Examinando por Autor "Dehghan, Mahshid"

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    Association of dairy consumption with metabolic syndrome, hypertension and diabetes in 147 812 individuals from 21 countries
    (BMJ Journals, 2020-05-18) Bhavadharini, Balaji; Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Sheridan, Patrick; Mohan, Viswanathan; Iqbal, Romaina; Gupta, Rajeev; Lear, Scott; Wentzel-Viljoen, Edelweiss; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Mony, Prem; Prasad Varma, Ravi; Kumar, Rajesh; Chifamba, Jephat; Alhabib, Khalid F; Mohammadifard, Noushin; Oguz, Aytekin; Lanas, Fernando; Rozanska, Dorota; Bengtsson Bostrom, Kristina; Yusoff, Khalid; Tsolkile, Lungiswa P; Dans, Antonio; Yusufali, Afzalhussein; Orlandini, Andres; Poirier, Paul; Khatib, Rasha; Hu, Bo; Wei, Li; Yin, Lu; Deeraili, Ai; Yeates, Karen; Yusuf, Rita; Ismail, Noorhassim; Mozaffarian, Dariush; Teo, Koon; Anand, Sonia S; Yusuf, Salim; Everest
    Objective Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study. Methods The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes). Results In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend<0.0001) was associated with a lower prevalence of MetS after multivariable adjustment. Higher intakes of whole fat dairy consumed alone (OR 0.72, 95% CI 0.66 to 0.78, p-trend<0.0001), or consumed jointly with low fat dairy (OR 0.89, 95% CI 0.80 to 0.98, p-trend=0.0005), were associated with a lower MetS prevalence. Low fat dairy consumed alone was not associated with MetS (OR 1.03, 95% CI 0.77 to 1.38, p-trend=0.13). In prospective analysis, 13 640 people with incident hypertension and 5351 people with incident diabetes were recorded. Higher intake of total dairy (at least two servings/day vs zero serving/day) was associated with a lower incidence of hypertension (HR 0.89, 95% CI 0.82 to 0.97, p-trend=0.02) and diabetes (HR 0.88, 95% CI 0.76 to 1.02, p-trend=0.01). Directionally similar associations were found for whole fat dairy versus each outcome. Conclusions Higher intake of whole fat (but not low fat) dairy was associated with a lower prevalence of MetS and most of its component factors, and with a lower incidence of hypertension and diabetes. Our findings should be evaluated in large randomized trials of the effects of whole fat dairy on the risks of MetS, hypertension, and diabetes.
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    Association of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE) : A prospective cohort study
    (2018-09-11) Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Sheridan, Patrick; Mohan, Viswanathan; Iqbal, Romaina; Gupta, Rajeev; Lear, Scott A.; Wentzel Viljoen, Edelweiss; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Mony, Prem; Varma, Ravi Prasad; Kumar, Rajesh; Chifamba, Jephat; AlHabib, Khalid F.; Mohammadifard, Noushin; Oguz, Aytekin; Lanas, Fernando; Rozanska, Dorota; Bengtsson Bostrom, Kristina; Yusoff, Khalid; Tsolekile, Lungiswa P.; Dans, Antonio; Yusufali, Afzalhussein; Orlandini, Andres; Poirier, Paul P.; Khatib, Rasha; Hu, Bo; Wei, Li; Yin, Lu; Deeraili, Ai; Yeates, Karen; Yusuf, Rita; Ismail, Noorhassim; Mozaffarian, Dariush; Teo, Koon; Anand, Sonia S.; Yusuf, Salim; Prospective Urban Rural Epidemiology (PURE), Study investigators
