Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis

Abstract

BACKGROUND: Low carbohydrate diets, which restrict carbohydrate in favour of increased protein or fat intake, or both, are a popular weight-loss strategy. However, the long-term effect of carbohydrate restriction on mortality is controversial and could depend on whether dietary carbohydrate is replaced by plant-based or animal-based fat and protein. We aimed to investigate the association between carbohydrate intake and mortality. METHODS: We studied 15 428 adults aged 45-64 years, in four US communities, who completed a dietary questionnaire at enrolment in the Atherosclerosis Risk in Communities (ARIC) study (between 1987 and 1989), and who did not report extreme caloric intake ( 4200 kcal per day for men and 3600 kcal per day for women). The primary outcome was all-cause mortality. We investigated the association between the percentage of energy from carbohydrate intake and all-cause mortality, accounting for possible non-linear relationships in this cohort. We further examined this association, combining ARIC data with data for carbohydrate intake reported from seven multinational prospective studies in a meta-analysis. Finally, we assessed whether the substitution of animal or plant sources of fat and protein for carbohydrate affected mortality. FINDINGS: During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40 181 deaths across all cohort studies. In the ARIC cohort, after multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50-55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption ( 70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09-1·32 for low carbohydrate consumption; 1·23, 1·11-1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08-1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78-0·87). INTERPRETATION: Both high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50-55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality. FUNDING: National Institutes of Health.

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References 30

1. 1.

   US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 2015–2020 Eighth edition https://health.gov/dietaryguidelines/2015/guidelines/ (accessed Aug 7, 2018).

   Not in our library

2. 2.

   Sacks FM, Lichtenstein AH, Wu JHY, Dietary fats and cardiovascular disease: a presidential advisory from the American Heart Association. Circulation 2017; 136: e1–23.

   Not in our library10.1161/cir.0000000000000510

3. 3.

   WHO. Healthy diet fact sheet. 9 14, 2015 http://www.who.int/mediacentre/factsheets/fs394/en/ (accessed Aug 7, 2018).

   Not in our library

4. 4.

   Nordmann AJ, Nordmann A, Briel M, Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166: 285–93.

   Not in our library10.1001/archinte.166.3.285

5. 5.

   No authors listed. Summaries for patients. Comparing low-fat and low-carbohydrate diets. Ann Intern Med 2014; 161: 309–18.

   Not in our library10.7326/p14-9029

6. 6.
   Low Carbohydrate versus Isoenergetic Balanced Diets for Reducing Weight and Cardiovascular Risk: A Systematic Review and Meta-Analysis · 2014

   Corrected
7. 7.

   Shai I, Schwarzfuchs D, Henkin Y, Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008; 359: 229–41.

   Not in our library10.1056/nejmoa0708681

8. 8.

   Nilsson LM, Winkvist A, Eliasson M, Low-carbohydrate, high-protein score and mortality in a northern Swedish population-based cohort. Eur J Clin Nutr 2012; 66: 694–700.

   Not in our library10.1038/ejcn.2012.9

9. 9.

   Fung TT, van Dam RM, Hankinson SE, Stampfer M, Willett WC, Hu FB. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med 2010; 153: 289–98.

   Not in our library10.1059/0003-4819-153-5-201009070-00003

10. 10.

    Lagiou P, Sandin S, Weiderpass E, Low carbohydrate-high protein diet and mortality in a cohort of Swedish women. J Intern Med 2007; 261: 366–74.

    Not in our library10.1111/j.1365-2796.2007.01774.x

11. 11.

    Trichopoulou A, Psaltopoulou T, Orfanos P, Hsieh CC, Trichopoulos D. Low-carbohydrate-high-protein diet and long-term survival in a general population cohort. Eur J Clin Nutr 2007; 61: 575–81.

