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Dietary Fatty Acids, Macronutrient Substitutions, Food Sources and Incidence of Coronary Heart Disease: Findings From the EPIC-CVD Case-Cohort Study Across Nine European Countries.

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Johnson, Laura 
Sharp, Stephen J 
Sluijs, Ivonne 


Background There is controversy about associations between total dietary fatty acids, their classes (saturated fatty acids [SFAs], monounsaturated fatty acids, and polyunsaturated fatty acids), and risk of coronary heart disease (CHD). Specifically, the relevance of food sources of SFAs to CHD associations is uncertain. Methods and Results We conducted a case-cohort study involving 10 529 incident CHD cases and a random subcohort of 16 730 adults selected from a cohort of 385 747 participants in 9 countries of the EPIC (European Prospective Investigation into Cancer and Nutrition) study. We estimated multivariable adjusted country-specific hazard ratios (HRs) and 95% CIs per 5% of energy intake from dietary fatty acids, with and without isocaloric macronutrient substitutions, using Prentice-weighted Cox regression models and pooled results using random-effects meta-analysis. We found no evidence for associations of the consumption of total or fatty acid classes with CHD, regardless of macronutrient substitutions. In analyses considering food sources, CHD incidence was lower per 1% higher energy intake of SFAs from yogurt (HR, 0.93 [95% CI, 0.88-0.99]), cheese (HR, 0.98 [95% CI, 0.96-1.00]), and fish (HR, 0.87 [95% CI, 0.75-1.00]), but higher for SFAs from red meat (HR, 1.07 [95% CI, 1.02-1.12]) and butter (HR, 1.02 [95% CI, 1.00-1.04]). Conclusions This observational study found no strong associations of total fatty acids, SFAs, monounsaturated fatty acids, and polyunsaturated fatty acids, with incident CHD. By contrast, we found associations of SFAs with CHD in opposite directions dependent on the food source. These findings should be further confirmed, but support public health recommendations to consider food sources alongside the macronutrients they contain, and suggest the importance of the overall food matrix.



coronary heart disease, dietary guidelines, nutritional epidemiology, primary prevention, saturated fat, Cohort Studies, Coronary Disease, Dietary Fats, Europe, Fatty Acids, Food, Humans, Incidence, Nutrients

Journal Title

J Am Heart Assoc

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Ovid Technologies (Wolters Kluwer Health)


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Medical Research Council (G0700463)
Cambridge University Hospitals NHS Foundation Trust (CUH) (146281)
Medical Research Council (G1000143)
Medical Research Council (G0800270)
Medical Research Council (MR/L003120/1)
British Heart Foundation (None)
Medical Research Council (MR/P013880/1)
British Heart Foundation (RG/18/13/33946)
MRC (MC_UU_00006/1)
MRC (MC_UU_00006/3)
Department of Health (via National Institute for Health Research (NIHR)) (NIHR202397)
European Research Council (268834)
National Institute for Health and Care Research (IS-BRC-1215-20014)
Medical Research Council (G0401527)
Medical Research Council (MR/N003284/1)
Medical Research Council (G0700463/1)
Medical Research Council (G0800270/1)
Medical Research Council (G0401527/1)
EPIC-CVD was supported by the European Commission Framework Programme 7 (HEALTH-F2-2012-279233), the European Research Council (268834). The coordinating centre was supported by core funding from the: United Kingdom MRC (G0800270; MR/L003120/1), British Heart Foundation (BHF) (SP/09/002; RG13/13/30194; RG/18/13/33946)), and National Institute for Health Research (NIHR) Cambridge Biomedical Research Centre (BRC) (BRC-1215-20014)* The establishment of the study subcohort was supported by the European Union Sixth Framework Programme (FP6) (grant LSHM_CT_2006_037197 to the InterAct project) and the MRC Epidemiology Unit (grant MC_UU_00006/1). The coordination of EPIC is financially supported by International Agency for Research on Cancer (IARC) and also by the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London which has additional infrastructure support provided by NIHR Imperial BRC. The national cohorts are supported by: Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l’Education Nationale, Institut National de la Santé et de la Recherche Médicale (France); German Cancer Aid, German Cancer Research Center, German Institute of Human Nutrition Potsdam-Rehbruecke, Federal Ministry of Education and Research (Germany); Associazione Italiana per la Ricerca sul Cancro-AIRC-Italy, Compagnia di SanPaolo and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports, Netherlands Cancer Registry, LK Research Funds, Dutch Prevention Funds, Zorg Onderzoek Nederland, World Cancer Research Fund, Statistics Netherlands (The Netherlands); Health Research Fund - Instituto de Salud Carlos III, Regional Governments of Andalucía, Asturias, Basque Country, Murcia and Navarra, and the Catalan Institute of Oncology (Spain); Swedish Cancer Society, Swedish Research Council and County Councils of Skåne and Västerbotten (Sweden); Cancer Research UK (14136 to EPIC-Norfolk; C8221/A29017 to EPIC-Oxford), MRC(1000143 to EPIC-Norfolk; MR/M012190/1 to EPIC-Oxford). (United Kingdom). EPIC-Greece was supported by the Hellenic Health Foundation. (Greece) MS, NJW, NGF and FI acknowledge support from MRC Epidemiology Unit (MC_UU_00006/1 and MC_UU_00006/5). NJW and NGF acknowledge support from NIHR Cambridge BRC: Nutrition, Diet, and Lifestyle Research Theme (IS-BRC-1215-20014) and both are NIHR Senior Investigator Award holders. MS was also supported by BHF for part of this work whilst working in the BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom. RZ-R thanks the “Miguel Servet” program (CP15/00100) from the Institute of Health Carlos III (Co-funded by the European Social Fund – European Social Fund investing in your future). AW was supported by a BHF-Turing Cardiovascular Data Science Award and by the European Commission-Innovative Medicines Initiative (BigData@Heart). RC was funded by a MRC-Newton project grant to study genetic risk factors of cardiovascular disease among South-East Asians and the Academy of Sciences Malaysia (grant number MR/P013880/1) and a United Kingdom Research and Innovation-Global Challenges Research Fund Project Grant to study risk factors of non-communicable diseases in Bangladesh. JD holds a BHF Professorship and a NIHR Senior Investigator Award.