    Background Dietary guidelines recommend minimising consumption of whole-fat dairy products, as they are a source of saturated fats and presumed to adversely affect blood lipids and increase cardiovascular disease and mortality. Evidence for this contention is sparse and few data for the effects of dairy consumption on health are available from low-income and middle-income countries. Therefore, we aimed to assess the associations between total dairy and specific types of dairy products with mortality and major cardiovascular disease. Methods The Prospective Urban Rural Epidemiology (PURE) study is a large multinational cohort study of individuals aged 35–70 years enrolled from 21 countries in five continents. Dietary intakes of dairy products for 136 384 individuals were recorded using country-specific validated food frequency questionnaires. Dairy products comprised milk, yoghurt, and cheese. We further grouped these foods into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios (HRs) were calculated using multivariable Cox frailty models with random intercepts to account for clustering of participants by centre. Findings Between Jan 1, 2003, and July 14, 2018, we recorded 10 567 composite events (deaths [n=6796] or major cardiovascular events [n=5855]) during the 9·1 years of follow-up. Higher intake of total dairy (>2 servings per day compared with no intake) was associated with a lower risk of the composite outcome (HR 0·84, 95% CI 0·75–0·94; ptrend=0·0004), total mortality (0·83, 0·72–0·96; ptrend=0·0052), non-cardiovascular mortality (0·86, 0·72–1·02; ptrend=0·046), cardiovascular mortality (0·77, 0·58–1·01; ptrend=0·029), major cardiovascular disease (0·78, 0·67–0·90; ptrend=0·0001), and stroke (0·66, 0·53–0·82; ptrend=0·0003). No significant association with myocardial infarction was observed (HR 0·89, 95% CI 0·71–1·11; ptrend=0·163). Higher intake (>1 serving vs no intake) of milk (HR 0·90, 95% CI 0·82–0·99; ptrend=0·0529) and yogurt (0·86, 0·75–0·99; ptrend=0·0051) was associated with lower risk of the composite outcome, whereas cheese intake was not significantly associated with the composite outcome (0·88, 0·76–1·02; ptrend=0·1399). Butter intake was low and was not significantly associated with clinical outcomes (HR 1·09, 95% CI 0·90–1·33; ptrend=0·4113). Interpretation Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational cohort. Funding Full funding sources are listed at the end of the paper (see Acknowledgments).
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    Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries
    (American Journal of Clinical Nutrition, 2020-04-01) Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Mohan, Viswanathan; Lear, Scott; Swaminathan, Sumathi; Wielgosz, Andreas; Seron, Pamela; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Turbide, Ginette; Chifamba, Jephat; AlHabib, Khalid F.; Mohammadifard, Noushin; Szuba, Andrzej; Khatib, Rasha; Altuntas, Yuksel; Liu, Xiaoyun; Iqbal, Romaina; Rosengren, Annika; Yusuf, Rita; Smuts, Marius; Yusufali, AfzalHussein; Li, Ning; Diaz, Rafael; Yusoff, Khalid; Kaur, Manmeet; Soman, Biju; Ismail, Noorhassim; Gupta, Rajeev; Dans, Antonio; Sheridan, Patrick; Teo, Koon; Anand, Sonia S; Yusuf, Salim; Behalf of the PURE investigators; Everest
    ABSTRACT Background: Eggs are a rich source of essential nutrients, but they are also a source of dietary cholesterol. Therefore, some guidelines recommend limiting egg consumption. However, there is contradictory evidence on the impact of eggs on diseases, largely based on studies conducted in high-income countries. Objectives: Our aim was to assess the association of egg consumption with blood lipids, cardiovascular disease (CVD), and mortality in large global studies involving populations from low-, middle-, and high-income countries. Methods: We studied 146,011 individuals from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Egg consumption was recorded using country-specific validated FFQs. We also studied 31,544 patients with vascular disease in 2 multinational prospective studies: ONTARGET (Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects with Cardiovascular Disease). We calculated HRs using multivariable Cox frailty models with random intercepts to account for clustering by study center separately within each study. Results: In the PURE study, we recorded 14,700 composite events (8932 deaths