WHO guidelines for a healthy diet and mortality from cardiovascular disease in European and American elderly: the CHANCES project.
BACKGROUND
Cardiovascular disease (CVD) represents a leading cause of mortality worldwide, especially in the elderly. Lowering the number of CVD deaths requires preventive strategies targeted on the elderly.


OBJECTIVE
The objective was to generate evidence on the association between WHO dietary recommendations and mortality from CVD, coronary artery disease (CAD), and stroke in the elderly aged ≥60 y.


METHODS
We analyzed data from 10 prospective cohort studies from Europe and the United States comprising a total sample of 281,874 men and women free from chronic diseases at baseline. Components of the Healthy Diet Indicator (HDI) included saturated fatty acids, polyunsaturated fatty acids, mono- and disaccharides, protein, cholesterol, dietary fiber, and fruit and vegetables. Cohort-specific HRs adjusted for sex, education, smoking, physical activity, and energy and alcohol intakes were pooled by using a random-effects model.


RESULTS
During 3,322,768 person-years of follow-up, 12,492 people died of CVD. An increase of 10 HDI points (complete adherence to an additional WHO guideline) was, on average, not associated with CVD mortality (HR: 0.94; 95% CI: 0.86, 1.03), CAD mortality (HR: 0.99; 95% CI: 0.85, 1.14), or stroke mortality (HR: 0.95; 95% CI: 0.88, 1.03). However, after stratification of the data by geographic region, adherence to the HDI was associated with reduced CVD mortality in the southern European cohorts (HR: 0.87; 95% CI: 0.79, 0.96; I(2) = 0%) and in the US cohort (HR: 0.85; 95% CI: 0.83, 0.87; I(2) = not applicable).


CONCLUSIONS
Overall, greater adherence to the WHO dietary guidelines was not significantly associated with CVD mortality, but the results varied across regions. Clear inverse associations were observed in elderly populations in southern Europe and the United States.
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands; Centre of Clinical Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, University Hospital, University Duisburg-Essen, Essen, Germany;
Nicole
N
Jankovic
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands;
Anouk
A
Geelen
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands;
Martinette T
MT
Streppel
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands;
Lisette Cpgm
LC
de Groot
Department of Epidemiology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands; Global Public Health, Leiden University College, the Hague, Netherlands;
Jessica C
JC
Kiefte-de Jong
Department of Hygiene, Epidemiology and Medical Statistics, University of Athens, Medical School, Athens, Greece; Hellenic Health Foundation, Athens, Greece;
Philippos
P
Orfanos
Department of Hygiene, Epidemiology and Medical Statistics, University of Athens, Medical School, Athens, Greece; Hellenic Health Foundation, Athens, Greece;
Christina
C
Bamia
Department of Hygiene, Epidemiology and Medical Statistics, University of Athens, Medical School, Athens, Greece; Hellenic Health Foundation, Athens, Greece;
Antonia
A
Trichopoulou
Department of Hygiene, Epidemiology and Medical Statistics, University of Athens, Medical School, Athens, Greece; The Tisch Cancer Institute, Mount Sinai School of Medicine, New York, NY;
Paolo
P
Boffetta
Department of Epidemiology and Public Health, University College London, London, United Kingdom;
Martin
M
Bobak
Department of Epidemiology and Public Health, University College London, London, United Kingdom;
Hynek
H
Pikhart
UKCRC Centre of Excellence for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, United Kingdom;
Frank
F
Kee
UKCRC Centre of Excellence for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, United Kingdom;
Mark G
MG
O'Doherty
Unit of Nutrition, Environment and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology, Barcelona, Spain;
Genevieve
G
Buckland
UKCRC Centre of Excellence for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, United Kingdom;
Jayne
J
Woodside
Department of Epidemiology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands;
Oscar H
OH
Franco
Department of Epidemiology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands;
M Arfan
MA
Ikram
Department of Epidemiology, Julius Centre, Utrecht, Netherlands;
Ellen A
EA
Struijk
Department of Epidemiology and Population Studies, Jagiellonian University, Krakow, Poland;
Andrzej
A
Pajak
Institute of Internal and Preventive Medicine, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk, Russia; Novosibirsk State Medical University, Novosibirsk, Russia;
Sofia
S
Malyutina
National Institute of Public Health, Prague, Czech Republic;
Růžena
R
Kubinova
Department of Public Health and Clinical Medicine, Nutritional Research, Umeå University, Umeå, Sweden;
Maria
M
Wennberg
Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD;
Yikyung
Y
Park
Department for Determinants of Chronic Diseases, National Institute for Public Health and the Environment, Bilthoven, Netherlands; Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, Netherlands; Department of Epidemiology and Biostatistics, The School of Public Health, Imperial College London, London, United Kingdom; and Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
H Bas
HB
Bueno-de-Mesquita
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands;
Ellen
E
Kampman
Division of Human Nutrition, Wageningen University, Wageningen, Netherlands; edith.feskens@wur.nl.
Edith J
EJ
Feskens
D000368:Aged; D002318:Cardiovascular Diseases / Q000401:mortality* / Q000517:prevention & control; D002791:Cholesterol, Dietary / Q000008:administration & dosage; D002908:Chronic Disease; D004032:Diet / Q000592:standards*; D004040:Dietary Carbohydrates / Q000008:administration & dosage; D004043:Dietary Fiber / Q000008:administration & dosage; D004044:Dietary Proteins / Q000008:administration & dosage; D005006:Ethnicity; D005060:Europe / Q000453:epidemiology; D005227:Fatty Acids / Q000008:administration & dosage; D005231:Fatty Acids, Unsaturated; D005260:Female; D005638:Fruit; D006801:Humans; D008297:Male; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D015596:Nutrition Assessment; D018673:Nutrition Policy; D010349:Patient Compliance; D011446:Prospective Studies; D014481:United States / Q000453:epidemiology; D014675:Vegetables; D014944:World Health Organization
D002791:Cholesterol, Dietary; D004040:Dietary Carbohydrates; D004043:Dietary Fiber; D004044:Dietary Proteins; D005227:Fatty Acids; D005231:Fatty Acids, Unsaturated
CHANCES; aging; cardiovascular disease; cohort; meta-analysis