The Mediterranean Score of Dietary Habits in Chinese Populations in Four Different Geographical Areas

The Mediterranean score of dietary habits in Chinese populations in four different geographical areas

J Woo1*, KS Woo1, SSF Leung1, P Chook1, B Liu1,RIp1,SCHo2, SW Chan3, JZ Feng4 and DS Celermajer5

1Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China; 2Department of Community and Family Medicine, The Chinese University of Hong Kong, Hong Kong, People's Republic of China; 3Chinese Hospital, San Francisco, California, USA; 4Guangdong Provincial Cardiovascular Institute, Guangzhou, People's Republic of China; and 5Department of Cardiology, The Royal Prince Alfred Hospital, Sydney, Australia

Objective: To compare the dietary intake of Chinese people living in Pan Yu, Hong Kong, San Francisco and Sydney with respect to cardiovascular health, using the Mediterranean diet score, examining the effects of age, gender, urbanization and acculturation on the diet score. Subjects: A total of 500 men and 510 women in Hong Kong were recruited as a territory-wide strati®ed random sample. Subjects were recruited in response to local advertisements for the other three sites: Pan Yu, 58 men, 95 women; San Francisco, 166 men, 192 women; Sydney, 95 men, 73 women. Method: Food-frequency questionnaire over a 7 week period. A high=healthy score was taken as 4 for men and 3 for women, representing a dietary pattern bene®cial for cardiovascular health. Results: In Hong Kong, more women in the middle age group (35 ± 54) had a high score than other age groups, and overall more women had high scores than men. In comparing the four geographical regions, Pan Yu had the highest number of subjects with high score, and Hong Kong had the lowest. With the exception of the younger population and men in Hong Kong, the percentage of the population with a high score in all sites is greater than among elderly Greeks consuming a more traditional heart-healthy Mediterranean diet. Conclusion: Considerable variations in Chinese dietary patterns exist with respect to age, gender and geographic location. Overall, the Chinese diet is comparable to the Mediterranean diet and may be expected to have similar health bene®ts that have been documented for the traditional Mediterranean diet. Descriptors: Chinese diet; cardiovascular disease; acculturation; urbanization; Mediterranean diet European Journal of Clinical Nutrition (2001) 55, 215±220