and 8477 CVD events). In the PURE study, after excluding those with history of CVD, higher intake of egg (≥7 egg/wk compared with <1 egg/wk intake) was not significantly associated with blood lipids, composite outcome (HR: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.74), total mortality (HR: 1.04; 95% CI: 0.94, 1.15; P-trend = 0.38), or major CVD (HR: 0.92; 95% CI: 0.83, 1.01; P-trend = 0.20). Similar results were observed in ONTARGET/TRANSCEND studies for composite outcome (HR 0.97; 95% CI: 0.76, 1.25; P-trend = 0.09), total mortality (HR: 0.88; 95% CI: 0.62, 1.24; P-trend = 0.55), and major CVD (HR: 0.97; 95% CI: 0.73, 1.29; P-trend = 0.12). Conclusions: In 3 large international prospective studies including ∼177,000 individuals, 12,701 deaths, and 13,658 CVD events from 50 countries in 6 continents, we did not find significant associations between egg intake and blood lipids, mortality, or major CVD events. The ONTARGET and TRANSCEND trials were registered at clinicaltrials.gov as NCT00153101. The PURE trial was registered at clinicaltrials.gov as NCT03225586. Am J Clin Nutr 2020;111:795–803.
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    Association of nut intake with risk factors, cardiovascular disease, and mortality in 16 countries from 5 continents
    (American Society for Nutrition, 2020-05-20) De Souza, Russell J; Dehghan, Mahshid; Mente, Andrew; Bangdiwala, Shrikant I; Ahmed, Suad Hashim; Alhabib, Khalid F; Altuntas, Yuksel; Basiak-Rasała, Alicja; Dagenais, Gilles-R; Diaz, Rafael; Amma, Leela Itty; Kelishadi, Roya; Khatib, Rasha; Lear, Scott A; Lopez-Jaramillo, Patricio; Mohan, Viswanathan; Poirier, Paul; Rangarajan, Sumathy; Rosengren, Annika; Ismail, Rosnah; Swaminathan, Sumathi; Wentzel-Viljoen, Edelweiss; Yeates, Karen; Yusuf, Rita; Teo, Koon; Anand, Sonia S; Yusuf, Salim; PURE Study Investigators; Everest
    Background: The association of nuts with cardiovascular disease and deaths has been investigated mostly in Europe, the USA, and East Asia, with few data available from other regions of the world or from low- and middle-income countries. Objective: To assess the association of nuts with mortality and cardiovascular disease (CVD). Methods: The Prospective Urban Rural Epidemiology study is a large multinational prospective cohort study of adults aged 35–70 y from 16 low-, middle-, and high-income countries on 5 continents. Nut intake (tree nuts and ground nuts) was measured at the baseline visit, using country-specific validated FFQs. The primary outcome was a composite of mortality or major cardiovascular event [nonfatal myocardial infarction (MI), stroke, or heart failure]. Results: We followed 124,329 participants (age = 50.7 y, SD = 10.2; 41.5% male) for a median of 9.5 y. We recorded 10,928 composite events [deaths (n = 8,662) or major cardiovascular events (n = 5,979)]. Higher nut intake (>120 g per wk compared with <30 g per mo) was associated with a lower risk of the primary composite outcome of mortality or major cardiovascular event [multivariate HR (mvHR): 0.88; 95% CI: 0.80, 0.96; P-trend = 0.0048]. Significant reductions in total (mvHR: 0.77; 95% CI: 0.69, 0.87; Ptrend <0.0001), cardiovascular (mvHR: 0.72; 95% CI: 0.56, 0.92; Ptrend = 0.048), and noncardiovascular mortality (mvHR: 0.82; 95% CI: 0.70, 0.96; P-trend = 0.0046) with a trend to reduced cancer mortality (mvHR: 0.81; 95% CI: 0.65, 1.00; P-trend = 0.081) were observed. No significant associations of nuts were seen with major CVD (mvHR: 0.91; 95% CI: 0.81, 1.02; P-trend = 0.14), stroke (mvHR: 0.98; 95% CI: 0.84, 1.14; P-trend = 0.76), or MI (mvHR: 0.86; 95% CI: 0.72, 1.04; P-trend = 0.29). Conclusions: Higher nut intake was associated with lower mortality risk from both cardiovascular and noncardiovascular causes in low-, middle-, and high-income countries. Am J Clin Nutr 2020;112:208–219.