    Not in our library10.1038/sj.ejcn.1602557

12. 12.
    Low-Carbohydrate Diets and All-Cause Mortality: A Systematic Review and Meta-Analysis of Observational Studies · 2013

    Corrected
13. 13.

    Dehghan M, Mente A, Zhang X, Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet 2017; 390: 2050–62.

    Not in our library10.1016/s0140-6736(17)32252-3

14. 14.

    Ramsden CE, Domenichiello AF. PURE study challenges the definition of a healthy diet: but key questions remain. Lancet 2017; 390: 2018–19.

    Not in our library10.1016/s0140-6736(17)32241-9

15. 15.

    No authors listed. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. The ARIC investigators. Am J Epidemiol 1989; 129: 687–702.

    Not in our library

16. 16.

    Willett WC, Sampson L, Stampfer MJ, Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol 1985; 122: 51–65.

    Not in our library10.1093/oxfordjournals.aje.a114086

17. 17.

    Baecke JA, Burema J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982; 36: 936–42.

    Not in our library10.1093/ajcn/36.5.936

18. 18.

    Harrell FE. Regression modeling strategies: with applications to linear models, logistic regression, and survival analysis. New York: Springer, 2001.

    Not in our library

19. 19.

    Claggett B, Packer M, McMurray JJ, Estimating the long-term treatment benefits of sacubitril-valsartan. N Engl J Med 2015; 373: 2289–90.

    Not in our library10.1056/nejmc1509753

20. 20.

    Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med 2010; 152: 726–32.

    Not in our library10.7326/0003-4819-152-11-201006010-00232

21. 21.

    von Elm E, Altman DG, Egger M, The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007; 370: 1453–57.

    Not in our library10.1016/s0140-6736(07)61602-x

22. 22.

    Wells GA, Shea B, O’Connell D, The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed Aug 7, 2018).

    Not in our library

23. 23.

    Fung TT, Willett WC, Stampfer MJ, Manson JE, Hu FB. Dietary patterns and the risk of coronary heart disease in women. Arch Intern Med 2001; 161: 1857–62.

    Not in our library10.1001/archinte.161.15.1857

24. 24.

    Nakamura Y, Okuda N, Okamura T, Low-carbohydrate diets and cardiovascular and total mortality in Japanese: a 29-year follow-up of NIPPON DATA80. Br J Nutr 2014; 112: 916–24.

    Not in our library10.1017/s0007114514001627

25. 25.

    Diehr P, Beresford SA. The relation of dietary patterns to future survival, health, and cardiovascular events in older adults. J Clin Epidemiol 2003; 56: 1224–35.

    Not in our library10.1016/s0895-4356(03)00202-6

26. 26.

    Oh K, Hu FB, Cho E, Carbohydrate intake, glycemic index, glycemic load, and dietary fiber in relation to risk of stroke in women. Am J Epidemiol 2005; 161: 161–69.

    Not in our library10.1093/aje/kwi026

27. 27.

    Song M, Fung TT, Hu FB, Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Intern Med 2016; 176: 1453–63.

    Not in our library10.1001/jamainternmed.2016.4182

28. 28.

    Hu FB. Plant-based foods and prevention of cardiovascular disease: an overview. Am J Clin Nutr 2003; 78 (suppl 3): 544S–51S.

    Not in our library10.1093/ajcn/78.3.544s

29. 29.

    Augustin LS, Kendall CW, Jenkins DJ, Glycemic index, glycemic load and glycemic response: An International Scientific Consensus Summit from the International Carbohydrate Quality Consortium (ICQC). Nutr Metab Cardiovasc Dis 2015; 25: 795–815.

    Not in our library10.1016/j.numecd.2015.05.005

30. 30.

    Shen X, Fang A, He J, Trends in dietary fat and fatty acid intakes and related food sources among Chinese adults: a longitudinal study from the China Health and Nutrition Survey (1997–2011). Public Health Nutr 2017; 20: 2927–36.

    Not in our library10.1017/s1368980017001781

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