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,**
,3
* Department of Nutrition,
Department of Epidemiology and
** Department of Biostatistics, Harvard School of Public Health, Boston, MA;
Centro Centroamericano de Población, University of Costa Rica, San Pedro, Costa Rica
3To whom correspondence should be addressed. E-mail: hcampos{at}hsph.harvard.edu.
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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KEY WORDS: • fatty acids • myocardial infarction • diet
The link between trans-fatty acid intake and coronary heart disease (CHD) has been a controversial topic (1 –4 ). Although trans-fatty acids (FA) are found in many foods, they are more prevalent in ruminant fat (meats and dairy products) and partially hydrogenated vegetable oils. The food source (animal or vegetable) determines the type and content of specific trans-isomers in adipose tissue (5 ). Most hydrogenated products have substantially higher amounts of trans-FA than meats and dairy products (1 ). Partially hydrogenated oils are the major source of dietary trans-FA in the United States (6 ) and Europe, whereas in Mediterranean countries, animal products provide >50% of trans-FA (7 ). In the last two decades, the intake of trans-FA in Europe has decreased, mainly as a result of the availability of margarines with lower trans-FA concentrations (7 ,8 ). Although softer margarines are available in the United States, the current intake of trans-FA is similar to that observed in the 1960s (2% of energy). This is due mainly to high use of hydrogenated oils in baked products and fast foods (9 ).
All five prospective studies performed with dietary data from food-frequency questionnaires (FFQ) and other dietary assessment methods showed a positive association between total trans-fat intake and myocardial infarction (MI) (8 ,10 –14 ). A comprehensive analysis of four of these studies showed that a 2% increase in energy intake from trans-FA was associated with a 25% [95% confidence interval (CI) 11%–40%] increase in the risk of CHD (8 ). Surprisingly, case-control studies using biomarkers of trans-fatty acid intake (15 –19 ) have not been consistent; several studies showed no association (16 –18 ,20 ) and some studies suggested that trans-FA vary in their potential for atherogenicity and that the type of trans-fat consumed may explain some of the differences across populations (15 ,19 ).
Cardiovascular disease (CVD) is the main cause of death in several developing countries (21 ), many of which are gradually replacing traditional fats with hydrogenated vegetable oils (22 ). To date, there are no published studies on trans-fatty acid intake or their effects in populations with dietary patterns and lifestyles different from those of developed countries. Because food products vary widely in their content of total and specific trans-isomers (1 ), obtaining reliable data on intake is difficult. Biomarkers of intake are a good alternative to FFQ because they do not require knowledge of the trans-fat content of foods, do not rely on memory or self-reported information and are not subject to interviewer bias (23 ). In this study we used adipose tissue biomarkers of intake to examine the association between 16:1, 18:1 and 18:2 trans-FA and risk of MI.
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SUBJECTS AND METHODS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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The catchment area for this study was the 18 counties that compose the metropolitan area of San José, Costa Rica. Eligible case subjects were men and women who were diagnosed as survivors of a first acute MI by two independent cardiologists at any of the three recruiting hospitals in the catchment area (San Juan de Dios Hospital, Calderón Guardia Hospital and México Hospital) between 1994 and 1998 as previously described (24
). All cases met the WHO criteria for MI, which require typical symptoms plus either elevations in cardiac enzyme levels or diagnostic changes in the electrocardiogram (25
). Cases were ineligible if they 1) died during hospitalization, 2) were 
75 y old on the day of their first MI, 3) were physically or mentally unable to answer the questionnaire, and 4) had a previous hospital admission related to CVD. Enrollment was carried out while cases were in the hospital’s step-down unit. To achieve 100% ascertainment, fieldworkers carried out daily visits to the three hospitals.
Cases (n = 530) were matched by age (±5 y), sex and area of residence to population controls (n = 531) randomly identified with the aid of data from the National Census and Statistics Bureau of Costa Rica. Because of the comprehensive social services provided in Costa Rica, all persons living in the catchment area had access to medical care without regard to income. Therefore, control subjects came from the source population that gave rise to the cases and were unlikely to have undiagnosed CVD due to poor access to medical care. Control subjects were ineligible if they had ever had an MI or if they were physically or mentally unable to answer the questionnaires. All cases and controls were visited in their homes for the collection of dietary and health information, anthropometric measurements and biological specimens. Participation was 97% for cases and 90% for controls. All subjects gave informed consent on documents approved by the Human Subjects Committee of the Harvard School of Public Health and the University of Costa Rica.
