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Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
1To whom correspondence should be addressed. E-mail: uajani{at}cdc.gov.
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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20 y old, dietary fiber intake was inversely associated with serum CRP concentration. The odds ratio (OR) for increased CRP concentration (>3.0 mg/L) was 0.49 (95% CI 0.37–0.65; P for trend < 0.001) for the highest quintile of fiber intake compared with the lowest. Adjustment for age, gender, race, education, smoking, physical activity, BMI, total energy, and fat intake resulted in a slight attenuation (OR 0.59; CI 0.41–0.85; P for trend = 0.006). Excluding participants with cardiovascular conditions, diabetes, or cancer did not alter the results. Our findings indicate that fiber intake is independently associated with serum CRP concentration and support the recommendation of a diet with a high fiber content.
KEY WORDS: • dietary fiber • C-reactive protein • cardiovascular disease • nutrition • survey
The role of inflammation in the etiology of atherosclerosis and cardiovascular disease (CVD)2 has gained much attention in the health and medical fields. A growing body of literature suggests that the inflammatory process is a major contributor to the development of atherosclerosis and, hence, CVD. Scientists have explored a number of biomarkers of inflammation (e.g., cytokines, adhesion molecules, serum amyloid A protein) to determine their relation to CVD and to assess their ability to predict future health-related events. Of these, C-reactive protein (CRP), a nonspecific marker of inflammation, was consistently shown to be a strong predictor of CVD (1–4). It is possible that at least some of the known cardiovascular risk factors may affect the risk for CVD by modulating inflammation. Researchers have reported associations between traditional cardiovascular risk factors and some of these inflammatory biomarkers (5–12). The intake of dietary fiber, a group of polysaccharides and lignins of plant origin, shows a strong inverse relation between the level of dietary fiber intake and risk of CVD (13–17). Several possible mechanisms have been suggested, including the lowering of serum cholesterol concentration and blood pressure, glucose and insulin modulation, and influence on body weight regulation and fibrinolysis (18). However, dietary fiber may also exert its effect through other physiologic processes. Currently, little is known about the potential relations between dietary risk factors (especially dietary fiber) and markers of inflammation (e.g., CRP). To explore whether the effect of dietary fiber on the risk of CVD may be mediated in part by affecting the inflammatory process, we examined the association between the intake of dietary fiber and the serum concentration of CRP among participants of the National Health and Nutrition Examination Survey (NHANES).
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SUBJECTS AND METHODS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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The CRP was measured using latex-enhanced nephelometry. For quantification of CRP, particles consisting of a polystyrene core and a hydrophilic shell were used. A dilute solution of a test sample was mixed with latex particles coated with anti-CRP antibodies. CRP present in the test sample formed an antigen-antibody complex with the latex particles. An automatic blank subtraction was performed, and CRP concentrations were calculated using a calibration curve. These assays were performed on a Behring Nephelometer for quantitative CRP determination. Dietary intake data were assessed by means of dietary interviews. Total intake of energy and nutrients (including dietary fiber, total fat, and alcohol intake) were computed from foods and beverages consumed during a 24-h period before the interview (from midnight to midnight). The interview data were imported into the University of Texas Food Intake Analysis System, and the USDA 1994–1998 Survey Nutrient Database was used for coding.
Information on several other covariates was collected by questionnaire and used as follows: age at screening (continuous), gender, race or ethnicity (Caucasian, African-American, Mexican-American, other), education [less than high school, high school or general equivalency diploma (GED), greater than high school], smoking (never, former, current), physical activity (none, <150 min/wk, 150+ min/wk of moderate or vigorous activities), BMI [defined as body weight in kilograms divided by square of height in meters (kg/m2) and categorized into 3 groups (<25, 25 to <30, 30)], total energy intake (kJ), total grams of fat intake, and total grams of alcohol intake.
Statistical analysis.
We limited our analysis to participants 20 y old. Initially, we used simple regression models with log-transformed CRP to account for skewed distribution as a dependent variable. Dietary fiber intake was used as the independent variable and included as both a continuous and a categorized (quintiles) variable. Multivariate models were used to assess the independence of the association after simultaneously adjusting for potential confounders and covariates. In a separate analysis, we used logistic regression models to compute the odds ratio (OR) and 95% CI for the probability of having a high CRP, defined as CRP > 3.0 mg/L based on recommendations of the CDC and the AHA (20). We used the continuous variable indicating dietary fiber intake to test for linear trend. In addition, we conducted separate analyses in which we excluded participants who reported either the presence of any coronary heart disease (CHD; defined as positive reports of CHD, angina, or myocardial infarction), CVD (defined as any CHD or stroke) diabetes, hypertension, or cancer. Analyses were also conducted after excluding participants with a CRP concentration > 10 mg/L due to the possibility of other sources of inflammation. We used SUDAAN (Software for the Statistical Analysis of Correlated Data) (21) for analyses to account for the complex sampling design and to calculate weighted estimates using the medical examination clinic sampling weights.