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    Association of ultra-processed food intake with risk of inflammatory bowel disease. Prospective cohort study
    (BMJ Journals, 2021-07-14) Narula, Neeraj; Wong, Emily C.L.; Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Lanas, Fernando; Lopez-Jaramillo, Patricio; Rohatgi, Priyanka; Lakshmi, P. V. M.; Prasad Varma, Ravi; Orlandini, Andres; Avezum, Alvaro; Wielgosz, Andreas; Poirier, Paul; Almadi, Majid A.; Altuntas, Yuksel; Ng, Kien Keat; Chifamba, Jephat; Yeates, Karen; Puoane, Thandi; Khatib, Rasha; Yusuf, Rita; Bengtsson Boström, Kristina; Zatonska, Katarzyna; Iqbal, Romaina; Weida, Liu; Yibing, Zhu; Sidong, Li; Dans, Antonio; Yusufali, Afzalhussein; Mohammadifard, Noushin; Marshall, John K.; Moayyedi, Paul; Reinisch, Walter; Yusuf, Salim; Masira
    OBJECTIVE To evaluate the relation between intake of ultraprocessed food and risk of inflammatory bowel disease (IBD). DESIGN Prospective cohort study. SETTING 21 low, middle, and high income countries across seven geographical regions (Europe and North America, South America, Africa, Middle East, south Asia, South East Asia, and China). PARTICIPANTS 116087 adults aged 35-70 years with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data (country specific validated FFQs were used to document baseline dietary intake). Participants were followed prospectively at least every three years. MAIN OUTCOME MEASURES The main outcome was development of IBD, including Crohn’s disease or ulcerative colitis. Associations between ultra-processed food intake and risk of IBD were assessed using Cox proportional hazard multivariable models. Results are presented as hazard ratios with 95% confidence intervals. RESULTS Participants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (interquartile range 8.9-11.2 years), 467 participants developed incident IBD (90 with Crohn’s disease and 377 with ulcerative colitis). After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD (hazard ratio 1.82, 95% confidence interval 1.22 to 2.72 for ≥5 servings/day and 1.67, 1.18 to 2.37 for 1-4 servings/day compared with <1 serving/day, P=0.006 for trend). Different subgroups of ultra-processed food, including soft drinks, refined sweetened foods, salty snacks, and processed meat, each were associated with higher hazard ratios for IBD. Results were consistent for Crohn’s disease and ulcerative colitis with low heterogeneity. Intakes of white meat, red meat, dairy, starch, and fruit, vegetables, and legumes were not associated with incident IBD. CONCLUSIONS Higher intake of ultra-processed food was positively associated with risk of IBD. Further studies are needed to identify the contributory factors within ultraprocessed foods. STUDY REGISTRATION ClinicalTrials.gov NCT03225586.
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    Associations of cereal grains intake with cardiovascular disease and mortality across 21 countries in prospective urban and rural epidemiology study
    (BMJ, 2021-02-03) Dehghan, Mahshid; Raj, John Michael; Thomas, Tinku; Rangarajan, Sumathy; Jenkins, David; Mony, Prem; Mohan, Viswanathan; Lear, Scott A.; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Rosengren, Annika; Lanas, Fernando; AlHabib, Khalid F.; Dans, Antonio; Keskinler, Mirac Vural; Puoane, Thandi; Soman, Biju; Wei, Li; Zatonska, Katarzyna; Diaz, Rafael; Ismail, Noorhassim; Chifamba, Jephat; Kelishadi, Roya; Yusufali, Afzalhussein; Khatib, Rasha; Xiaoyun, Liu; Bo, Hu; Iqbal, Romaina; Yusuf, Rita; Yeates, Karen; Teo, Koon; Yusuf, Salim; Masira
    Objective. To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study. Design. Prospective cohort study. Setting PURE study in 21 countries. Participants 148858 participants with median follow-up of 9.5 years. Exposures Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice. Main outcome measure Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, nonfatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre. Results Analyses were based on 137130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes. Conclusion High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.
