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Dietary Patterns and the Risk of Coronary Heart Disease in Women
Teresa T. Fung, ScD, RD;
Walter C. Willett, MD, DrPH;
Meir J. Stampfer, MD, DrPH;
JoAnn E. Manson, MD, DrPH;
Frank B. Hu, MD, PhD
Arch Intern Med. 2001;161:1857-1862.
ABSTRACT
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Background Although substantial information on individual nutrients or foods and
risk of coronary heart disease (CHD) is available, little is known about the
role of overall eating pattern.
Methods Using dietary information from a food frequency questionnaire in 1984
from the Nurses' Health Study, we conducted factor analysis and identified
2 major dietary patterns—"prudent" and "Western"—and calculated
factor scores of each pattern for individuals in the cohort. We used logistic
regression to examine prospectively the associations between dietary patterns
and CHD risk among 69 017 women aged 38 to 63 years in 1984 without history
of major chronic diseases.
Results The prudent pattern was characterized by higher intakes of fruits, vegetables,
legumes, fish, poultry, and whole grains, while the Western pattern was characterized
by higher intakes of red and processed meats, sweets and desserts, french
fries, and refined grains. Between 1984 and 1996, we documented 821 CHD cases.
After adjusting for coronary risk factors, the prudent diet score was associated
with a relative risk (RR) of 0.76 (95% confidence interval (CI), 0.60-0.98; P for trend test, .03) comparing the highest with lowest
quintile. Extreme quintile comparison yielded an RR of 1.46 (95% CI, 1.07-1.99; P for trend test, .02) for the Western pattern. Those who
were jointly in the highest prudent diet quintile and lowest Western diet
quintile had an RR of 0.64 (95% CI, 0.44-0.92) compared with those with the
opposite pattern profile.
Conclusion A diet high in fruits, vegetables, whole grains, legumes, poultry, and
fish and low in refined grains, potatoes, and red and processed meats may
lower risk of CHD.
INTRODUCTION
TRADITIONALLY, nutritional epidemiology has largely focused on the effects
of single nutrients or foods on disease outcomes.1-3
However, because nutrients and foods are consumed in combination, their joint
effects may be best investigated by considering the entire eating pattern.
Analyzing food consumption in the form of dietary patterns offers a perspective
different from the traditional single-nutrient focus and may provide a comprehensive
approach to disease prevention or treatment, which has been used in several
settings, including Dietary Approach to Stop Hypertension4
and the Lyon Diet Heart Study.5
In a previous study of men, we identified 2 major dietary patterns by
factor analysis.6 One is labeled the "prudent
pattern," characterized by a higher intake of fruits, vegetables, fish, whole
grains, and legumes. The other pattern is labeled the "Western pattern," characterized
by a higher intake of red and processed meat, high-fat dairy products, sweets,
and desserts. These 2 patterns significantly predicted the risk of coronary
heart disease (CHD) during 8 years of follow-up among 44 875 men in the
Health Professionals' Follow-up Study.7 However,
such associations have not been examined in women. Because eating patterns
may differ between men and women, we therefore examined prospectively the
associations between dietary patterns and the risk of CHD among women in the
Nurses' Health Study.
SUBJECTS AND METHODS
STUDY POPULATION
The Nurses' Health Study began in 1976, when 121 700 female nurses
aged 30 to 55 years in 11 US states responded to a questionnaire regarding
medical, lifestyle, and other health-related information.8
Since then, questionnaires have been sent biennially to update this information.
In 1980, the participants completed a 61-item food frequency questionnaire
(FFQ). In 1984, the FFQ was expanded to 116 items. Similar FFQs were sent
to the women in 1986, 1990, and 1994. We used the 1984 FFQ as baseline for
this study because it was similar to the baseline (1986) FFQ used in the Health
Professionals' Follow-up Study.
