Prospective investigation of major dietary patterns and risk of cardiovascular mortality in Bangladesh

Abstract

Background Dietary pattern analysis is emerging as a practical, effective tool for relating comprehensive dietary intake to risk of cardiovascular disease mortality. However, no studies have applied this technique to a population outside of the developed world. Methods We conducted prospective cohort analyses in 11,116 participants enrolled in the Health Effects of Arsenic Study in Araihazar, Bangladesh, measuring deaths attributable to disease of circulatory system, heart disease, and cerebrovascular disease. Participants were enrolled in 2000 and followed up for an average of 6.6 years. Dietary information was obtained through a previously validated food-frequency questionnaire at baseline. Results Principal component analysis based on our comprehensive, 39 item FFQ yielded 3 dietary patterns: (i) a “balanced” pattern, comprised of steamed rice, red meat, fish, fruit and vegetables; (ii) an “animal protein” diet, which was more heavily weighted towards eggs, milk, red meat, poultry, bread, and vegetables; and (iii) a “gourd and root vegetable” diet that heavily relied on a variety of gourds, radishes, pumpkin, sweet potato, and spinach. We observed a positive association between increasing adherence to the animal protein diet and risk of death from both disease of the circulatory system and heart disease; the hazard ratio was 1.13 (95% CI, 1.00-1.28, p = 0.05) and 1.17 (95% CI, 0.99-1.38, p = 0.07), respectively, in relation to one standard deviation increase in the factor scores for the animal protein diet pattern, after controlling for age, sex, body mass index, smoking status, and energy intake. The positive association was more significant among ever smokers; the hazard ratios (95% CI) for deaths from disease of the circulatory system and heart disease was 1.17 (1.02-1.34) and 1.20 (1.00-1.45), respectively, in relation to one standard deviation increase in the factor scores for the animal protein diet pattern. Conclusions An animal protein-rich diet in rural Bangladesh may increase risk of heart disease mortality, especially among smokers. This emphasizes the need to further explore and address the impact of dietary patterns on cardiovascular disease in populations undergoing epidemiologic transition into a future of higher chronic disease burden.

Dietary Patterns, Smoking, and Cardiovascular Diseases: A Complex Association

“…First, it is well established that smoking confounds the association between diet and CVD. Thus, all studies reviewed adjusted for smoking in their analysis [35,[64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][87][88][89][90][91][92][93][94][95][96][97] and showed that the effect of diet is attenuated when smoking is considered [73,91]. However, as discussed, smoking may interact with diet and modify the effect of diet on CVD, which has been an increasing focus of more recent studies.…”

“…Most of the studies that examined relationships of smoking status and a posteriori patterns with CVDs were in the United States and Europe [65,[87][88][89][90][91][92][93][94][95][96][97]. Three cross-sectional studies evaluated the interrelationships of dietary patterns and smoking status with subclinical CVD and hypertension [87][88][89].…”

“…To elucidate the relationships, nine studies prospectively assessed the associations of empirical patterns and smoking status on subclinical heart disease, CAD, stroke, and cardiovascular mortality [65,[90][91][92][93][94][95][96][97] (Table 2). Stratified analyses were conducted based on a priori hypotheses in three studies [90,92,93].…”

“…Stratified analyses were conducted based on a priori hypotheses in three studies [90,92,93]. Studies that tested for interactions did not report any statistically significant results [65,[94][95][96][97]; of these, three studies performed stratified analyses [94][95][96]. In the Framingham Offspring/Spouse Study, women with a Heart Healthy pattern (higher in vegetables, fruits, low-fat dairy, and legumes and lower in diet beverages) who had never smoked or formerly smoked were less likely to develop subclinical heart disease than current smokers with less heart healthy patterns.…”

“…Another prospective study in Bangladesh showed that the animal protein factor (high in eggs, milk, red meat, poultry, wheat bread, vegetables) was associated with cardiovascular mortality only among smokers (RR 1.17; 95 % CI 1.02-1.34) [95]. Greater consumption of a comparable pattern derived by reduced rank regression (high in meat, soft drinks, beer and lower in vegetables, fruits, whole-meal bread, cereals, dairy products) increased risk for CAD and CVD mortality in a German cohort.…”