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    Associations of Fish Consumption with Risk of Cardiovascular Disease and Mortality among Individuals with or without Vascular Disease from 58 Countries
    (JAMA Network, 2021-03-08) Mohan, Deepa; Mente, Andrew; Dehghan, Mahshid; Rangarajan, Sumathy; O’Donnell, Martin; Hu, Weihong; Dagenais, Gilles; Wielgosz, Andreas; Lear, Scott; Wei, Li; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Lanas, Fernando; Swaminathan, Sumathi; Kaur, Manmeet; Vijayakumar, K.; Mohan, Viswanathan; Gupta, Rajeev; Szuba, Andrzej; Iqbal, Romaina; Yusuf, Rita; Mohammadifard, Noushin; Khatib, Rasha; Yusoff, Khalid; Gulec, Sadi; Rosengren, Annika; Yusufali, Afzalhussein; Wentzel-Viljoen, Edelweiss; Chifamba, Jephat; Dans, Antonio; Alhabib, Khalid F.; Yeates, Karen; Teo, Koon; Gerstein, Hertzel C.; Yusuf, Salim; The PURE, ONTARGET, TRANSCEND, and ORIGIN investigators; Masira
    Importance Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown. Objective To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease. Design, Setting, and Participants This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies—147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020. Exposures Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish. Main Outcomes and Measures Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death). Results Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]). Conclusions and Relevance Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.
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    Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries. An analysis of the PURE study data
    (ScienceDirect, 2016-10-05) Miller, Victoria; Yusuf, Salim; Chow, Clara K.; Dehghan, Mahshid; Corsi, Daniel J.; Lock, Karen; Popkin, Barry; Rangarajan, Sumathy; Khatib, Rasha; Lear, Scott A.; Mony, Prem; Kaur, Manmeet; Mohan, Viswanathan; Vijayakumar, Krishnapillai; Gupta, Rajeev; Kruger, Annamarie; Tsolekile, Lungiswa; Mohammadifard, Noushin; Rahman, Omar; Rosengren, Annika; Avezum, Alvaro; Orlandini, Andrés; Ismail, Noorhassim; Lopez-Jaramillo, Patricio; Yusufali, Afzalhussein; Karsidag, Kubilay; Iqbal, Romaina; Chifamba, Jephat; Oakley, Solange Martinez; Ariffin, Farnaza; Zatonska, Katarzyna; Poirier, Paul; Wei, Li; Jian, Bo; Hui, Chen; Xu, Liu; Xiulin, Bai; Teo, Koon; Mente, Andrew; Masira
    Methods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. Findings Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66–3·86) per day. Mean daily consumption was 2·14 servings (1·93–2·36) in low-income countries (LICs), 3·17 servings (2·99–3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09–4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13–5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06–57·88) of household income in LICs, 18·10% (14·53–21·68) in LMICs, 15·87% (11·51–20·23) in UMICs, and 1·85% (−3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040). Interpretation The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.
