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© 2008 American Society for Nutrition J. Nutr. 138:1469-1475, August 2008

Nutritional Epidemiology

Food Intake Patterns May Explain the High Prevalence of Cardiovascular Risk Factors among Iranian Women1,2

Ahmad Esmaillzadeh* and Leila Azadbakht

Department of Nutrition, School of Public Health, and Food Security and Nutrition Research Center, Isfahan University of Medical Sciences, Isfahan PO Box 81745, Iran

* To whom correspondence should be addressed. E-mail: esmaillzadeh{at}hlth.mui.ac.ir.


   ABSTRACT
TOP
 ABSTRACT
Introduction
 Subjects and Methods
 Results
 Discussion
 LITERATURE CITED
 
Some cardiovascular risk factors are more prevalent in Middle Eastern countries than in other parts of the world. Lifestyle-related factors, including diet, might account for this discrepancy. We aimed to identify the association between food intake patterns and cardiovascular risk factors among Iranian adult women. We studied 486 apparently healthy Iranian women aged 40–60 y. We used a Willett-format FFQ for collecting dietary data. Fasting plasma glucose (FPG) concentrations, lipid profiles, and blood pressure were measured. Diabetes was defined as FPG ≥ 6.93 mmol/L; dyslipidemia was based on Adult Treatment Panel III and hypertension on Joint National Committee VI recommendations. The presence of at least 1 risk factor and at least 2 risk factors of the 3 major risk factors for cardiovascular disease (hypertension, dyslipidemia, and diabetes) was also evaluated. We identified 3 major eating patterns (healthy, Western, and Iranian). After controlling for potential confounders, subjects in the top quintile of the healthy dietary pattern were less likely to have dyslipidemia [odds ratio (OR), 0.36; 95% CI, 0.19–0.53], hypertension (OR, 0.33; 95% CI, 0.17–0.60), at least 1 (OR, 0.30; 95% CI, 0.18–0.58), and at least 2 risk factors (OR, 0.39; 95% CI, 0.20–0.77) compared with the lowest quintile. In contrast, those with greater adherence to the Western dietary pattern had greater odds for cardiovascular risk factors (OR, 2.59–3.11; P < 0.05). The Iranian dietary pattern was significantly associated with dyslipidemia (OR, 1.73; 95% CI, 1.02–2.99) and at least 1 risk factor (OR, 1.89; 95% CI, 1.05–3.20). The major dietary patterns and diabetes were not associated. Eating patterns of this Middle Eastern population might explain the higher prevalence of some cardiovascular risk factors in this region. However, our findings need to be confirmed in other Middle Eastern countries.


   Introduction
TOP
 ABSTRACT
 Introduction
Subjects and Methods
 Results
 Discussion
 LITERATURE CITED
 
Dietary intake is inherently complex with the possibility of unknown components in foods that may interact with known nutrients or yet other unknown food components (1). Single food or nutrient effects may be small, but their cumulative effects may be beneficial or harmful to human health (2). To capture the whole diet, the dietary pattern analysis has been suggested (3–5). This approach incorporates all food and nutrient interactions in the diet and allows us to identify diet-disease relations without knowing the exact nutrient or food component involved. The American Dietetic Association suggests that healthful eating messages to the public should emphasize the total diet, or overall pattern of food eaten, rather than any single nutrient, food, or meal (6). Dietary patterns reflect actual consumption; analyzing them can provide insights into possibilities for dietary changes and also may help facilitate the translation of findings into public health recommendations (7).

Studying the links between food intake patterns and cardiovascular risk factors is not new. This association has been reported from the US (8–10) and most European countries (11–13), but few data are available on this association from Asian countries (14,15), particularly from Middle Eastern populations. Besides huge differences in dietary intakes of Middle Eastern populations with those of other Asian and Western populations, it seems that some cardiovascular risk factors are more prevalent in this part of the world than in others (16). Previous investigations have revealed great differences between Middle Eastern countries and other countries in the prevalence of low serum HDL-cholesterol and hypertriglyceridemia (17,18). For instance, low serum HDL-cholesterol is prevalent in 37% of U.S. adults (19), and in 69% of Middle Eastern populations (20). These differences are greater than would be explained by genetic factors. Lifestyle-related factors, including diet, might account for this discrepancy. Consumption of high-carbohydrate diets (mostly from refined sources) high in hydrogenated fats, in addition to lack of alcohol use, might offer some reasons (21–23). However, other components of the diet might also be important.