For the present analysis, women were included if they completed the
1984 semiquantitative FFQ with less than 70 missing items and a total caloric
range (as calculated from the FFQ) between 500 and 3500 kcal/d. We excluded
women with a history of myocardial infarction (MI) (n = 484), angina (n =
1604), coronary artery bypass surgery (n = 40), hypercholesterolemia (n =
5669), diabetes (n = 2127), and stroke (n = 178). We excluded subjects with
diabetes and high cholesterol level because diagnoses of these conditions
at baseline may lead to change in diet. We then included in this analysis
69 017 women with follow-up for up to 12 years, from 1984 to 1996.
ASSESSMENT OF DIETARY INTAKE
Dietary intake information was collected by FFQs. The questionnaire
was designed to assess average food intake during the previous year, and standard
portion size was given for each food item. Cohort members were asked to choose
from 9 possible frequency responses, ranging from "never" to "more than 6
times a day" for each food. Total caloric intake was calculated by summing
up intakes from all foods. For this analysis, we used information from the
FFQ administered in 1984, which had 116 items. Foods from the FFQ were classified
into 38 food groups based on nutrient profiles or culinary usage in a manner
similar to that in a previous study in men (food group classifications are
available from the authors).7 Foods that did
not fit into any of the groups or that may represent distinctive dietary behaviors
were left as individual categories (eg, pizza, tea, beer). Previous validation
studies among members of the NHS cohort showed good correlations between nutrients
assessed by the FFQ and multiple weeks of food records completed during the
previous year.9
END POINT ASCERTAINMENT
Our end point included fatal CHD and nonfatal MI that occurred between
the return of the 1984 questionnaire and June 1, 1996. We sought permission
to review medical records of all self-reports of incident MI for confirmation
of diagnosis. These records were reviewed by physicians with no knowledge
of the participants' risk factor status. Myocardial infarctions were confirmed
by World Health Organization criteria based on symptoms and changes in electrocardiogram
or cardiac enzymes.10 Infarctions that required
hospitalization were classified as probable when confirmatory information
was obtained by letter or interview, but medical records were not available.
Probable cases were included in our analysis (approximately 17%).
Deaths were reported by family members, by the postal service, or through
searches in the National Death Index,11 and
ascertainment was 98% complete. Fatal MI was confirmed by medical records,
autopsy reports, or death certificate if a diagnosis of CHD was also identified
from other sources. We also designated the cause of death as presumed CHD
if it was indicated on death certificates but additional medical records were
not available. In addition, deaths that occurred within 1 hour after the onset
of symptoms with no other plausible non–CHD-related cause of death were
also included as fatal CHD cases (about 12% of fatal CHD cases).
STATISTICAL ANALYSIS
Dietary patterns were generated by factor analysis (principal components)
on the basis of 38 food groups by means of the orthogonal rotation procedure.12 This results in uncorrelated factors, which are easier
to interpret. We determined the number of factors to retain by eigenvalue
(greater than 1), Scree test, and factor interpretability. The factor score
for each pattern was found by summing intakes of food groups weighted by factor
loading,13 and each individual received a factor
score for each identified pattern. Good reproducibility with this method has
been obtained in a parallel cohort of men.6
Factor analysis was conducted with SAS PROC FACTOR (SAS Institute Inc, Cary,
NC).14
To quantify association between dietary patterns and CHD risk, we used
person-time analysis. Study participants began contributing follow-up time
from the date of return of the 1984 FFQ. Accumulation of follow-up time ceased
on first diagnosis of MI, death, the last date of questionnaire return, or
June 1, 1996. The incidence rate for each dietary pattern was calculated by
dividing the number of CHD cases in each quintile of pattern scores by the
person-years of follow-up.
