Accepted Manuscript Associations of Dietary Fiber Intake with Long-Term Predicted Cardiovascular Disease Risk and C-Reactive Protein Levels (From the National Health and Nutrition Examination Survey Data [2005-2010]) Hongyan Ning, MD, MS Linda Van Horn, PhD, RD Christina Shay, PhD, MA Donald M. Lloyd-Jones, MD ScM PII:
S0002-9149(13)01942-5
DOI:
10.1016/j.amjcard.2013.09.020
Reference:
AJC 20016
To appear in:
The American Journal of Cardiology
Received Date: 11 July 2013 Revised Date:
19 September 2013
Accepted Date: 21 September 2013
Please cite this article as: Ning H, Van Horn L, Shay C, Lloyd-Jones DM, ScM , Associations of Dietary Fiber Intake with Long-Term Predicted Cardiovascular Disease Risk and C-Reactive Protein Levels (From the National Health and Nutrition Examination Survey Data [2005-2010]), The American Journal of Cardiology (2013), doi: 10.1016/j.amjcard.2013.09.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 Associations of Dietary Fiber Intake with Long-Term Predicted Cardiovascular Disease Risk and C-Reactive Protein Levels (From the National Health and Nutrition Examination
RI PT
Survey Data [2005-2010])
Hongyan Ning, MD, MSa; Linda Van Horn, PhD, RDa; Christina Shay, PhD, MAa; and Donald M. Lloyd-Jones, MD, ScMa,b
SC
Author Affiliations: aDepartment of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; bBluhm Cardiovascular Institute, Department of Medicine, Northwestern University Feinberg School
M AN U
of Medicine, Chicago, IL.
Running title: Dietary fiber intake and lifetime risk for CVD and CRP Corresponding Author: Donald M. Lloyd-Jones, MD, ScM
Department of Preventive Medicine
TE D
Northwestern University Feinberg School of Medicine
680 N. Lake Shore Drive, Suite 1400
Phone: 312-908-1718 Fax: 312-908-9588
AC C
[email protected]
EP
Chicago, IL 60611
ACCEPTED MANUSCRIPT 2 Abstract Dietary fiber intake may reduce cardiovascular risk factor levels, and in turn, may lower longterm risk for cardiovascular disease (CVD). A total of 11,113 subjects who were 20 to 79 years
RI PT
old with no prior history of CVD from 2005-2010 National Health and Nutrition Examination Survey (NHANES) were included to examine associations of dietary fiber intake with predicted lifetime CVD risk and C-reactive protein (CRP) levels. Dietary fiber intake showed significant
SC
gradient association with likelihood of having low or intermediate predicted lifetime CVD risk among young and middle aged adults. In fully adjusted multinomial logistic models, dietary fiber
M AN U
intake was related to low lifetime CVD risk with odds ratios (95%CI) of 2.71 (2.05-3.59) in young, 2.13 (1.42-3.20) in middle age adults and related to intermediate lifetime risk of 2.65 (1.79-3.92) in young and 1.98 (1.32-2.98) in middle ages adults compared to high lifetime risk. There was a significant inverse linear association between dietary fiber intake and log-CRP
TE D
levels with regression coefficient (standard error) of -0.18 (0.04) in highest quartile of fiber intake compared to lowest fiber intake. In conclusion, these data suggest that dietary fiber intake is independently associated with predicted lifetime CVD risk, especially in young and middle
EP
age adults. Greater amount of dietary fiber intake may be associated with lower CRP levels.
AC C
Keywords: Dietary fiber, Lifetime Cardiovascular Disease Risk, CRP
ACCEPTED MANUSCRIPT 3 Epidemiological studies examining association of dietary intake and CVD have reported that higher dietary fiber intake is associated with lower risk for CVD events in short and intermediate-term follow-up.1-3 However it is unclear whether there is dose response relation
RI PT
between dietary fiber intake and long term risk for CVD. Knowledge of the association between dietary fiber intake and predicted lifetime CVD risk could help guide clinical and public health recommendations regarding optimal dietary patterns to improve long-term survival free of CVD.
SC
C-reactive protein (CRP), a non-specific biomarker of inflammation has been shown to be a consistent risk marker for incident CVD.4-6 Available reports also support the hypothesis of a
9
M AN U
potential correlation between dietary fiber intake and CRP levels in selected samples7_ENREF_10, but more contemporary nationally representative data are limited. Thus, the
primary objective of this study was to examine dose response associations between dietary fiber intake, predicted long-term CVD risk and CRP levels in a representative sample of the US
TE D
population. Methods
All participants were from National Health and Nutrition Examination Surveys (NHANES)
EP
datasets. Detailed methods and protocols for this study are reported elsewhere.10 Originally there were 31, 034 participants in the 2005-2006, 2007-2008 and 2009-2010 NHANES cycles. We
AC C
hierarchically excluded lactating or pregnant women (n=615), individuals younger than 20 or older than 79 years of age (n=15, 106), with previous CVD history (n=1, 650), with energy intake above or below the plausible intakes (< 600 or > 6,000 kcal/day for women or < 800 or > 8,000 kcal/day for men) (n=1, 298), and those with incomplete data information (n=1, 252). A total of 11,113 participants were pooled and included in the analyses.