Introduction Lorgeril et al, 1998), and reduced cardiovascular complications after myocardial infarction (de Lorgeril et al, 1999). The dietary pattern of inhabitants around the shores of the The diet emphasizes food groups rather than speci®c Mediterranean has long been noted to have health bene®ts, nutrients, and this traditional plant-based diet may provide particularly with respect to coronary heart disease (Keys, bene®t through the intake of antioxidants, ®bre, or indir- 1995; Nestle, 1995). The main features of the diet are: high ectly by lowering blood pressure (de Lorgeril, 1998). While consumption of fruits, vegetables, legumes and grains; individual items of the Mediterranean diet may not be foods with high monosaturated to saturated fats ratio; predictive of outcome, the extent to which dietary patterns moderate consumption of dairy products and ethanol conform to the Mediterranean diet, quanti®ed as a score, (mainly wine); and low consumption of meat and meat is predictive of outcome (de Groot et al, 1996; Osler & products (Trichopoulou & Lagiou, 1997). Longitudinal Schroll 1997). studies and randomized controlled trials showed that a Among Chinese populations, the incidence of coronary Mediterranean dietary pattern is associated with improved heart disease is lower than in Caucasians (Woo & Donnan, survival among elderly Europeans (de Groot et al, 1996; 1989), and a difference in dietary habits may be a con- Osler & Schroll 1997), possibly reduced cancer rate (de tributory factor. The Chinese diet has many similar features with the Mediterranean diet, in that vegetable and fruit consumption is high, and fat and meat consumption is low. *Correspondence: J Woo, Department of Medicine and Therapeutics, However, there is no longitudinal observation study or Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, People's Republic randomized controlled trial to determine if a traditional of China. Chinese diet is related to improved survival or better E-mail: [email protected] Received 6 September 2000; revised 3 November 2000; health outcomes. Since such evidence is available for the accepted 6 November 2000 Mediterranean diet, it would be of interest to determine Mediterranean score in Chinese JWooet al 216 whether the dietary habit of Chinese populations is similar, 3. High consumption of legumes (men > 60 g=day, women by quantifying the features using the Mediterranean diet > 49 g=day). score, developed by other researchers (de Groot et al, 4. High consumption of cereals (mean > 291 g=day, 1996). The proportion of the population with a high score women > 248 g=day). representing a dietary pattern bene®cial to cardiovascular 5. High consumption of fruits (men > 249 g=day, women health may be compared with published studies for Cau- > 216 g=day). casian populations, as a useful indicator of the dietary 6. High consumption of vegetables (men > 303 g=day, pattern of the community with respect to chronic diseases. women > 248 g=day). In this study, the Mediterranean score is calculated for 7. Low consumption of meat and meat products (men Chinese populations in four geographic regions throughout < 109 g=day, women < 91 g=day). the world, and the effect of age, gender, urbanization, 8. Low consumption of milk and dairy products (men acculturation and, indirectly, the effect of public health < 201 g=day, women < 194 g=day). education in different countries on the Mediterranean score is also examined. These values were adjusted to daily intakes of 2500 kcal for men and 2000 kcal for women. For our population, since very few women drink, item 2 was deleted, so that a total score of 7 for women was used instead of 8. For this study, Subjects and method a high score for men is de®ned as 4 for men, and 3 for women, and represents a dietary pattern that is bene®cial Four cohorts of ethnic Chinese subjects