Multivariate relative risks (RRs) of each of the dietary patterns in
1984 for CHD were calculated by means of pooled logistic regression with 2-year
increments. For rare events, this method approximates the Cox proportional
hazard model with time-dependent covariates.15-16
We adjusted for age (5-year categories), smoking (never, past, and 1-14, 15-24,
or  25 cigarettes per day), energy intake, body mass index (calculated
as weight in kilograms divided by the square of height in meters; 5 categories),
multivitamin and vitamin E supplement use, physical activity (5 categories
in hours per week), hormone replacement therapy (premenopause, never, past,
or current), parental history of MI, and history of hypertension. We also
tested for interaction between the 2 dietary patterns by creating categorical
interaction terms of the 2 patterns and comparing the log likelihood of this
model with the model that contained the main effects only. We also considered
dietary pattern scores as cumulative average to reduce within-person variation
and to represent long-term intake.17 For example,
the 1984 dietary patterns were used in relation to incidence from 1984 to
1986, the average of 1984 and 1986 dietary pattern scores were used to predict
incidence in 1986 and 1988, and so forth. We stopped updating dietary information
if an individual developed hypertension or an intermediate cardiac end point
such as angina.
RESULTS
We identified 2 major dietary patterns with the factor analysis procedure. Table 1 shows the factor loading matrix
for the 2 patterns. A positive loading indicates positive association with
the factor, and vice versa for a negative loading. The magnitude of the loading
indicates the degree of contribution of the particular food group to the factor.
The first factor was heavily contributed to by fruits, vegetables, whole grains,
legumes, poultry, and fish. The second factor was heavily contributed to by
refined grains, processed and red meats, desserts, high-fat dairy products,
and french fries. As with our previous studies, we labeled the first factor
the "prudent" pattern and the second factor the "Western" pattern.6
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Table 1. Factor Loading Matrix for the 1984 FFQ in the NHS*
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Individuals with high prudent-pattern scores tended to smoke less; use
more vitamin supplements; drink more alcohol; consume more folate, fiber,
and protein; and consume less saturated and monounsaturated fats (Table 2). As expected, they also had higher
intakes of fruits, vegetables, whole grains, and low-fat dairy products. On
the other hand, those with high "Western" pattern scores were more likely
to be current smokers, use fewer vitamin supplements, consume more fat, and
consume less folate and fiber (Table 3).
Their diets also contained more red and processed meats, eggs, butter, and
refined grains.
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Table 2. Age-Standardized Baseline Characteristics According to Quintiles
of "Prudent" Diet Score in 1984*
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Table 3. Age-Standardized Baseline Characteristics According to Quintiles
of Western Diet Score in 1984*
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Between 1984 and 1996, we accumulated 801 075 person-years of follow-up
and identified 821 incident cases of CHD. After adjustment for age, a higher
prudent-pattern score was associated with a lower risk of total CHD (P for trend, <.001) (Table 4). The RR comparing the highest prudent-pattern quintile
to the lowest was 0.61 (95% confidence interval [CI], 0.49-0.76). After adjusting
for body mass index, smoking, caloric intake, supplemental vitamin use, hormone
replacement therapy, and other coronary risk factors, the prudent pattern
remained significantly and inversely associated with the risk of CHD (P for trend, .03) (Table
4). The RR for the top quintile was 0.76 (95% CI, 0.60-0.98) compared
with the lowest quintile of prudent-pattern score. In contrast, a higher Western-pattern
score was associated with a higher risk of total MI after adjusting for age
(P for trend, <.001) (Table 4). The RR for the top quintile vs the lowest quintile was
1.44 (95% CI, 1.16-1.78). The significant positive association remained after
multivariate adjustment (P for trend = .02). The
RR for the top quintile vs the lowest quintile was 1.46 (95% CI, 1.07-1.99).
Separate analyses of fatal CHD and nonfatal MI produced similar results (data
not shown). The inverse association between the prudent pattern and the risk
of CHD was not appreciably different between smokers and nonsmokers, lean
and overweight individuals, and those with and without a family history of
CHD (data not shown). Also, the positive associations between the Western
pattern and CHD persisted in all subgroups. Results using average dietary
patterns between 1984 and 1994 were also similar to those using the 1984 dietary
information only. The RRs comparing extreme quintiles were 0.76 (95% CI, 0.60-0.95)
for the prudent pattern and 1.30 (95% CI, 0.98-1.73) for the Western pattern.
