Relation of Intake of Saturated Fat to Atherosclerotic Risk Factors, Health Behaviors, Coronary Atherosclerosis, and All-Cause Mortality Among Patients Who Underwent Coronary Artery Calcium Scanning

doi:10.1016/j.amjcard.2020.10.014

The American Journal of Cardiology

Volume 138, 1 January 2021, Pages 40-45

https://doi.org/10.1016/j.amjcard.2020.10.014 Get rights and content

Although very brief questionnaires are commonly used to assess physical activity, an analogous approach for assessing diet quality within clinical practice has not been developed. Thus, we undertook an exploratory study to evaluate the association between a single-item questionnaire regarding dietary quality and patient risk profiles, lifestyle habits, lipid values, coronary artery calcium (CAC) scores and mortality. We assessed 15,368 patients who underwent CAC scanning, followed for a median of 12.1 years for all-cause mortality. Diet quality was assessed according to a single-item question regarding self-reported adherence to a low saturated fat diet (0 = never, 10 = always), with patients categorized into 4 dietary groups based on their response, ranging from low to very high saturated fat intake. We observed a significant stepwise association between reported saturated fat intake and smoking, exercise activity, obesity, and serum cholesterol, low density lipoprotein, and triglyceride values. Following adjustment for age and risk factors, patients reporting very high saturated fat intake had an elevated hazard ratio for mortality versus low saturated fat intake: 1.22 (95% confidence interval 1.04 to 1.44). The hazard ratio was no longer significant after further adjustment for exercise activity. Upon division of patients according to baseline CAC, a stepwise relationship was noted between increasing saturated fat intake and mortality among patients with CAC scores ≥400 (p = 0.002). Thus, within our cohort, just a single-item exploratory questionnaire regarding very high saturated fat intake revealed stepwise associations with health behaviors and cardiac risk factors, suggesting the basis for further development of a practical dietary questionnaire for clinical purposes.

Section snippets

Methods

The trial participants consisted of 19,583 consecutive patients who underwent coronary artery calcium (CAC) scanning at Cedars-Sinai Medical Center between September 1, 1998 and December 31, 2012. Of those, 18,223 had self-reported information available about their dietary fat intake. We excluded 1,446 with known coronary artery disease and 1,409 who were lost to >5 years follow-up. This resulted in a study cohort of 15,368. The study was approved by the Cedars-Sinai Institutional Review Board.

Results

Comparison of the clinical characteristics of our patient cohort, divided according to self-reported saturated fat dietary intake, is shown in Table 1. There were only modest differences in family history of premature CAD, hypertension, and diabetes among the groups, but the frequency of smoking was highest among the subjects reporting the highest saturated fat intake. The mean body mass index was also highest among the patients reporting very high saturated fat intake. Mean reported exercise

Discussion

Diet quality is generally assessed using quantitative techniques, such as food frequency questionnaires or dietary recall. The use of ultra-short dietary questionnaires, consisting of just few items, has not yet been assessed for their potential use in clinical practice settings. Thus, we undertook the present study to examine the clinical correlates of an ultrashort, single-item dietary survey concerning saturated fat intake. Among our patients, the frequency of smoking, very low exercise

Author Contributions

Alan Rozanski, MD - conception, analysis of data, writing draft, editing

Yoav Arnson, MD – conception, analysis of data, writing draft, editing

Heidi Gransar, MS -statistical analysis

Sean W. Hayes, MD – data curation, supervision, review and editing

John D. Friedman, MD – data curation, supervision, review and editing

Louise E.J. Thomson, MD – data curation, supervision, review and editing

Daniel S. Berman, MD - conception, analysis of data, writing draft, editing

Disclosures

Dr. Berman participates in software royalties for QPS software at Cedars-Sinai Medical Center. None of the other authors have conflicts of interest.