Data collection.
Trained personnel visited the subjects at their homes for data collection. Subjects provided information on socioeconomic, demographic and health characteristics during an interview. A subcutaneous adipose tissue biopsy was collected from the upper buttock as previously described (26 ). The samples were stored at -80°C and later shipped to the Harvard School of Public Health for analysis. Energy and nutrient intakes were assessed with an FFQ developed and validated specifically for use among Costa Ricans (26 ,27 ). Dietary information obtained by the FFQ was used for validation purposes and to assess confounding by dietary factors that do not have good biomarkers of intake such as saturated fat intake. The fatty acid composition of all major types of fat used for cooking in Costa Rica was determined (Campos, H., unpublished data, 1999–2001) and incorporated into the nutrient calculation.
Fatty acid analysis.
Fatty acids were extracted from adipose tissue and analyzed by gas-liquid chromatography (GLC) (26 ). Briefly, the fatty acids in the in the adipose tissue biopsy were extracted using a hexane/isopropanol (3:2) mixture and esterified with methanol and acetyl chloride. After esterification, the methanol and acetyl chloride were evaporated, and the fatty acid methyl esters were redissolved in isooctane. The methyl esters were quantitated by GLC. Peak retention times and area percentages of total fatty acids were identified by injecting known standards (Nu-Chek-Prep, Elysium, MN), and analyzed with the Agilent Technologies ChemStation A.08.03 software (Agilent Technologies, Inc., Palo Alto, CA). Twelve identical samples were analyzed throughout the study. The CV for 16:1, 18:1 and 18:2 trans-FA were 8.4, 15.7 and 6.4%, respectively. We previously showed that adipose tissue trans-FA are good biomarkers of trans-fatty acid intake in the Costa Rican population (26 ).
Statistical analysis.
Of the 1061 subjects that were recruited, 48 cases and 49 controls were excluded because of missing data. The final sample size consisted of 482 case-control pairs that included 712 men and 252 women. Nutrient intakes were adjusted for total energy intake using regression methods (23 ). The trans-fatty acids in the models below were defined as follows: 16:1 = 16:1(n-7t); 18:1 = 18:1(n-7t) + 18:1(n-9t) + 18:1(n-12t); 18:2 = 18:2(n-6tt) + 18:2(n-6ct) + 18:2(n-6tc); Total trans- FA = 16:1 + 18:1 + 18:2. Odds ratios (OR) and 95% confidence intervals (CI) of the top quintiles relative to the lowest quintile of total or each adipose tissue trans-FA (16:1, 18:1 and 18:2) were estimated using conditional logistic regression (28 ). Subjects were divided in quintiles and the median value for each quintile was assigned. Tests for trend were performed across quintiles, using the median value for each of the quintiles modeled as a continuous variable. We performed stratified analyses using unconditional logistic regression (with matching variables in the model) to test whether the associations varied by type of oil used for cooking. We tested for the statistical significance of interactions between gender and adipose tissue trans-fatty acids using the likelihood ratio test (28 ).
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RESULTS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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-linolenic and linoleic acid and vitamin E, whereas alcohol intake was negatively associated. The same analysis by each adipose tissue trans-fatty acid (i.e., 16:1, 18:1 and 18:2) yielded similar results. However, compared with 18:1 and 18:2 trans-FA, the correlations between 16:1 trans-FA and the variables above were weaker (data not shown). The major source of 18:1 and 18:2 trans-FA in Costa Rica is partially hydrogenated soybean oil, which was used by >40% of the subjects. Other important sources of 18:1 and 18:2 trans-FA were margarine and baked products. It is notable that ruminant products contain substantial amounts of 18:1 trans-FA and were a major source of 16:1 trans-FA.
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-linolenic acid and intake of alcohol, vitamin E, saturated fat and total energy. Total adipose tissue trans-fat comprised 
3% 16:1 trans-FA, 55% 18:1 trans-FA, and 45% 18:2 trans-FA.
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-linolenic acid and other dietary variables strengthened this association. The significant effect observed only in the highest quintile may suggest a threshold effect for 16:1 trans-FA (Table 4)
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-linolenic acid. For example, when only -linolenic acid was added to the model with established CVD risk factors, subjects in the highest quintile showed a higher risk of MI compared with those in the lowest quintile (OR = 4.04; 95% CI, 1.88–8.71, P, test for trend <0.0001).