Our previous investigations have shown that, like other parts of the world, the use of factor analysis on dietary data in Middle Eastern countries can result in meaningful and interpretable eating patterns (24,25). In the current study, we aimed to identify the association between food intake patterns and cardiovascular risk factors among Iranian adult women.


   Subjects and Methods
TOP
 ABSTRACT
 Introduction
 Subjects and Methods
Results
 Discussion
 LITERATURE CITED
 
    Participants. This cross-sectional study was performed in the framework of a project approved by the ethical committee of National Nutrition and Food Technology Research Institute, Shaheed Beheshti University of Medical Sciences, Tehran, Iran. In this project, a representative sample of 583 Tehrani female teachers aged 40–60 y, selected by a multistage cluster random sampling method, were invited to participate; 521 women agreed and provided informed written consent (response rate, 89%). After excluding individuals with a prior history of chronic diseases (because of possible changes in diet), those who had left >70 items blank on the FFQ, those who reported a total daily energy intake outside the range of 800–4200 kcal (3344–17,556 kJ), and those taking medications that would affect serum lipoprotein, blood pressure, and carbohydrate metabolism, 486 women remained for the current analysis.

    Assessments of variables. Detailed information about dietary, anthropometric, biochemical, and blood pressure measurements have been published (24–26). Briefly, usual dietary intakes were assessed using a validated semiquantitative Willett-format 168-item FFQ administered by a trained dietitian (21,23). We collapsed 168 food items into 41 predefined food groups based on the similarity of nutrients. Details of food groupings were described elsewhere (24). After using principal component analysis with orthogonal transformation, 3 major dietary patterns (healthy, Western, and Iranian), explaining 24% of the total variance were identified based on their natural interpretation, eigenvalues (>1), and Scree test (24,25). The healthy dietary pattern was high in fruits, vegetables, tomatoes, poultry, legumes, cruciferous and green leafy vegetables, tea, fruit juices, and whole grains. The Western dietary pattern was high in refined grains, red meat, butter, processed meat, high-fat dairy products, sweets and desserts, pizza, potatoes, eggs, hydrogenated fats, and soft drinks, and was low in other vegetables and low-fat dairy products. The Iranian dietary pattern included higher intakes of refined grains, potato, tea, whole-grains, hydrogenated fats, legumes, and broth. Factor-loading matrixes for these dietary patterns were previously published (24). The factor score for each pattern was constructed by summing observed intakes of component food items weighted by their factor loadings (27). Each participant received a factor score for each identified pattern.

After a 12-h overnight fast, we drew a blood sample for biochemical assessment. As described elsewhere in more detail (26), the analysis of samples was performed using Selectra 2 auto-analyzer (Vital Scientific). Fasting plasma glucose (FPG)3 was measured on the day of blood collection by enzymatic colorimetric method using glucose oxidase (Pars Azmoon). Serum triglyceride concentrations were assayed using triglyceride kits (Pars Azmoon) by enzymatic colorimetric tests with glycerol phosphate oxidase. Serum HDL-C was measured after precipitation of the apolipoprotein B containing lipoproteins with phosphotungistic acid. Serum LDL-C was calculated from serum total cholesterol, triglyceride, and HDL-C [LDL-C (mmol/L) = TC – (HDL-C + TG/2.2)], except when the triglyceride concentration was >4.4 mmol/L. The inter- and intra-assay CV of this method were <10%.

Blood pressure was measured 3 times after the participants sat for 15 min, as reported earlier (28). Weight was measured using digital standard scales to the nearest 100 g without shoes while wearing minimal clothes. Height was measured without shoes with shoulders in a normal position using a tape measure. BMI was calculated as weight (kg)/height (m2). Data on physical activity were obtained using the International Physical Activity Questionnaire and expressed as metabolic equivalent h/wk (MET-h/wk). Additional covariate information regarding age, smoking habits, socioeconomic status, medical history, and current use of medications was obtained using questionnaires.

    Definition of terms. Hypertriglyceridemia was defined as serum triglyceride ≥2.2 mmol/L, hypercholesterolemia as serum total cholesterol ≥6.24 mmol/L, high serum LDL-C as ≥4.1 mmol/L, and low serum HDL-C as <1.29 mmol/L (29). Dyslipidemia was defined based on the 3rd report of the National Cholesterol Education Program Expert Panel (30) as having hypertriglyceridemia, hypercholesterolemia, high LDL-C, or low HDL-C. Hypertension was defined as systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥90 mm Hg based on Joint National Committee VI (30). Diabetes mellitus was defined as FPG ≥6.93 mmol/L (31). The presence of at least 1 risk factor and at least 2 risk factors of the 3 major risk factors for cardiovascular disease (hypertension, dyslipidemia, and diabetes) was also evaluated.