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2023, American Journal of Clinical Nutrition
The impact of the dietary fat type on type 2 diabetes (T2D) remains unclear.
We aimed to evaluate the effects of replacing dietary saturated fatty acids (SFA) with mono- or poly-unsaturated fatty acids (MUFA and PUFA, respectively) on insulin sensitivity, pancreatic β-cell function, and glucose tolerance, as surrogate endpoints for T2D.
We conducted a systematic review and meta-analysis of randomized controlled trials that replaced ≥5% of total energy intake provided by SFA with MUFA or PUFA and reported indexes of insulin sensitivity, β-cell function, and/or glucose tolerance. We searched MEDLINE, Scopus, and the Cochrane Library (CENTRAL) up to 9 January, 2023. Eligible interventions had to be isocaloric, with no significant difference in other macronutrients. Data were synthesized using random-effects model meta-analysis.
Of 6355 records identified, 10 parallel and 20 crossover trials with 1586 participants were included. The mean age of the participants was 42 years, 47% were male, mean body mass index (BMI; in kg/m²) was 26.8, median baseline fasting glucose was 5.13 mmol/L, and the median duration of interventions was 5 weeks. Replacing SFA with MUFA or PUFA had no significant effects on insulin sensitivity [standardized mean difference (SMD) SFA compared with MUFA: 0.01, 95% confidence interval (CI): −0.06 to 0.09, I² = 0% and SMD SFA compared with PUFA: 0, 95% CI: −0.15 to 0.14, I² = 0%]. Replacing SFA with MUFA did not significantly impact the β-cell function, evaluated by the disposition index (mean difference: −12, 95% CI: −158 to 133, I²=0%). Evidence on glucose tolerance (SFA compared with MUFA or PUFA) and on β-cell function when SFA were replaced with PUFA was scant.
Short-term substitution of saturated with unsaturated fat does not significantly affect insulin sensitivity nor β-cell function (the latter in the SFA compared with MUFA comparison). Future studies are needed to elucidate longer term effects of dietary fat saturation on glucose homeostasis. This trial was registered at PROSPERO as CRD42020178382.
Assessment of lifestyle “vital signs” in healthcare settings
2023, Progress in Cardiovascular Diseases
Unhealthy lifestyles, such as maintenance of poor diets and physical inactivity, are a powerful driver of disease-producing risk factors and chronic illnesses. This has led to an increasing call to assess adverse lifestyle factors in healthcare settings. This approach could be aided by designating health-related lifestyle factors as “vital signs” that can be recorded during patient visits. Just such an approach has been used for assessing patients' smoking habits since the 1990s. In this review, we assess the rationale for addressing six other health-related lifestyle factors, beyond smoking, in patient care settings: physical activity (PA), sedentary behavior (SB), participation in muscle strengthening exercises, mobility limitations, diet, and sleep quality. For each domain, we evaluate the evidence that supports currently proposed ultra-short screening tools. Our analysis indicates strong medical evidence to support the use of one to two-item screening questions for assessing patients' PA, SB, muscle strengthening activities, and presence of “pre-clinical” mobility limitations. We also present a theoretical basis for measuring patients' diet quality through use of an ultrashort dietary screen, based on evaluation of healthy food intake (fruits/vegetables) and unhealthy food intake (high consumption of highly processed meats and/or consumption of sugary foods and beverages) and a proposed evaluation of sleep quality using a single-item screener. The result is a 10-item lifestyle questionnaire that is based on patient self-report. As such, this questionnaire has the potential to be employed as a practical tool for assessing health behaviors in clinical care settings without impairing the normal workflow of healthcare providers.
Subclinical cardiovascular disease and utility of coronary artery calcium score
2021, IJC Heart and Vasculature
Citation Excerpt :
Gao et al. [131] observed an inverse non-linear association of carbohydrate intake with CAC-s progression which is most pronounced for male-vs-female genders and white-vs-black ethnicities, across 3 categories of carbohydrate intake as percentage intervals of total energy (low < 43%, moderate 43%-53% and high ≥ 53%) most significant difference in risk of CAC-progression was for those High-vs-Low carbohydrate intake (HR = 0.731, 95% CI:0.552–0.968) at which in LCD-score (Low Carbohydrate Diet Score) analysis, as the summary for intake of carbohydrate and either animal or plant sourced protein and fat, animal-based LCD score significantly associated with CAC-progression (HR = 1.456, p = 0.041) yet plant-based LCD score remained similar for risk of CAC-progression (HR = 1.016, p = 0.884). A cohort study by Rozanski et al. [132] including 15,368 participants with median follow-up period of 12.1 years to examine relations of self-reported frequencies on 10-unit scale for physical activity and intake of low-saturated fat intake, which was subsequently categorized inversely to 4 saturated-fat score categories noted as low[8,10], moderate[6,7], high[3,5] and very-high[0,2], with CACs and serum lipid panel, observed a significant stepwise trend across increasing self-reported saturated fat consumption categories with higher levels of cholesterol, LDL and TG, and lower HDL and physical activity yet no significant difference for CACs, moreover, by Kaplan-Meir survival curve participants with self-reported very-high saturated-fat category had lowest survival rate in adjusted model (of age, gender, hypertension, diabetes, dyslipidemia and smoking) but further adjustment for self-reported physical activity attenuates