor of survival than diet. Being male (non-modifiable) also increased risk of death by 63%. Diet, particularly the Mediterranean Diet, operates irrespective and together with other factors as an appreciable contributor to survival, with a strength comparable to or greater than all other measured variables. The independence and strength of the predictiveness of food pattern for survival, and for this to be cross-cultural from Europe to Asia is a novel and important observation for food and health policy.

Nutrition and environmental risk factors of deaths of men in the Podlasie region

The aim of the study was to determine the risk factors in early deaths of men living in the north-eastern region of Poland. The study involved a population of 1000 men employed in an industrial firm in the region. The observation was carried out in the years 1987-98. At the start, the age of the men ranged between 25 and 54 years (mean 35 years). Health problems of men included hypertension, ischaemic heart disease, as well as deaths and their causes. Environmental, economic and social conditions, nourishment and dietary habits with reference to health state were evaluated. The findings were elaborated using logistic analysis and the method of proportional Cox gambling. During the 11-year observation period 40 men died, including 17 due to cardiovascular disorders. The overall risk factors were age, marital status (single) and increased alcohol consumption. Predictors of death due to cardiovascular diseases included age, abnormal arterial blood pressure and low intake of carbohydrates and vitamin C.

Epidemiological evidence of higher susceptibility to vCJD in the young

Background

The strikingly young age of new variant Creutzfeldt-Jacob disease (vCJD) cases remains unexplained. Age dependent susceptibility to infection has been put forward, but differential dietary exposure to contaminated food products in the UK population according to age and sex during the bovine spongiform encephalopathy (BSE) epidemic may provide a simpler explanation.

Methods

Using recently published estimates of dietary exposure in mathematical models of the epidemiology of the new variant Creutzfeldt Jacob disease (vCJD), we examine whether the age characteristics of vCJD cases may be reproduced.

Results

The susceptibility/exposure risk function has likely peaked in adolescents and was followed by a sharp decrease with age, evocative of the profile of exposure to bovine material consumption according to age. However, assuming that the risk of contamination was proportional to exposure, with no age dependent susceptibility, the model failed to reproduce the observed age characteristics of the vCJD cases: The predicted cumulated proportion of cases over 40 years was 48%, in strong disagreement with the observed 10%. Incorporating age dependent susceptibility led to a cumulated proportion of cases over 40 years old of 12%.

Conclusions

This analysis provides evidence that differential dietary exposure alone fails to explain the pattern of age in vCJD cases. Decreasing age related susceptibility is required to reproduce the characteristics of the age distribution of vCJD cases.

Secular trend of colon cancer incidence and mortality in relation to fat and meat intake in Japan

Mortality from colon cancer has rapidly increased in the past decades in Japan, and the increase has generally been ascribed to the Westernized diet, characterized by a high intake of fat and meat. However, fat and meat consumption in Japan stopped increasing in the 1970s. The secular trend of colon cancer incidence and mortality was examined in relation to changing patterns of the consumption of selected foods and nutrients and other related factors in Japan, focusing on the relationship with fat and meat consumption. The incidence and mortality rates of colon cancer both increased almost linearly on a log scale until the early 1990s, the increase then ceasing. The temporal change in fat and meat intake coincided with the incidence of colon cancer approximately 20 years later. Although figures for the consumption of red meat was not available in the early years, red meat accounted for 70-80% of the total meat intake in the mid 1960s and thereafter. Cereal consumption showed a continuous decrease even after the 1970s, that of vegetables showing no marked change. The current observation adds to evidence that red meat intake is an important determinant of colon cancer risk.

