Diet and cardiometabolic disease Dietary trends and the impact of diet on diabetes and cardiovascular disease in northern Sweden Front cover: Sucktomten vallar lörpvålmar – illustration from a modern fairy tale describing the life of a benevolent goblin-sheppard in the woods of northern Sweden. This and all other illustrations are from the as yet unpublished book “Sucktomtens berättelser” by Tore ‘Rasp’ Hylander. Printed by permission of the author. • Copyright © 2007 by Benno Krachler ISBN 978-91-7264-354-3 Printed in Sweden by Print&Media Umeå university:2003462 Umeå 2007 2 To parents, teachers, tutors, colleagues, patients and all other friends with gratitude. 3 CONTENTS DIET AND CARDIOMETABOLIC DISEASE............................................. 1 DIETARY TRENDS AND THE IMPACT OF DIET ON DIABETES AND CARDIOVASCULAR DISEASE IN NORTHERN SWEDEN........... 1 ABSTRACT-ENGLISH............................................................................................................................................ 6 SAMMANFATTNING PÅ SVENSKA (ABSTRACT-SWEDISH)....................................................................................... 8 LIST OF PAPERS.................................................................................................................................................. 10 ABBREVIATIONS ............................................................................................................................................... 11 1 INTRODUCTION..................................................................................... 14 1.1 METABOLIC SYNDROME (METS) AND CARDIOMETABOLIC DISEASE (CMD).................................................. 14 1.1.1 Definition ............................................................................................................................................... 14 1.1.2 Body composition and lipoprotein profile ........................................................................................................ 18 1.1.3 Inflammation and coagulability.................................................................................................................... 20 1.1.4 Glycaemia and insulin resistance.................................................................................................................. 21 1.1.5 Cardiovascular and renal function................................................................................................................ 21 1.1.6 Non-dietary lifestyle factors and MetS........................................................................................................... 22 1.2 DIET ............................................................................................................................................................ 25 1.2.1 Dietary recommendations ........................................................................................................................... 25 1.2.2 Dietary assessment in nutritional epidemiology................................................................................................ 25 1.2.3 FA in erythrocyte membrane as a marker of fatty acids intake........................................................................... 27 1.2.4 Enterolactone as a marker of intake of whole-grain products, fruits, and vegetables ................................................. 30 1.3 DIET AND CARDIOMETABOLIC DISEASE ....................................................................................................... 32 1.3.1 Macronutrients ........................................................................................................................................ 33 1.3.2 Foods..................................................................................................................................................... 37 • 1.3.3 Dietary patterns.................................................................................................................................. 38 1.3.4 Energy balance......................................................................................................................................... 39 1.4 MECHANISMS: LIFESTYLE –CMD................................................................................................................. 39 1.5 STUDY AREA: NORTHERN SWEDEN.............................................................................................................. 41 2 AIMS AND HYPOTHESIS....................................................................... 42 3 STUDY POPULATION ............................................................................ 43 3.1 MONICA .................................................................................................................................................... 43 3.2 VIP.............................................................................................................................................................. 43 3.3 MAMMOGRAPHY SCREENING PROJECT (MSP).............................................................................................. 43 3.4 FIA STUDY OF MYOCARDIAL INFARCTION.................................................................................................... 44 3.5 TRIM STUDY OF DIABETES .......................................................................................................................... 44 4 STATISTICAL METHODS ...................................................................... 45 5 RESULTS ................................................................................................... 48 5.1 DIETARY TRENDS IN NORTHERN SWEDEN (PAPER I).................................................................................... 48 5.2 FOOD ITEMS AND FAT DISTRIBUTION (PAPER II) .......................................................................................... 53 5.3 FATTY ACIDS AND DIABETES (PAPER III)...................................................................................................... 55 5.4 LIGNANS AND MYOCARDIAL INFARCTION (PAPER IV) .................................................................................. 57 5.5 GENERAL LIFESTYLE FACTORS AND FAT DISTRIBUTION (PAPER V)............................................................... 59 6 DISCUSSION............................................................................................. 60 6.1 SUMMARY OF RESULTS.................................................................................................................................. 60 6.2 STATISTICAL ANALYSIS ................................................................................................................................. 60 6.3 STUDY DESIGN............................................................................................................................................. 61 6.4 INTERNAL VALIDITY .................................................................................................................................... 61 6.5 EXTERNAL VALIDITY ................................................................................................................................... 62 6.6 PRECISION ................................................................................................................................................... 62 6.7 COMPARING OUR FINDINGS WITH THOSE REPORTED ELSEWHERE ............................................................... 63 4 6.8 INTERPRETATION AND IMPLICATIONS.......................................................................................................... 66 6.9 NEED FOR FURTHER STUDY ......................................................................................................................... 67 7 CONCLUSION.......................................................................................... 67 8 ACKNOWLEDGEMENTS ....................................................................... 68 9 REFERENCES .......................................................................................... 69 10 ORIGINAL PAPERS I-V ......................................................................... 81 I Trends in food intakes in Swedish adults 1986-1999..................................................................................... 85 II Reported food intake and distribution of body fat. .......................................................................................... 95 III Fatty acid profile of the erythrocyte membrane preceding development of type 2 diabetes mellitus. ............................. 109 IV Risk of myocardial infarction according to serum concentrations of enterolactone. ................................................. 131 V Population-wide changes in reported lifestyle are associated with redistribution of adipose tissue............................... 147 Table 1: Clinical criteria for the diagnosis of the Metabolic syndrome..................... 16 Table 2: Selected adipokines in the Metabolic syndrome............................................ 21 Table 3: Dietary recommendations................................................................................. 26 Table 4: Dietary assessment in nutritional epidemiology. ........................................... 27 Table 5: Biomarkers of nutrient intake........................................................................... 28 Table 6: Nomenclature of fatty acids.............................................................................. 30 Table