living in Hong for cardiovascular health. A score of 3 or 4 has also been Kong, a rural village on the outskirts of Pan Yu in used to relate Mediterranean dietary pattern to better health Guangdong province in Southern China, in Sydney and in outcomes (Osler & Schroll, 1997). San Francisco were studied. (Hong Kong), 500 M, 510 F; Mean nutrient intakes between the four cohorts were Pan Yu, 58 M, 95 F; San Francisco, 166 M, 192 F; Sydney, compared using Tukey's method of pairwise multiple 95 M, 73 F). Subjects in the Hong Kong cohort were comparisons. Chi-square test was used to compare the recruited as part of a territory-wide cardiovascular risk number of subjects with high score between different age factor study from October 1995 to May 1996, a strati®ed and sex groups, and between different geographical random survey where the sample was representative of the regions. Hong Kong population. Details of the recruitment have been given elsewhere (Woo et al, 1998). The other three cohorts were community volunteers. The total population Results of the rural village, Pan Yu district, China, is approximately 3000, and has one of the lowest annual rates of acute The mean nutrient intake of Chinese people in the four myocardial infarction in this region, being approximately regions is shown by age and sex in Table 1. For the younger 40 per 100 000 among those age 40 y and over, compared age group (34 y), there was no difference in energy intake with 90.8 ± 117.3 per 100 000 in Hong Kong (Woo & among men, but women in San Francisco had the lowest Donnan, 1989). Posters advertising a cardiovascular risk intake. Men and women in Pan Yu had the highest factor survey were placed in the community in the vicinity carbohydrate and lowest protein percentage of total of the hospital or health centre. All advertising material was energy compared to the other regions. Men in Pan Yu written only in the local language in each centre. For San also consumed the lowest percentage fat. The MUFA:SFA Francisco and Sydney, subjects were included if they were ratio was also the highest for both men and women in Pan originally of southern Chinese origin (for the past three Yu, while the PUFA:SFA ratio was also the highest among generations), and had lived in these cities for at least 10 y. men in Pan Yu. Both men and women in Hong Kong had Dietary intake was assessed in all cohorts using the same the highest cholesterol intake per 1000 kcal of energy food frequency method. The quantity and frequency of compared with other regions, while women in Hong consumption per day and per week for each item were Kong also had the highest percentage fat consumption. recorded with the aid of photographs to illustrate portion Among middle aged Chinese (35 ± 54 y), men in Sydney sizes, and nutrient quantity was calculated using food tables and Hong Kong had higher energy intakes. The lowest from multiple sources Ð UK and two mainland Chinese percentage protein was still observed for the Pan Yu institutions. Details of the method have been described population, while it was highest for San Francisco. Inter- elsewhere (Woo et al, 1997). estingly, the percentage fat was highest for Pan Yu; at the The Mediterranean score was calculated according to same time the MUFA:SFA and PUFA:SFA ratio were also the consumption of eight categories of food, and a score of high. The cholesterol intake was also the highest in Hong one was given if the criteria for each category was full®lled Kong, as for the younger age group. For the older age group (de Groot et al, 1996): (55 y), fewer differences between regions were observed. The pattern of lowest protein percentage, higher fat per- 1. High monounsaturated: saturated fat ratio (> 1.6). centage and MUFA:SFA ratios in the Pan Yu population 2. Moderate ethanol consumption (men: < 10 g=day). was also observed.