    Statistical methods. We calculated quintiles of dietary pattern scores and categorized participants accordingly. One-way ANOVA and chi-square tests were used to compare means and percentages, respectively. Age- and energy-adjusted means for dietary intakes were computed using the General Linear Model. Multivariate-adjusted means for cardiovascular risk factors were computed by adjusting for age (y), energy intake (kJ/d), smoking (yes or no), current estrogen use (yes or no), family history of diabetes and stroke (yes or no), menopausal status (yes or no), socioeconomic status (categorical), and physical activity (MET-h/wk). We did not control for BMI and waist circumference (WC) in our main analyses because adjustment for obesity measures in a cardiovascular risk study would be an overadjustment. Furthermore, our recent study showed that major dietary patterns in this population were predictors of general and central obesity (24). We used logistic regression analyses (with covariates as above) to calculate adjusted odds ratios (OR) and 95% CI. In an additional model of logistic regression, we controlled for BMI and WC to determine whether the associations were mediated through obesity. The overall trend of OR was computed by the use of Mantel-Haenszel extension chi-square test. P < 0.05 was considered significant.


   Results
TOP
 ABSTRACT
 Introduction
 Subjects and Methods
 Results
Discussion
 LITERATURE CITED
 
Higher healthy dietary pattern scores were associated with more physical activity and greater fiber intake but lower energy and cholesterol intakes. In contrast, higher Western dietary pattern scores were associated with less physical activity and lower fiber intake but greater energy and cholesterol intakes. Subjects in the upper quintile of the Iranian dietary pattern score were older, slightly more physically active, and had lower energy intakes than those in the lowest quintile (Table 1).


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  		TABLE 1 Dietary intakes and descriptive characteristics of the study participants across quintiles of dietary patterns scores1

 
Subjects in the top quintile of the healthy dietary pattern were less likely to have cardiovascular risk factors compared with those in the lowest quintile (Table 2). In contrast, individuals in the highest quintile of the Western dietary pattern had a greater prevalence of cardiovascular risk factors compared with those in the lowest category. There was a trend for an increasing prevalence of dyslipidemia (P-trend = 0.09) and at least 2 risk factors (P-trend = 0.11) in the highest quintile of Iranian dietary pattern.


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  		TABLE 2 Prevalence of cardiovascular risk factors in Iranian women across quintiles of dietary pattern scores1

 
Individuals in the top quintile of the healthy dietary pattern had lower serum triglyceride, total and LDL cholesterol, and FPG concentrations, lower systolic and diastolic blood pressures, and a higher serum HDL-cholesterol concentration than those in the lowest quintile (Fig. 1). In contrast, the Western dietary pattern was associated with unfavorable cardiovascular risk factors, except for high FPG. Higher Iranian dietary pattern scores were associated with higher FPG and serum total cholesterol concentrations (P-trend < 0.05).


Figure 1
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  		FIGURE 1  Multivariate-adjusted means for individual cardiovascular risk factors in Iranian women across quintiles of dietary pattern scores. Adjustments were made for age (y), energy intake (kJ/d), smoking (yes or no), current estrogen use (yes or no), family history of diabetes and stroke (yes or no), menopausal status (yes or no), socioeconomic status (categorical), and physical activity (MET-h/wk). Individuals in the top quintile of the healthy dietary pattern had lower cardiovascular risks (P < 0.05), whereas those in the highest quintile of the Western dietary pattern had unfavorably higher cardiovascular risks (P < 0.05 except FPG, P = 0.23). Higher scores of the Iranian dietary pattern were associated with higher FPG and serum total cholesterol concentrations (P < 0.05).

 
The healthy eating pattern was inversely associated with all cardiovascular risk factors (Table 3). After adjustment for potential confounders, all associations remained significant except for the association with diabetes that became marginally significant (OR, 0.29; 95% CI, 0.11–1.07; P = 0.07). Additional controlling for BMI and WC nullified the association with at least 2 risk factors (OR, 0.58; 95% CI, 0.33–1.17), whereas the others remained significant. Individuals in the top quintile of the Western dietary pattern were more likely to have dyslipidemia, hypertension, at least one, and at least 2 risk factors. Adjustment for potential confounders, including BMI and WC, attenuated the associations, but all were still significant (OR, 2.08; 95% CI, 1.24–4.17 for dyslipidemia; OR, 2.26; 95% CI, 1.14–4.77 for hypertension; OR, 2.83; 95% CI, 1.58–5.31 for at least 1 risk factor; and OR, 2.31; 95% CI, 1.13–5.28 for at least 2 risk factors). The Western dietary pattern and diabetes were not associated. The Iranian dietary pattern was associated with greater odds for dyslipidemia and at least 1 risk factor (P < 0.05 for both). However, controlling for BMI and WC removed the associations (1.55; 0.89–2.71 for dyslipidemia and 1.63; 0.92–2.98 for at least 1 risk factor).


