Evaluating the Quality of Epidemiological Studies

Low Intake of Fruits, Berries and Vegetables is Associated with Excess Mortality in Men: the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study

Low Intake of Fruits, Berries and Vegetables is Associated with Excess Mortality in Men: the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study

The Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study

Kuopio

(kw'py') The city is surrounded by lake Kallavesi, located in Central Finland. Kuopio is known as a strong center of health (e.g. it has the biggest yearly enrollment rate of medical students in Finland), pharmacy, environment, food & nutrition (all legalized Clinical and Public Health Nutritionists in Finland graduate from the University of Eastern Finland) Finland has one of the highest mortality rates related to CHD accdg to the Seven Countries Study

The Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study

The Kuopio Ischemic Heart Disease Risk Factor Study (KIHD) is an ongoing prospective population-based cohort study designed to investigate risk factors for cardiovascular disease, atherosclerosis, and related outcomes in middle-aged men from eastern Finland, the population with one of the highest recorded rates of CHD. The study protocol was approved by the Research Ethics Committee of the University of Kuopio.

ABSTRACT:
The aim of this work was to assess the association of the dietary intake of a food group that includes fruits, berries, and vegetables with all-cause, CVD-related and non-CVD related mortality. Although several prospective studies have directly related fruits and vegetables intake to CVD, few studies have reported an association between fruits and vegetables and overall mortality.

SUBJECTS AND METHODS:

SUBJECTS: The study population comprised a random, age stratified sample of middle aged men living in the city of Kuopio, Finland, or surrounding rural communities. The men were aged 42, 48, 54, or 60 years at the baseline examination that was carried out between March 1984 and December 1989. All subjects gave informed consent. A total of 2682 participants (82.9% those eligible) were enrolled in the study between 1984 and 1989. Because previous disease affects the diet, men with a prevalent CHD (n=677) were excluded from the main analyses. Of the remaining 2005 men, food record data were available for 1980 men.

SUBJECTS AND METHODS:

Assessment of Food Consumption Dietary intake of nutrients was assessed quantitatively with a 4-day food recording at the KIHD baseline examinations. Intake of nutrients was calculated by use of NUTRICA version 2.5 software, which uses mainly Finnish values of nutrient composition of foods and takes into account food preparation losses of vitamins. Intake of fruits, berries and vegetables also included jams, nectars and juices but not potato.

SUBJECTS AND METHODS:

OTHER MEASUREMENTS includes: Assessment of medical hx and meds, family hx of diseases, smoking, alcohol consumption, and blood pressure. Collection of blood specimens and measurement of maximal oxygen uptake, serum lipid, serum lipoproteins, and 24-hr urinary excretion of nicotine metabolites. Diabetes was defined. Plasma fibrinogen was also determined.

SUBJECTS AND METHODS:

FOLLOW UP EVENTS: All deaths included from the study entry to December 2000 were included. (12.8y follow-up) 485 all-cause deaths 245 CVD-related causes 240 non-CVDrelated causes

SUBJECTS AND METHODS:

STATISTICAL ANALYSIS: Data analyzed using SPSS 10.0 software. Subjects were divided into fifths for their mean intake of fruits, berries, and vegetables. The mean of each fifth was reported and compared by ANOVA. Relationship between the specific group intake with risk of mortality and survival were analyzed using Cox proportional hazards model. (five covariates were used) Correlations between cardiovascular risk factors and dietary intake of fruits, berries and vegetables were estimated by Pearsons correlation coefficient.

RESULTS:
The daily intake of fruits, berries and vegetables was 284182 grams (mean). The subjects were divided into fifths of the mean daily intake, and the main characteristics of the subjects in those categories is shown in Table1.

RESULTS: Table 1

RESULTS:
Men in the highest fifth (highest consumption of the food group) were younger, smoked and drank alcohol less; have lower blood pressure, plasma fibrinogen, and LDL cholesterol; and higher intake of fiber, vit C and E, folate, Bcarotene and total energy. Occurrences of total mortality (incld CVD and non-CVD related) were the highest among men with the lowest consumption of fruits and vegetables.

RESULTS:
In a Cox proportional hazards model (Table 2) shows a significant inverse association between the intake of fruits, berries, and vegetables and all cause, CVD- and non-CVD-related deaths. CVD-related mortality is presented to illustrate the earlier occurrence of deaths among men in the two lowest fifths compared to others. (Fig.1) Nutrients that were negatively associated with all-cause mortality were vitamin C, folate, and vitamin E.

RESULTS: Table 2

RESULTS: Figure 1

RESULTS:
Table presents the correlation between the intake of fruits, berries and vegetables and common cardiovascular risk factors. The strongest negative correlations found between intake of the specific food group to serum haptoglobin and plasma fibrinogen. Weaker negative correlation between particular intake with age, serum total HDL and LDL cholesterol, and also diastolic and systolic blood pressures. Positive correlation between the maximal oxygen uptake and intake of fruits, berries and vegetables.

RESULTS: Table 3

DISCUSSION:
The authors of the study stated that Our results provide further evidence for the hypothesis that a high intake of fruits, berries, and vegetable is associated with reduced risk of mortality. The proposed beneficial substances from the food group include antioxidant vitamins, folate, fiber, potassium, and magnesium. Low contents of fat, energy and sodium may reduce in part the risk of obesity and high blood pressure. Advantages and disadvantages of using the 4 day Food Record. Men who consumed more plant products seemed to have a healthier lifestyle compared to men who consumed less.

CONCLUSION OF THE STUDY:

In conclusion, the findings of this prospective cohort study indicate that a higher intake of fruits, berries and vegetables is associated with a reduced risk of CVD-related, non-CVD related and overall mortality in middle-aged men in Eastern Finland. Our findings provide further additional evidence that higher intakes of fruit and vegetable can prevent heart diseases and mortality.

Low Intake of Fruits, Berries and Vegetables is Associated with Excess Mortality in Men: the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study

AS A COHORT STUDY:

 Yes, a large number of participants were included in the baseline study, a total of 2,682. CVD-related mortality: 1,950 men All-cause and non-CVD related mortality: 2,641 men Yes, 12.8 y follow up. Yes, for this follow up study it defined the baseline characteristics of the 2641 study participants in the fifths of intake and grouped the incidence of death in three: all-cause death, CVD-related and non-CVD related. Exposure: Advantages and Disadvantages of Food Record Outcome: The study used three types of statistical test to analyzed data: ANOVA, Cox Proportional hazard model, and Pearsons Correlation Coefficient. No, follow up was done regarding dietary food record after a few years from the baseline.

 No losses to follow up. I think it was able to include in its data collection some confounding variables like age, alcohol intake, smoking, and family history of heart disease. It also excluded subjects with CVD history in analyzing CVD related deaths. For all cause mortality and non CVD related deaths there may be other confounding variables (eventhough Cox model made adjustments for age and examination years). Yes, although study is not particular only about the development of disease but also on the mortality rate. Mortality rate: Deaths were ascertained by a computer linkage to the national death registry using Finnish Social Security number. There were no losses to follow up. All deaths that occurred from the study entry to December 31, 2000, were included. Biological samples collected but storage form not discussed.

Strengths and Weaknesses of the Study:

Strengths: Weaknesses:

Large number of subjects and longer time span Has established a baseline information recorded/eliminate recall bias Was able to measure multiple outcomes Establish time sequence for possible causality Can adjust for confounding variables Was able to calculate risk

No follow up data on food consumption (may change over time) Some confounding variables for example: accuracy of cause of death recording maybe questionable. Further studies may be needed to establish causation.

Elisha Gay C. Hidalgo, RND