European Journal of Clinical Nutrition Mediterranean score in Chinese JWooet al 217 Table 1 Mean (s.d.) nutrient intake in four regions by age and sex

Male Female

Macronutrient composition Sydney Pan Yu San Francisco Hong Kong Sydney Pan Yu San Francisco Hong Kong

(A) 34-y-old or below n 11 21 28 103 11 45 28 106 Energy (kcal) 2622 2596 2173 2557 1931 1982b 1502b**c 1891c* (736) (879) (749) (723) (766) (649) (592) (583) Carbohydrate (%) 51a 60a*b 49b*** 52b** 55 59b 53 50b*** (10) (12) (9) (7) (12) (10) (12) (7) Protein (%) 18 15b 21b*** 19b*** 16a 15b 20b*** 20a*b*** (4) (4) (7) (3) (6) (4) (6) (3) Fat (%) 31 25b 30 30b*25a 26b 27c 32a**b***c* (8) (12) (8) (6) (8) (9) (9) (5) MUFA:SFA 1.26a 1.62a***b 1.26b*** 1.27b*** 1.15a 1.48a***b 1.27b*** 1.27b*** (0.21) (0.38) (0.28) (0.01) (0.18) (0.30) (0.21) (0.13) PUFA:SFA 0.87 1.01b 0.73b** 0.77b** 0.86 0.85 0.79 0.84 (0.23) (0.48) (0.35) (0.21) (0.44) (0.45) (0.42) (0.24) Cholesterol (mg=1000 kcal) 137.80 117.00b 145.6 170.2b*** 88.60a 134.3b 150.1a* 171.5a***b*** (57.6) (68.2) (53.8) (45.6) (39.4) (61.5) (78.7) (47.8) (B) 35 ± 54-y-old n 67 19 91 267 48 29 110 276 Energy (kcal) 2556a 2147 2200a*c 2470c*** 2061 2113 1759 1857 (1051) (499) (810) (650) (1160) (668) (676) (598) Carbohydrate (%) 55 54 52 53 53 55 52 53 (8) (12) (9) (8) (8) (10) (8) (7) Protein (%) 19a 16a*b 23a***b***c 19c*** 19a 14a***b 21a***b***c 19b***c*** (5) (4) (6) (3) (4) (5) (6) (3) Fat (%) 26a 30a*b 25b*c 29a***c*** 30 32b 28b*29 (6) (11) (8) (6) (8) (10) (7) (5) MUFA:SFA 1.35a 1.56a***b 1.41b*c 1.29b***c*** 1.41a 1.70a***b 1.38b***c 1.29a*b***c** (0.20) (0.30) (0.35) (0.12) (0.34) (0.30) (0.36) (0.16) PUFA:SFA 1.01a 1.11b 0.89b* 0.81a***b*** 1.10a 1.22b 0.95b** 0.94a*b*** (0.40) (0.65) (0.34) (0.24) (0.39) (0.62) (0.40) (0.31) Cholesterol (mg=1000 kcal) 109.80a 162.6a***b 124.8b*c 171.0a***c*** 110.00a 125.8b 132.4c 154.9a***b*c** (47.1) (71.6) (56.6) (53.90) (48.2) (70.1) (54.60) (54.1) (C) 55-y-old or above n 17 18 47 130 14 21 54 128 Energy (kcal) 2336 2379 1966 2211 1948 1827 1657 1654 (749) (686) (817) (612) (834) (589) (928) (454) Carbohydrate (%) 53 52 55 57 57 58 54 57 (6) (10) (9) (8) (10) (9) (9) (7) Protein (%) 20a 15a*b 21b***c 18c*** 19 15b 22b***c 18b*c*** (4) (5) (7) (3) (4) (3) (7) (3) Fat (%) 28 29b 24b**c 27c*25282527 (7) (8) (6) (7) (7) (9) (9) (5) MUFA:SFA 1.36a 1.67a***b 1.42b***c 1.31b***c** 1.42 1.61b 1.41b* 1.31b*** (0.23) (0.22) (0.29) (0.14) (0.17) (0.27) (0.44) (0.17) PUFA:SFA 0.99 0.94 1.13c 0.91c*** 1.01 1.04 0.98 0.96 (0.32) (0.29) (0.45) (0.30) (0.41) (0.41) (0.46) (0.35) Cholesterol (mg=1000 kcal) 118.9 141.8 122.8 137.8 118.9 123.6 132 136.7 (38.3) (71.0) (63.5) (55.7) (53.2) (47.0) (60.1) (48.4) aDiffer signi®cantly from Sydney. bDiffer signi®cantly from Pan Yu. cDiffer signi®cantly from San Francisco. *P < 0.05; **P < 0.01; ***P < 0.001. Post hoc pairwise multiple comparisons (Tukey method).