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RESULTS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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20 y old were included in the nationally representative survey. We excluded 880 participants who lacked data for dietary fiber (n = 626) and CRP (n = 735) as well as 80 participants who were missing one or more of the covariate data. This report is based on a total of 3920 participants. Dietary fiber intake among all participants ranged from 0 to 145 g with a more than 6-fold difference in mean/median fiber intake between the lowest and highest quintiles (Table 1). Compared with participants who consumed low amounts of dietary fiber, participants with high fiber intake were slightly older, more likely to be male, better educated, more physically active, and less likely to be smokers. However, they also tended to consume higher amounts of fat (P for trend < 0.001), alcohol (P for quadratic trend 0.038), and total energy (P for trend < 0.001) than the low fiber intake group. The CRP values among all participants ranged from 0.1 to 140 mg/L. Participants with higher CRP concentrations (>3.0 mg/L) were more likely to be female, slightly older, less educated, and more obese as a group compared with those with lower CRP concentrations (Table 2). They also tended to consume less fat (P for trend 0.027), alcohol (P for trend 0.017), and total energy (P for trend < 0.001). These baseline characteristics between the categories of dietary fiber intake as well as concentrations of CRP were significantly different (P < 0.05) across categories. As expected, participants with higher concentrations of CRP also reported more health conditions compared with those with serum CRP concentration 
3.0 mg/L, i.e., CVD (9.5 vs. 5.5%), hypertension (32.6 vs. 18.9%), and diabetes (9.0 vs. 5.4%). The prevalence of cancer, however, did not differ between the 2 groups (6.4 vs. 6.2%).
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DISCUSSION |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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Our findings are consistent with several other reports that explored the association between CVD risk factors and concentrations of CRP. Earlier reports showed that inflammatory markers are independently associated with CVD risk factors. To our knowledge, only 1 study reported a possible reduction in CRP concentrations with a conventional cholesterol-lowering diet high in fiber, plant sterol, soy protein, and almonds (22). Dietary fiber intake has been reported to be an important risk factor for CVD, although the mechanisms of how increased fiber intake might reduce the risk of CVD are not yet fully understood (23). Several possible mechanisms have been suggested, including hypocholesterolemic effects, modulation of glucose and effect on insulin, hypotensive effects, effects on body weight regulation, and fibrinolysis (18). However, a possible role for dietary fiber in the inflammatory process, particularly in relation to CRP, has not been established. Dietary fiber may decrease the oxidation of lipids, which in turn may reduce inflammation. This finding would be consistent with an earlier report from Rezar et al. (24) showing that a high intake of wheat bran and oat bran effectively reduced oxidative stress induced by a high-fat diet in pigs.
Several strengths and limitations of this study should be highlighted. The study sample is representative of the U.S population 20 y old; therefore, our results are applicable to the general U.S. population of this age group. The sample size of this study is sufficiently large to make reasonable inferences. Our results from an unadjusted model remained significant after adjusting for various potential confounders. Therefore, it is unlikely that our results are due to chance. Although we controlled for a number of potential confounders, we may have failed to include all relevant ones. Thus, the possibility of uncontrolled or unknown confounding remains. NHANES dietary data are based on a 24-h recall diet. Misclassification of dietary fiber intake is a possibility; therefore, we may have underestimated the protective effects of dietary fiber. The cross-sectional nature of the study is a limitation that does not permit assessing causality due to uncertain temporality of this association. In addition, because separate data on type of dietary fiber were not available, we could not assess the associations separately by type of dietary fiber.
Our study showed a significant correlation between dietary fiber and CRP, a marker of inflammation and a possible predictor of future cardiovascular events (25). Lower concentrations of CRP were observed among people who consumed higher amounts of dietary fiber. Consistent with current dietary recommendation from the AHA (26) and the American Dietetic Association (27), greater consumption of dietary fiber should be recommended.
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FOOTNOTES |
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Manuscript received 14 November 2003. Initial review completed 23 January 2004. Revision accepted 17 February 2004.
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LITERATURE CITED |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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1. Koenig, W., Sund, M., Frohlich, M., Fischer, H. G., Lowel, H., Doring, A., Hutchinson, W. L. & Pepys, M. B. (1999) C-reactive protein, a sensitive marker of inflammation, predicts future risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Augsburg Cohort Study, 1984 to 1992. Circulation 99:237-242.
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17. Wolk, A., Manson, J. E., Stampfer, M. J., Colditz, G. A., Hu, F. B., Speizer, F. E., Hennekens, C. H. & Willett, W. C. (1999) Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. J. Am. Med. Assoc. 281:1998-2004.
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19. Centers for Disease Control and Prevention () NHANES 1999–2000 Data Files www.cdc.gov/nchs/about/major/nhanes/NHANES99_00.htm. 2003. Accessed July 30, 2003.
20. Pearson, T. A., Mensah, G. A., Alexander, R. W., Anderson, J. L., Cannon, R. O., III, Criqui, M., Fadl, Y. Y., Fortmann, S. P., Hong, Y., Myers, G. L., Rifai, N., Smith, S. C., Jr., Taubert, K., Tracy, R. P. & Vinicor, F. (2003) Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation 107:499-511.
21. Research Triangle Institute 2001 SUDAAN User’s Manual Research Triangle Institute Research Triangle Park, NC.
22. Jenkins, D. J., Kendall, C. W., Marchie, A., Faulkner, D. A., Wong, J. M., de Souza, R., Emam, A., Parker, T. L., Vidgen, E., Lapsley, K. G., Trautwein, E. A., Josse, R. G., Leiter, L. A. & Connelly, P. W. (2003) Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. J. Am. Med. Assoc. 290:502-510.
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