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Table 4. Relative Risk (RR) and 95% CI of 1984 Dietary Patterns for
Total CHD (1984-1996)*
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In an additional analysis, we examined the association between joint
classifications of both patterns and risk of CHD. As expected, the risk of
CHD tended to decrease with increasing prudent-pattern score at any level
of Western pattern score (Figure 1).
Similarly, the risk of CHD tended to increase with increasing Western-pattern
score. The lowest risk was at the highest level of prudent score and lowest
level of Western score (RR, 0.64; 95% CI, 0.44-0.92). The test for interaction
between the 2 dietary patterns was not statistically significant (P = .26 for interaction).
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Multivariate relative risk (RR) of dietary patterns and coronary
heart disease, adjusted for age, period, smoking, body mass index, hormone
replacement therapy, aspirin use, caloric intake, family history, history
of hypertension, multivitamin and vitamin E use, and physical activity.
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COMMENT
In this large cohort of women, we identified 2 major dietary patterns
by means of factor analysis. The prudent pattern was characterized by a higher
intake of fruits, vegetables, whole grains, legumes, poultry, and fish. On
the other hand, the Western pattern was characterized by a higher intake of
red and processed meats, high-fat dairy products, french fries, refined grains,
and desserts and sweets. We found a significant inverse association between
the prudent pattern and the risk of total CHD and a positive association between
the Western pattern and the risk of CHD.
The 2 major patterns were similar to those observed among men in the
Health Professionals' Follow-up Study.7 Also,
our observed association between dietary patterns and MI were consistent with
that in our previous study in men, in which the RR of CHD comparing extreme
quintiles was 0.70 (95% CI, 0.56-0.86) for the prudent pattern and 1.64 (1.24-2.17)
for the Western pattern.7 Therefore, the major
dietary patterns derived through factor analysis appear to be applicable to
both men and women. The relationship between eating patterns and CHD risk
may act through biochemical risk factors for CHD. In a previous study of 466
men, we found that the prudent pattern was associated with lower levels of
insulin, and the Western pattern was associated with higher levels of tissue
plasminogen activator, fasting insulin, leptin, and homocysteine.18 Women with a higher prudent-pattern score in our
study had a higher intake of fiber, protein, and folate. Thus, it is likely
that the inverse association between prudent pattern and CHD was mediated
by these nutrients.
The 2 major patterns were also similar to those observed in other studies.
In a study of diet and colon cancer from members of the Kaiser Permanente
Medical Care Program, several patterns were identified, and the 2 major patterns
were similar to those we have identified.19
In a group of Canadians, 3 food patterns—high-energy, traditional, and
health-conscious—were identified.20 The
health-conscious pattern was similar to the prudent diet in our study. A major
challenge in studying dietary patterns and disease risk is to establish a
quantitative method to identify eating patterns, unless a specific pattern
(eg, Mediterranean) has been specified. The factor analysis approach involves
several arbitrary but important decisions, including the consolidation of
food items into food groups, and the number of factors to extract. Nevertheless,
the major patterns identified through factor analyses are consistent with
a priori expectation of patterns. The lower rate of CHD in Asia and the Mediterranean
region may in part result from their respective dietary patterns.21 Diets in Japan and Crete, for example, are in some
ways similar to the prudent pattern in this study, with low amounts of animal
products and higher amounts of vegetables and whole grains.22-23
Intervention studies have demonstrated the effectiveness of modifying multiple
aspects of the diet in prevention or treatment of diseases. The Dietary Approach
to Stop Hypertension trial emphasized fruits, vegetables, and low-fat dairy
products and successfully reduced both diastolic and systolic blood pressure
in hypertensive subjects.4 Also, in the Lyon
Diet Heart Study, patients with a history of MI who followed the Mediterranean
diet with a high amount of  -linolenic acid had significantly fewer
subsequent cardiac events and mortality than those who followed a regular
low-fat diet.5
The present study used prospectively collected data with minimal loss
to follow-up and therefore rendered information and selection bias highly
improbable. We also extensively controlled for variables that could possibly
confound the association, such as physical activity, vitamin supplements,
smoking, obesity, and use of postmenopausal hormones. However, because different
ethnic groups or populations at different regions may have different dietary
patterns, our results need to be verified in different populations.