ACCEPTED MANUSCRIPT 4 Race was categorized as non-Hispanic White, non-Hispanic African-American, American Hispanic or Other. Current smoking, diabetic status, physical activity, alcohol drinking, education and income level were all determined based on self-response to questionnaires. Low
RI PT
physical activity was defined as < 1 min/week moderate/vigorous intensity activity. Heavy alcohol drinking was defined as > 2 drink/day in male or >1 drink/day in female. Dietary fiber intake in the NHANES was based on two interviewer-administered 24-hour recalls, developed
SC
and validated by the US Department of Agriculture (USDA). Each unique food of a listing of the foods recorded during NHANES data collection was matched to a corresponding food item listed
M AN U
in the USDA nutrient database by name and available nutrient content. Participants' dietary intake of total fiber (in grams per 24 hours) was calculated.11 The use of fiber supplements was not included in the daily total because of limited information regarding type and quantity. Height and weight were measured during the clinical exam and used to calculate BMI (kg/m2). The
TE D
CRP level was measured by high-sensitivity latex-enhanced nephelometry for quantitative CRP determination.10
Predicted lifetime risk (LTR) for CVD was estimated using our previously published
EP
algorithm,12 as shown in Table 1. This algorithm was developed in the Framingham cohorts,13 and it has been shown to stratify lifetime CVD risk in adults. This algorithm has been validated
AC C
across the spectrum of age, sex and race using pooled data from numerous US-based cohort studies in the Cardiovascular Lifetime Risk Pooling Project.14 Here the participants were stratified a priori into three mutually exclusive groups according to their predicted LTR for CVD: low (“all optimal” or “not optimal risk factors”), intermediate (“elevated risk factors”) and high predicted LTR group (“any major risk factors”).
ACCEPTED MANUSCRIPT 5 To incorporate the complex, multistage sampling design of the NHANES in the statistical analysis, SAS procedures SURVEYFREQ, SURVEYMEANS, SURVEYREG and SURVEYLOGISTIC were utilized. Dietary fiber intake was used both as continuous and
RI PT
categorical variables (quartiles) in the analysis. Multinomial logistic regressions were performed to assess the independent association of dietary fiber intake with predicted CVD risk status (low, intermediate and high). The analyses were stratified into three age groups a priori: young (age
SC
20-39), middle (age 40-59) and old (age 60-79). We used multivariable linear regression models
0.05 was considered statistically significant. Results
M AN U
to assess the association of log-transformed CRP and dietary fiber intake. A two-tailed P value
S0002-9149(13)01942-5
DOI:
10.1016/j.amjcard.2013.09.020
Reference:
AJC 20016
To appear in:
The American Journal of Cardiology
Received Date: 11 July 2013 Revised Date:
19 September 2013
Accepted Date: 21 September 2013
Please cite this article as: Ning H, Van Horn L, Shay C, Lloyd-Jones DM, ScM , Associations of Dietary Fiber Intake with Long-Term Predicted Cardiovascular Disease Risk and C-Reactive Protein Levels (From the National Health and Nutrition Examination Survey Data [2005-2010]), The American Journal of Cardiology (2013), doi: 10.1016/j.amjcard.2013.09.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 Associations of Dietary Fiber Intake with Long-Term Predicted Cardiovascular Disease Risk and C-Reactive Protein Levels (From the National Health and Nutrition Examination
RI PT
Survey Data [2005-2010])
Hongyan Ning, MD, MSa; Linda Van Horn, PhD, RDa; Christina Shay, PhD, MAa; and Donald M. Lloyd-Jones, MD, ScMa,b
SC
Author Affiliations: aDepartment of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; bBluhm Cardiovascular Institute, Department of Medicine, Northwestern University Feinberg School
M AN U
of Medicine, Chicago, IL.
Running title: Dietary fiber intake and lifetime risk for CVD and CRP Corresponding Author: Donald M. Lloyd-Jones, MD, ScM
Department of Preventive Medicine
TE D
Northwestern University Feinberg School of Medicine
680 N. Lake Shore Drive, Suite 1400
Phone: 312-908-1718 Fax: 312-908-9588
AC C
[email protected]
EP
Chicago, IL 60611
ACCEPTED MANUSCRIPT 2 Abstract Dietary fiber intake may reduce cardiovascular risk factor levels, and in turn, may lower longterm risk for cardiovascular disease (CVD). A total of 11,113 subjects who were 20 to 79 years
RI PT
old with no prior history of CVD from 2005-2010 National Health and Nutrition Examination Survey (NHANES) were included to examine associations of dietary fiber intake with predicted lifetime CVD risk and C-reactive protein (CRP) levels. Dietary fiber intake showed significant
SC
gradient association with likelihood of having low or intermediate predicted lifetime CVD risk among young and middle aged adults. In fully adjusted multinomial logistic models, dietary fiber
M AN U
intake was related to low lifetime CVD risk with odds ratios (95%CI) of 2.71 (2.05-3.59) in young, 2.13 (1.42-3.20) in middle age adults and related to intermediate lifetime risk of 2.65 (1.79-3.92) in young and 1.98 (1.32-2.98) in middle ages adults compared to high lifetime risk. There was a significant inverse linear association between dietary fiber intake and log-CRP
TE D
levels with regression coefficient (standard error) of -0.18 (0.04) in highest quartile of fiber intake compared to lowest fiber intake. In conclusion, these data suggest that dietary fiber intake is independently associated with predicted lifetime CVD risk, especially in young and middle
EP
age adults. Greater amount of dietary fiber intake may be associated with lower CRP levels.