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DISCUSSION |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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The association between total adipose tissue trans-fat and MI found in our study is consistent with findings from prospective studies that examined this association using intake data from industrialized nations (8 ,10 –14 ). In developed countries trans-fat derives mainly from margarines, baked products, fast foods and processed foods (9 ). In contrast, the main source of trans-FA in our study was partially hydrogenated soybean oil consumed in homemade meals.
Our data suggest a potential positive association between 16:1 trans-FA and MI. These data are consistent with previous studies but these early studies did not control for important confounders (15 ,29 ,30 ). Only the fifth quintile was associated with MI and the trend was weak. Therefore, it is possible that although we adjusted for confounders, some confounding may have remained because the main sources of 16:1 trans-FA are also important sources of saturated fat. More studies are required to confirm this result.
Other studies using biomarkers of intake have not found an association between trans-FA and CHD (16 ,17 ,20 ), probably because of small sample sizes (16 –18 ). In studies of diet and CHD, a small sample size limits the ability to adjust for dietary confounders such as cis-polyunsaturated FA that tend to be highly correlated with trans-FA but have opposite effects on MI. However, no association between adipose tissue trans-FA and MI was found in the EURAMIC study (20 ), a large European study on CHD. This association remained nonsignificant even after exclusion of the Spanish centers whose subjects had low adipose tissue trans-FA (20 ).
Our finding of distinct associations between types of trans-FA and MI offers some insight into these apparent discrepancies. It has been postulated that the adverse effects of trans-FA may be confined to specific isomers (31
), and some experimental studies suggest that elaidic acid (18:1n-9t) may be more harmful than trans-vaccenic acid (18:1n-11t) (32
). Consistent with our data, epidemiologic studies have also found that increased RBC 18:2, but not 18:1 trans-FA is associated with increased risk of primary cardiac arrest (19
). These differences in risk are difficult to explain because most intervention studies have focused on total or 18:1 trans-FA and data on the effects of 18:2 trans-FA on plasma lipids are scarce. Interestingly, the MI risk associated with intake of total trans-fat observed in epidemiologic studies is substantially higher than what is predicted from its effects on plasma lipoproteins (9
), suggesting that other factors may account for this association, such as lipoprotein[a] (33
–39
). Trans-FA can also impair 
6 desaturase activity and decrease eicosanoid production (1
,39
–41
). It is also possible that dietary trans-FA may include other isomers with more potent effects than those studied in intervention trials.
We compared the levels of adipose tissue 18:1 and 18:2 trans-FA in several populations. Adipose tissue trans-FA levels varied widely across populations (Fig. 1
). The highest levels (18:1 and 18:2 trans-FA) and higher variability were found in the United States where three prospective studies found an association between total trans-fat intake and MI (10
–13
). In contrast, adipose tissue 18:2 trans-FA were undetectable in some of the EURAMIC study populations and adipose tissue 18:1 trans-FA levels in The Netherlands (the country with the highest values) were still lower than those in the United States. Compared with the United States and Europe, Costa Rica had the highest adipose tissue 18:2 trans-FA but 18:1 trans-FA were relatively low and spanned a narrower range. Considering the low 18:2-levels in adipose tissue (1% of total fat), these data suggest that 18:2 trans-FA may be more atherogenic than 18:1 trans-FA. The lack of an association between 18:1 trans-FA and MI in Costa Rica may be due to the low levels of 18:1 in this population; therefore the effects on plasma lipoproteins are expected to be negligible (9
). Almost all 18:2 trans-isomers in the Costa Rican population derive from partially hydrogenated soybean oil and margarines, whereas 18:1 trans-isomers reflect a mixture of vegetable oils and animal fats. Health policies regarding the trans-fatty acid content of vegetable oils used in developing countries should be established and implemented. In particular, we recommend that vegetable oils used in processed foods and for cooking should not be hydrogenated.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Supported by grant HL 49086 from the National Institutes of Health.
4 Abbreviations used: CHD, coronary heart disease; CI, confidence interval; CVD, cardiovascular disease; FA, fatty acids; FFQ, food-frequency questionnaire; GLC, gas-liquid chromatography; MI, myocardial infarction.
Manuscript received 17 October 2002. Initial review completed 2 December 2002. Revision accepted 31 December 2002.
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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