In conclusion, major dietary patterns identified by means of factor
analysis significantly predicted the risk of CHD in this cohort of women.
This study indicates that a diet high in fruits, vegetables, legumes, whole
grains, poultry, and fish and low in red and processed meats and refined grain
products may lower risk of CHD in women.
AUTHOR INFORMATION
Accepted for publication January 11, 2001.
This study was supported by grants HL60712, CA40356, HL34594, and HL24074
from the National Institutes of Health, Bethesda, Md.
Presented as a poster at the Annual Meeting of the Society of Epidemiological
Research, Seattle, Wash, June 16, 2000.
Corresponding author and reprints: Teresa T. Fung, ScD, RD, Programs
in Nutrition, Simmons College, 300 The Fenway, Boston, MA 02115 (e-mail:
teresa.fung{at}simmons.edu).
From the Departments of Nutrition (Drs Fung, Willett, Stampfer, and
Hu) and Epidemiology (Drs Willett, Stampfer, and Manson), Harvard School of
Public Health, Boston, Mass; Channing Laboratory (Drs Willett, Stampfer, and
Manson), Department of Medicine, and Department of Preventive Medicine (Dr
Manson), Brigham and Women's Hospital and Harvard Medical School, Boston;
and Programs in Nutrition, Simmons College, Boston (Dr Fung).
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Application of a New Statistical Method to Derive Dietary Patterns in Nutritional Epidemiology
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Am J Epidemiol 2004;159:935-944.
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Dietary patterns associated with risk factors for cardiovascular disease in healthy US adults
Kerver et al.
Am. J. Clin. Nutr. 2003;78:1103-1110.
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Dietary Pattern Is Associated with Homocysteine and B Vitamin Status in an Urban Chinese Population
Gao et al.
J. Nutr. 2003;133:3636-3642.
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Plant-based diets: what should be on the plate?
Fung and Hu
Am. J. Clin. Nutr. 2003;78:357-358.
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Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy
Jacobs and Steffen
Am. J. Clin. Nutr. 2003;78:508S-513.
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Plant-based foods and prevention of cardiovascular disease: an overview
Hu
Am. J. Clin. Nutr. 2003;78:544S-551.
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Risk of Hypertension among Women in the EPIC-Potsdam Study: Comparison of Relative Risk Estimates for Exploratory and Hypothesis-oriented Dietary Patterns
Schulze et al.
Am J Epidemiol 2003;158:365-373.
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Adherence to a Mediterranean Diet and Survival in a Greek Population
Trichopoulou et al.
NEJM 2003;348:2599-2608.
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Patterns of food consumption and risk factors for cardiovascular disease in the general Dutch population
van Dam et al.
Am. J. Clin. Nutr. 2003;77:1156-1163.
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Effects of Comprehensive Lifestyle Modification on Blood Pressure Control: Main Results of the PREMIER Clinical Trial
Writing Group of the PREMIER Collaborative Researc
JAMA 2003;289:2083-2093.
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Major Dietary Patterns and the Risk of Colorectal Cancer in Women
Fung et al.
Arch Intern Med 2003;163:309-314.
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Optimal Diets for Prevention of Coronary Heart Disease
Hu and Willett
JAMA 2002;288:2569-2578.
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Invited Commentary: To Sleep, Perchance to Discover
Strohl
Am J Epidemiol 2002;155:394-395.
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Dietary Patterns and Risk for Type 2 Diabetes Mellitus in U.S. Men
van Dam et al.
ANN INTERN MED 2002;136:201-209.
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