AC C
Keywords: Dietary fiber, Lifetime Cardiovascular Disease Risk, CRP
ACCEPTED MANUSCRIPT 3 Epidemiological studies examining association of dietary intake and CVD have reported that higher dietary fiber intake is associated with lower risk for CVD events in short and intermediate-term follow-up.1-3 However it is unclear whether there is dose response relation
RI PT
between dietary fiber intake and long term risk for CVD. Knowledge of the association between dietary fiber intake and predicted lifetime CVD risk could help guide clinical and public health recommendations regarding optimal dietary patterns to improve long-term survival free of CVD.
SC
C-reactive protein (CRP), a non-specific biomarker of inflammation has been shown to be a consistent risk marker for incident CVD.4-6 Available reports also support the hypothesis of a
9
M AN U
potential correlation between dietary fiber intake and CRP levels in selected samples7_ENREF_10, but more contemporary nationally representative data are limited. Thus, the
primary objective of this study was to examine dose response associations between dietary fiber intake, predicted long-term CVD risk and CRP levels in a representative sample of the US
TE D
population. Methods
All participants were from National Health and Nutrition Examination Surveys (NHANES)
EP
datasets. Detailed methods and protocols for this study are reported elsewhere.10 Originally there were 31, 034 participants in the 2005-2006, 2007-2008 and 2009-2010 NHANES cycles. We
AC C
hierarchically excluded lactating or pregnant women (n=615), individuals younger than 20 or older than 79 years of age (n=15, 106), with previous CVD history (n=1, 650), with energy intake above or below the plausible intakes (< 600 or > 6,000 kcal/day for women or < 800 or > 8,000 kcal/day for men) (n=1, 298), and those with incomplete data information (n=1, 252). A total of 11,113 participants were pooled and included in the analyses.
ACCEPTED MANUSCRIPT 4 Race was categorized as non-Hispanic White, non-Hispanic African-American, American Hispanic or Other. Current smoking, diabetic status, physical activity, alcohol drinking, education and income level were all determined based on self-response to questionnaires. Low
RI PT
physical activity was defined as < 1 min/week moderate/vigorous intensity activity. Heavy alcohol drinking was defined as > 2 drink/day in male or >1 drink/day in female. Dietary fiber intake in the NHANES was based on two interviewer-administered 24-hour recalls, developed
SC
and validated by the US Department of Agriculture (USDA). Each unique food of a listing of the foods recorded during NHANES data collection was matched to a corresponding food item listed
M AN U
in the USDA nutrient database by name and available nutrient content. Participants' dietary intake of total fiber (in grams per 24 hours) was calculated.11 The use of fiber supplements was not included in the daily total because of limited information regarding type and quantity. Height and weight were measured during the clinical exam and used to calculate BMI (kg/m2). The
TE D
CRP level was measured by high-sensitivity latex-enhanced nephelometry for quantitative CRP determination.10
Predicted lifetime risk (LTR) for CVD was estimated using our previously published
EP
algorithm,12 as shown in Table 1. This algorithm was developed in the Framingham cohorts,13 and it has been shown to stratify lifetime CVD risk in adults. This algorithm has been validated
AC C
across the spectrum of age, sex and race using pooled data from numerous US-based cohort studies in the Cardiovascular Lifetime Risk Pooling Project.14 Here the participants were stratified a priori into three mutually exclusive groups according to their predicted LTR for CVD: low (“all optimal” or “not optimal risk factors”), intermediate (“elevated risk factors”) and high predicted LTR group (“any major risk factors”).
ACCEPTED MANUSCRIPT 5 To incorporate the complex, multistage sampling design of the NHANES in the statistical analysis, SAS procedures SURVEYFREQ, SURVEYMEANS, SURVEYREG and SURVEYLOGISTIC were utilized. Dietary fiber intake was used both as continuous and
RI PT
categorical variables (quartiles) in the analysis. Multinomial logistic regressions were performed to assess the independent association of dietary fiber intake with predicted CVD risk status (low, intermediate and high). The analyses were stratified into three age groups a priori: young (age
SC
20-39), middle (age 40-59) and old (age 60-79). We used multivariable linear regression models
0.05 was considered statistically significant. Results
M AN U
to assess the association of log-transformed CRP and dietary fiber intake. A two-tailed P value