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    Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels : Findings from the Prospective Urban Rural Epidemiology (PURE) study
    (2016-08-23) Lopez-Jaramillo, Patricio; Mente, Andrew; Teo, Koon; Xiulin, Bai; Xu, Liu; Hui, Chen; Jian, Bo; Wei, Li; Poirier, Paul P.; Zatonska, Katarzyna; Ariffin, Farnaza; Martinez Oakley, Solange; Chifamba, Jephat; Iqbal, Romaina; Karsidag, Kubilay; Yusufali, Afzalhussein; Ismail, Noorhassim; Orlandini, Andres; Avezum, Alvaro; Rosengren, Annika; Rahman, Omar; Mohammadifard, Noushin; Tsolekile, Lungiswa P.; Kruger, Annamarie; Gupta, Rajeev; Vijayakumar, Krishnapillai; Mohan, Viswanathan; Kaur, Manmeet; Mony, Prem; Lear, Scott A.; Khatib, Rasha; Rangarajan, Sumathy; Popkin, Barry; Lock, Karen; Corsi, Daniel J.; Dehghan, Mahshid; Chow, Clara K.; Yusuf, Salim; Miller, Victoria
    Background Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and aff ordability. Methods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random eff ects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. Findings Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66–3·86) per day. Mean daily consumption was 2·14 servings (1·93–2·36) in low-income countries (LICs), 3·17 servings (2·99–3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09–4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13–5·71) in highincome countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06–57·88) of household income in LICs, 18·10% (14·53–21·68) in LMICs, 15·87% (11·51–20·23) in UMICs, and 1·85% (–3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased ptrend=0·00040). Interpretation The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low aff ordability. Policies worldwide should enhance the availability and aff ordability of fruits and vegetables. Funding Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi -Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
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    Effects of lipid-lowering and antihypertensive treatments in addition to healthy lifestyles in primary prevention : An analysis of the HOPE-3 trial
    (2018) Lopez-Jaramillo, Patricio; Dagenais, Gilles; Jung, Hyejung; Lonn, Eva; Bogaty, Peter M.; Dehghan, Mahshid; Held, Claes; Avezum, Alvaro; Petr, Jansky; Keltai, Matyas; Lawrence A., Leiter; Toff, William D.; Bosch, Jackie; Yusuf, Salim
    Background-—It is not clear whether the effects of lipid-lowering or antihypertensive medications are influenced by adherence to healthy lifestyle factors. We assessed the effects of both drug interventions in subgroups by the number of healthy lifestyle factors in participants in the HOPE-3 (Heart Outcomes Prevention Evaluation) trial. Methods and Results-—In this primary prevention trial, 4 healthy lifestyle factors (nonsmoking status, physical activity, optimal body weight, and healthy diet) were recorded in 12 521 participants who were at intermediate risk of cardiovascular disease (CVD) and were randomized to rosuvastatin, candesartan/hydrochlorothiazide, their combination, or matched placebos. Median follow-up was 5.6 years. The outcome was a composite of CVD events. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models. Participants with ≥2 healthy lifestyle factors had a lower rate of CVD compared with those with fewer factors (HR: 0.85; 95% CI, 0.73–1.00). Rosuvastatin reduced CVD events in participants with ≥2 healthy lifestyle factors (HR: 0.74; 95% CI, 0.62–0.90) and in participants with <2 factors (HR: 0.79; 95% CI, 0.61–1.01). Consistent results were observed with combination therapy (≥2 factors: HR: 0.74; 95% CI, 0.57–0.97; <2 factors: HR: 0.61; 95% CI, 0.43–0.88). Candesartan/hydrochlorothiazide tends to reduce CVD only in participants with <2 healthy lifestyle factors (HR: 0.78; 95% CI, 0.61–1.00). Conclusions-—Healthy lifestyles are associated with lower CVD. Rosuvastatin alone and combined with candesartan/hydrochlorothiazide is beneficial regardless of healthy lifestyle status; however, the benefit of antihypertensive treatment appears to be limited to patients with less healthy lifestyles.