these associations, nonetheless, survival rate differences among 4 saturated-fat categories were modified with CACs categories (of 0, 1–399 and > 400 AU) as gaining strength with increasing CACs category and for CACs > 400 a stepwise decrease in survival as high and very-high vs low/moderate saturated-fat categories. A cross-sectional study by Gripeteg et al. [95], including 706 Swedish adult participants to analyze compound association of Healthy Food Index (HFI) compiled from consumption frequencies of 17 food items in 5 groups (as vegetables, fruits, nuts, vegetable oils of olive and canola, and fatty fish) and Cardiorespiratory Fitness Index (CRF) predicted by the Eklom-Bak equation derived from quotient of difference in heart rate over power, with CAC score demonstrated HFI significantly associated with higher rates of zero-CAC against non-zero CAC, and interaction of HFI and CRF significantly negatively associated with CAC-score in regression analysis.
ASCVD are the leading causes of mortality and morbidity among Globe. Evaluation of patients’ comprehensive and personalized risk provides risk management strategies and preventive interventions to achieve gain for patients. Framingham Risk Score (FRS) and Systemic Coronary Risk Evaluation Score (SCORE) are two well studied risk scoring models, however, can miss some (20–35%) of future cardiovascular events. To obtain more accurate risk assessment recalibrating risk models through utilizing novel risk markers have been studied in last 3 decades and both ESC and AHA recommends assessing Family History, hs-CRP, CACS, ABI, and CIMT. Subclinical Cardiovascular Disease (SCVD) has been conceptually developed for investigating gradually progressing asymptomatic development of atherosclerosis and among these novel risk markers it has been well established by literature that CACS having highest improvement in risk assessment. This review study mainly selectively discussing studies with CACS measurement. A CACS = 0 can down-stratify risk of patients otherwise treated or treatment eligible before test and can reduce unnecessary interventions and cost, whereas CACS ≥ 100 is equivalent to statin treatment threshold of ≥ 7.5% risk level otherwise statin ineligible before test. Since inflammation, insulin resistance, oxidative stress, dyslipidemia and ongoing endothelial damage due to hypertension could lead to CAC, ASCVD linked with comorbidities. Recent cohort studies have shown a CACS 100–300 as a sign of increased cancer risk. Physical activity, dietary factors, cigarette use, alcohol consumption, metabolic health, family history of CHD, aging, exposures of neighborhood environment and non-cardiovascular comorbidities can determine CACs changes.
Feasibility of Using an Ultrashort Lifestyle Questionnaire to Predict Future Mortality Risk among Patients with Suspected Heart Disease
2021, American Journal of Cardiology
Citation Excerpt :
Patients self-reported adherence to a low saturated fat diet was assessed according to another single-item question “To what extent are you on a low saturated fat diet?” ( 0 = never to 10 = always).13 The answers to both questions were assigned points to generate sub-scores in the following manner: scores of 0-2= 3 points; scores of 3-5= 2 points; scores of 6-7= 1 point; scores of 8-10= 0 points.
Adverse health behaviors are potent drivers of chronic disease and premature mortality. This has led to the development of various lifestyle scores to predict clinical risk, but their complexity makes them impractical for use in clinical settings. Thus, there is a need to develop a brief lifestyle score that can assess factors such as exercise and diet within the constraints of routine medical practice. Accordingly, we assessed 19,081 patients undergoing coronary artery calcium (CAC) scanning between September 1, 1998 and December 30, 2016. Each patient completed a questionnaire that included a two-item lifestyle scale regarding patients’ frequency of exercise and adherence to a low saturated fat diet. Patients’ responses were used to generate a lifestyle score which ranged from very low risk to high risk. Patients were followed for a median of 11.0 years for all-cause mortality. A stepwise relationship was noted between worse lifestyle scores and increased frequency of hypertension, diabetes, smoking, obesity, waist/hip ratio, and resting heart rate and blood pressure. Among patients with zero CAC scores, mortality risk was low regardless of lifestyle score, but as CAC abnormality increased, a stepwise relationship emerged between worse lifestyle scores and mortality. The lifestyle score was more predictive of mortality than conventional CAD risk factors according to multivariable Chi-square analysis. Thus, our results establish the practicality of an ultrashort lifestyle questionnaire that could be employed in nearly all clinical settings. Within our study, our two-item lifestyle scale showed a stepwise relationship to known CAD risk factors and predicted future mortality.

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Relation of Intake of Saturated Fat to Atherosclerotic Risk Factors, Health Behaviors, Coronary Atherosclerosis, and All-Cause Mortality Among Patients Who Underwent Coronary Artery Calcium Scanning

Section snippets

Methods

Results

Discussion

Author Contributions

Disclosures

JACC Cardiovasc Imaging

J Nutr

J Am Coll Cardiol

Using a single-item physical activity measure to describe and validate parents' physical activity patterns

Res Q Exerc Sport

Reliability and validity testing of a single-item physical activity measure

Br J Sports Med

Reproducibility and validity of a short food questionnaire for the assessment of dietary habits

Nutr Metab Cardiovasc Dis

Reproducibility and validity of a simple checklist-type questionnaire for food intake and dietary behavior

J Epidemiol