The Mediterranean score was calculated for men and women in the middle age group (35 ± 54) had a higher score women, and the number of subjects divided into those with compared with other age groups, while more men had low and high scores. The score differed by age and gender lower scores than women. The number of men and among the Hong Kong population only (Table 2). More women with high scores was the highest in Pan Yu and

European Journal of Clinical Nutrition Mediterranean score in Chinese JWooet al 218 Table 2 Mediterranean score of the Hong Kong population by age and Chinese dietary patterns with age, gender, and geographical gender locations. Mediterranean score high scorea

Sex and age group n Count % Discussion

Female age 34 or below 106 66 62 Female age 35 ± 54 276 209 76 To date, the only studies relating dietary patterns to health Female age 55 or above 128 85 66 outcomes are those relating to the Mediterranean diet Male age 34 or below 103 42 41 (Keys, 1995; Nestle, 1995; Trichopoulou & Lagiou, Male age 35 ± 54 267 129 48 1997; de Groot et al, 1996; Osler & Schroll, 1997; de Male age 55 or above 130 81 62 Lorgeril et al, 1998; de Lorgeril, 1998). These studies aScore 4 for male, score 3 for female. Chi-square: 62.359, suggest that dietary habits may be considered as a risk P < 0.001. factor for cardiovascular diseases or survival in older populations. It is likely that the lower incidence of cardiovascular diseases in Chinese populations may be partly lowest in Hong Kong (Table 3). When the dietary pattern attributed to the Chinese diet. Although there are many was examined by age group, for all age groups, Pan Yu had variants of the Mediterranean and Chinese diets, the devel- the highest percentage of subjects with a high score (Table opment of a Mediterranean diet score in some previous 4). For all age groups, the dietary pattern was worst in studies (de Groot et al, 1996; Osler & Schroll, 1997) Hong Kong. enables a quantitative comparison of the Chinese and In summary, the results show considerable variations in Mediterranean dietary habits. There are limitations in using a dietary score devised by another author, in that Table 3 Mediterranean score in different regions by sex the characteristics of the population to which the score applies will be different to Chinese populations. Further- a Mediterranean score high score more, there may be other characteristics in the Chinese diet Sex Place n Count % with adverse or bene®cial effects to health that have not been taken into account in comparison with different Femaleb Hong Kong 510 360 71 populations. Pan Yu 95 81 85 The percentage of the population with a high score San Francisco 192 147 77 Sydney 73 58 79 ranges from 51% to 96% in four geographic regions with Malec Hong Kong 500 252 50 different culture, educational background and socioeco- Pan Yu 58 56 97 nomic characteristics. With the exception of the younger San Francisco 166 117 70 population and men in Hong Kong, the percentage with a Sydney 95 61 64 high score was greater than the percentage among elderly aScore 4 for male; score 3 for female. Greeks (57%) (Trichopoulou et al, 1995). Therefore Chi- bPearson chi-square 11.174; P 0.011. nese populations as a whole have a dietary pattern similar cPearson chi-square 59.325; P < 0.001. to the Mediterranean dietary pattern, the majority achieving a high score irrespective of acculturation, age or socioeconomic factors. It is possible that the current dietary Table 4 Mediterranean score in different regions by age group patterns of Chinese populations may be `healthier' with respect to cardiovascular disease compared with the `Med- Mediterranean score high scorea iterranean' population, since the Mediterranean diet is a traditional diet and studies suggest that there has been a Age group Place n Count % deviation from traditional dietary patterns with time (Ferro- 34 or belowb Hong Kong 209 108 51 Luzzi & Branca, 1995; Alberti-Fidanza et al, 1999). Pan Yu 66 55 83 Among the Chinese population, the dietary pattern San Francisco 56 35 63 Sydney 22 13 59 shows interesting variations with age, gender and geogra- 35 ± 54c Hong Kong 543 338 62 phical region, re¯ecting in¯uences of local culture, health Pan Yu 48 46 96 messages promulgated by media and the government, San Francisco 201 154 77 differences in education, economic status and degree of Sydney 115 80 70 urbanization. In Pan Yu, being a rural area, the population 55 or aboved Hong Kong 258 166 64 Pan Yu 39 36 92 will tend to preserve a more traditional dietary pattern, and San Francisco 101 75 74 their relatively lower income may preclude a diet high in Sydney 31 26 84 protein from meat or seafood. However, they will be less exposed to nutrition education compared with societies in aScore 4 for male; score 3 for female. bPearson chi-square 21.115, P < 0.001. San Francisco or Sydney, and this may be re¯ected in the cPearson chi-square 34.402; P < 0.001. observation that the percentage fat comsumption increased dPearson chi-square 17.014; P < 0.001. with age in the Pan Yu residents, perhaps re¯ecting an

European Journal of Clinical Nutrition Mediterranean score in Chinese JWooet al 219 increase in income. Elsewhere it has been documented that representative of the whole of the Pan Yu district. Never- the consumption of fat and meat in China increases with theless, the strength of the study lies in that the same improvement in socioeconomic status (Ge et al, 1995). dietary assessment instrument had been used in all four In contrast, Hong Kong is entirely urban, and exposed to regions, and was administered by the same team of inter- Western in¯uences from other countries. Yet the dietary viewers. In spite of the limitations, one can conclude that habit of the population appears worse than that of Chinese currently the large majority of the Chinese population populations in Sydney or San Francisco. A difference in consume a diet comparable to the traditional Mediterranean socioeconomic status or a lower level of public health diet, whether in China or in Western countries, and by knowledge regarding nutrition and disease in Hong Kong extrapolating from the data for Mediterranean diet, are may account for the difference. It is also possible that the likely to have health bene®ts in terms of coronary heart lifestyle in Hong Kong, particularly for men and the young disease and survival. However, the adverse features of the and middle-aged groups, consists of eating away from Chinese diet have not been taken into account. There is home much of the time, the fast food outlets being a regular need for improved nutritional knowledge in urban Chinese source of meals for a large percentage of the population. populations in China, in order to prevent a worsening trend In general, there is less geographical variation in dietary in dietary habits. habits among the older population, perhaps re¯ecting a habit of taking more traditional Chinese meal patterns rather than adopting `Westernized' foods. The gender Acknowledgements ÐThis study is partially supported by the Bristol Myers Squibbs Foundation Unrestricted Nutrition Grant, and the Hong Kong difference in dietary habits in Hong Kong is of interest. Heart Foundation. Young and middle-aged women had a better pattern compared with men. This may be a difference in lifestyle, in that more women may stay at home to look after children, References or that women have better nutritional knowledge than men. 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