Fish and shellfish consumption in relation to death from myocardial infarction among men in Shanghai, China

Between 1986 and 1989, 18,244 men aged 45-64 years in Shanghai, China, participated in a prospective study of diet and cancer. All participants completed an in-person, structured interview and provided blood and urine samples. As of September 1, 1998, 113 deaths from acute myocardial infarction were identified. After analyses were adjusted for age, total energy intake, and known cardiovascular disease risk factors, men who consumed >or=200 g of fish/shellfish per week had a relative risk of 0.41 (95% confidence interval: 0.22, 0.78) for fatal acute myocardial infarction compared with men consuming <50 g per week. Similarly, dietary intake of n-3 fatty acids derived from seafood also was significantly associated with reduced mortality from myocardial infarction. Neither dietary seafood nor n-3 fatty acid intake was associated with a reduced risk of death from stroke or ischemic heart disease other than acute myocardial infarction. However, approximately a 20% reduction in total mortality associated with weekly fish/shellfish intake was observed in the study population (relative risk = 0.79, 95% confidence interval: 0.69, 0.91). These prospective data suggest that eating fish and shellfish weekly reduces the risk of fatal myocardial infarction in middle-aged and older men in Shanghai, China.

Voluntary and involuntary weight loss: associations with long term mortality in 9,228 middle-aged and elderly men

Recent studies have suggested that weight loss in middle-aged persons antecedes increased mortality. Therefore, the authors sought to examine the association between changes in body weight and subsequent mortality, according to self-reported dieting status. The authors followed 9,228 men aged 40-65 years in 1963, for whom weight changes between 1963 and 1968 were recorded and extensive clinical, anthropometric, biochemical, and dietary assessments were made. Of these men, 2,471 reported being on a diet when first examined in 1963, and 636 were dieting primarily to lose weight. Mortality follow-up covered an 18-year period (1968-1986). Men who lost 5 kg or more between 1963 and 1968 ("extreme weight losers") exhibited the following age-pooled risks of mortality relative to the stable weight group: for total mortality, 1.36 (95% confidence interval (CI) 1.20-1.55); for all cardiovascular disease mortality, 1.40 (95% CI 1.16-1.69); for all non-cardiovascular disease mortality, 1.33 (95% CI 1.11-1.59); for coronary heart disease mortality, 1.55 (95% CI 1.25-1.93); and for cancer mortality, 0.90 (95% CI 0.65-1.24). After adjustment for differences in coronary heart disease risk factor levels and morbidity between these groups at the end of the weight change period (1968), the excess risks associated with extreme weight loss declined by approximately one third. They declined further if adjustment was made for 1963 (pre-weight-change period) morbidity and risk factor levels. Being on a slimming diet, as reported in 1963, was associated with an approximate doubling of excess mortality in men with extreme weight loss. Weight loss in 1963-1968 coincided with an increased incidence of coronary heart disease and diabetes mellitus and a declining level of serum total cholesterol. This and other studies indicate that both voluntary and involuntary weight loss might be associated with a small increase in the risk of all-cause mortality.

Actual causes of death in the United States

OBJECTIVE

To identify and quantify the major external (nongenetic) factors that contribute to death in the United States.

DATA SOURCES

Articles published between 1977 and 1993 were identified through MEDLINE searches, reference citations, and expert consultation. Government reports and complications of vital statistics and surveillance data were also obtained.

STUDY SELECTION

Sources selected were those that were often cited and those that indicated a quantitative assessment of the relative contributions of various factors to mortality and morbidity.

DATA EXTRACTION

Data used were those for which specific methodological assumptions were stated. A table quantifying the contributions of leading factors was constructed using actual counts, generally accepted estimates, and calculated estimates that were developed by summing various individual estimates and correcting to avoid double counting. For the factors of greatest complexity and uncertainty (diet and activity patterns and toxic agents), a conservative approach was taken by choosing the lower boundaries of the various estimates.

DATA SYNTHESIS

The most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400,000 deaths), diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000). Socioeconomic status and access to medical care are also important contributors, but difficult to quantify independent of the other factors cited. Because the studies reviewed used different approaches to derive estimates, the stated numbers should be viewed as first approximations.

CONCLUSIONS

Approximately half of all deaths that occurred in 1990 could be attributed to the factors identified. Although no attempt was made to further quantify the impact of these factors on morbidity and quality of life, the public health burden they impose is considerable and offers guidance for shaping health policy priorities.