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    Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE) : A prospective cohort study
    (2017-11-04) Lopez-Jaramillo, Patricio; Miller, Victoria; Mente, Andrew; Dehghan, Mahshid; Rangarajan, Sumathy; Zhang, Xiaohe; Swaminathan, Sumathi; Dagenais, Gilles; Gupta, Rajeev; Mohan, Viswanathan; Lear, Scott A.; Bangdiwala, Shrikant I.; Schutte, Aletta Elisabeth; Wentzel Viljoen, Edelweiss; Avezum, Alvaro; Altuntas, Yuksel; Yusoff, Khalid; Ismail, Noorhassim; Peer, Nasheeta; Chifamba, Jephat; Diaz, Rafael; Rahman, Omar; Mohammadifard, Noushin; Lanas, Fernando; Zatonska, Katarzyna; Wielgosz, Andreas; Yusufali, Afzalhussein; Iqbal, Romaina; Khatib, Rasha; Rosengren, Annika; Kutty, V. Raman; Li, Wei; Liu, Jiankang; Liu, Xiaoyun; Yin, Lu; Teo, Koon; Anand, Sonia S.; Yusuf, Salim; The Prospective Urban Rural Epidemiology (PURE) study investigators
    Background The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. Methods We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and highincome countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. Findings Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5–9·3) of followup, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74–1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74–1·31; ptrend=0·2033), stroke (0·92, 0·67–1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53–1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68–1·04; ptrend =0·0038), and total mortality (0·81, 0·68–0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69–0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. Interpretation Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375–500 g/day). Funding Full funding sources listed at the end of the paper (see Acknowledgments).
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    Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE) : A case-control study
    (2016-07-15) O’Donnell, Martin J.; Chin, Siu Lim; Rangarajan, Sumathy; Xavier, Denis; Liu, Lisheng; Zhang, Hongye; Rao Melacini, Purnima; Zhang, Xiaohe; Pais, Prem; Agapay, Steven; Lopez-Jaramillo, Patricio; Damasceno, Albertino; Langhorne, Peter; McQueen, Matthew J.; Rosengren, Annika; Dehghan, Mahshid; Hankey, Graeme J.; Dans, Antonio; ElSayed, Ahmed; Avezum, Alvaro; Mondo, Charles; Diener, Hans Christoph; Ryglewicz, Danuta; Czlonkowska, Anna; Pogosova, Nana; Weimar, Christian; Iqbal, Romaina; Diaz, Rafael; Yusoff, Khalid; Yusufali, Afzalhussein; Oguz, Aytekin; Wang, Xingyu; Penaherrera, Ernesto; Lanas, Fernando; Ogah, Okechukwu S.; Ogunniyi, Adesola; Iversen, Helle K.; Malaga, German; Rumboldt, Zvonko; Oveisgharan, Shahram; Hussain, Fawaz Al; Magazi, Daliwonga; Nilanont, Yongchai; Ferguson, John; Paré, Guillaume; Yusuf, Salim; INTERSTROKE investigators
    Background Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. Methods We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. Findings Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72–3·28; PAR 47·9%, 99% CI 45·1–50·6), regular physical activity (0·60, 0·52–0·70; 35·8%, 27·7–44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65–2·06 for highest vs lowest tertile; 26·8%, 22·2–31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53–0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2–28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27–1·64 for highest vs lowest tertile; 18·6%, 13·3–25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78–2·72; 17·4%, 13·1–22·6), current smoking (1·67, 1·49–1·87; 12·4%, 10·2–14·9), cardiac causes (3·17, 2·68–3·75; 9·1%, 8·0–10·2), alcohol consumption (2·09, 1·64–2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4–9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05–1·30; 3·9%, 1·9–7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001). Interpretation Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. Funding Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
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    Glycemic index, glycemic load, and cardiovascular disease and mortality
    (The New England Journal of Medicine, 2021-04-08) Jenkins, David; Dehghan, Mahshid; Mente, Andrew; Bangdiwala, Shrikant I.; Rangarajan, Sumathy; Srichaikul, Kristie; Mohan, Viswanathan; Avezum, Alvaro; Díaz, Rafael; Rosengren, Annika; Lanas, Fernando; Lopez-Jaramillo, Patricio; Li, Wei; Oguz, Aytekin; Khatib, Rasha; Poirier, Paul; Mohammadifard, Noushin; Pepe, Andrea; Alhabib, Khalid F.; Chifamba, Jephat; Yusufali, Afzal Hussein; Iqbal, Romaina; Yeates, Karen; Yusoff, Khalid; Ismail, Noorhassim; Teo, Koon; Swaminathan, Sumathi; Liu, Xiaoyun; Zatońska, Katarzyna; Yusuf, Rita; Yusuf, Salim; The PURE Study Investigators; Masira
    BACKGROUND Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population. METHODS This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used countryspecific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause. RESULTS In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease. CONCLUSIONS In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death. (Funded by the Population Health Research Institute and others.)
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    Nutritional status among women with pre-eclampsia and healthy pregnant and non-pregnant women in a Latin American country
    (2012-02-22) Reyes, Laura M.; García, Ronald G.; Ruiz, Silvia L.; Dehghan, Mahshid; Lopez-Jaramillo, Patricio
    Aims: Pre‐eclampsia (PE) is one of the leading causes of maternal and perinatal morbidity and mortality worldwide. It has been proposed that, among other risk factors, the nutritional status of women can lead to the endothelial dysfunction that characterizes this entity. The aim of the present study was to compare the nutritional status of women with PE with healthy pregnant and non‐pregnant women. Material and Methods: A multicenter case–control study was carried out. Between September 2006 and July 2009, 201 women with PE were compared with 201 pregnant, and 201 non‐pregnant aged‐matched women without cardiovascular or endocrine diseases. A clinical history and physical examination was performed. Fasting blood samples were drawn to measure serum glucose and lipid profile. The nutritional status of participants was assessed using a food frequency questionnaire. Results: The average age of women was 26.6 ± 7.2 years. Compared to healthy pregnant controls, women with PE had a higher body mass index, higher fasting blood glucose levels, higher triglycerides, and lower high‐density lipoprotein cholesterol levels. Women with PE had a higher intake of carbohydrates, energy intake and cereal compared to healthy pregnant and non‐pregnant controls. A conditional logistic regression demonstrated that carbohydrate and sodium intake are associated with PE development. Conclusions: Diets of women with PE were characterized by higher energy and carbohydrate intake compared to normal pregnant and non‐pregnant women. This suggests that higher carbohydrate and sodium intake increases the risk of PE among women in Colombia.
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    White rice intake and incident diabetes: A study of 132,373 participants in 21 countries
    (Diabetes Care, 2020-09-01) Bhavadharini, Balaji; Mohan, Viswanathan; Dehghan, Mahshid; Rangarajan, Sumathy; Swaminathan, Sumathi; Rosengren, Annika; Wielgosz, Andreas; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Dans, Antonio; Yeates, Karen; Poirier, Paul; Chifamba, Jephat; Alhabib, Khalid F.; Mohammadifard, Noushin; Zatonska, Katarzyna; Khatib, Rasha; Keskinler, Mirac Vural; Wei, Li; Wang, Chuangshi; Liu, Xiaoyun; Iqbal, Romaina; Yusuf, Rita; Wentzel-Viljoen, Edelweiss; Yusufali, Afzalhussein; Diaz, Rafael; Kien Keat, Ng; Lakshmi, P.V.M.; Ismail, Noorhassim; Gupta, Rajeev; Palileo-Villanueva, Lia M.; Sheridan, Patrick; Mente, Andrew; Yusuf, Salim; Masira
    OBJECTIVE Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study. RESEARCH DESIGN AND METHODS Data on 132,373 individuals aged 35–70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model. RESULTS During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02–1.40; P for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13–2.30; P for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08–1.86; P for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77–1.40; P for trend = 0.38). CONCLUSIONS Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.