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  		TABLE 3 Crude and multivariate adjusted OR (95% CI) for cardiovascular risk factors in Iranian women across quintiles of dietary pattern scores1

 

   Discussion
TOP
 ABSTRACT
 Introduction
 Subjects and Methods
 Results
 Discussion
LITERATURE CITED
 
Our findings indicate that the healthy eating pattern was associated with lower odds of having cardiovascular risk factors, whereas the Western eating pattern was associated with greater odds. Although several studies have reported the contribution of major dietary patterns to cardiovascular risk factors, to our knowledge, this is among the first investigations reporting such an association in Middle Eastern countries.

Epidemiological and nutrition transitions in Middle Eastern countries have resulted in increased rates of noncommunicable chronic diseases (32). Cardiovascular diseases have been reported to account for 25–45% of total deaths in these countries (33). Besides being the leading cause of death, cardiovascular disease differs in this part of the world compared with other regions. For instance, cardiovascular risk factors are more prevalent among women than men (34), low HDL-cholesterol and hypertriglyceridemia are the most prevalent cardiovascular disease risk factors (35), and more than two-thirds of the adult population has dyslipidemia (36). This is not the case in most developed countries. Varying prevalence of cardiovascular risk factors in Middle Eastern countries would result in different population-attributable risks. Furthermore, whereas cardiovascular death rates have significantly declined in most developed countries in the past decades, rates have increased in the Middle East (37). Therefore, identification of correlates of cardiovascular risk factors is of particular value in these countries. However, most information about the disease has mainly been obtained from studies conducted in Western populations of European or American origins. It is unclear to what extent these findings apply to the worldwide population, because some data suggest that risk factors for cardiovascular disease vary greatly among populations (37).

Most data linking dietary patterns to cardiovascular risks come from observational studies in Western populations and few studies have considered dietary patterns of non-Western populations. In the current study, the healthy dietary pattern was inversely associated with most cardiovascular risk factors. This is consistent with a recently reported finding from the Swedish Mammography Cohort (38) in which the healthy eating pattern was reported to be significantly associated with decreased risk of incident myocardial infarction. In a longitudinal analysis among Finnish adolescents (39), a dietary pattern reflecting more health-conscious food choices (such as high consumption of vegetables, legumes and nuts, tea, rye, cheese, and other dairy products, and alcoholic beverages) was inversely associated with cardiovascular risk factors in adulthood. An inverse relationship between the healthy eating pattern and incident cardiovascular risks was also found in men (40) and women in the U.S. (9,41). This favorable association might be explained by the beneficial effects of the healthy eating pattern on inflammation, endothelial function, and insulin sensitivity (42). Besides other studies (43), even in the current population, our previous investigations showed lower marker levels of systemic inflammation and endothelial dysfunction and also decreased odds of having insulin resistance among those in the top quintile of the healthy dietary pattern compared with the lowest quintile (25,28).

Foods loaded in our Western dietary pattern were similar to those in other studies of the U.S. population (40,41). Economic growth, urbanization, and industrialization have changed traditional dietary patterns of developing countries to Western patterns. Fast foods, soft drinks, and meat products high in fat, sugar, and salt became more common in these countries. Such dietary intakes can explain why 80% of the burden of cardiovascular disease lies in these countries. In the current study, this dietary pattern was associated with greater odds of having cardiovascular risk factors. This is not new. Others have consistently reported the harmful effects of such dietary intakes. Using reduced-rank regression in the German Coronary Risk Factors for Atherosclerosis in Women study, Hoffmann et al. (44) identified a dietary pattern (characterized by high intakes of meat, margarine, poultry, and sauce and low intakes of vegetarian dishes, wine, vegetables, and whole-grain cereals) that was associated with lower HDL-cholesterol concentrations. The Western dietary patterns identified in the Nurses' Health Study (41) and Health Professional Follow-up Study (40) were positively associated with incident coronary heart disease risk. These associations are in the expected direction. Our Western dietary pattern was loaded with refined grains, red meat, butter, and hydrogenated fats; intake of each has been reported to increase cardiovascular risk. Our previous findings from Iran have shown the positive association of refined grain and hydrogenated fats intakes with atherogenic dyslipidemia (21,22). Furthermore, the Western dietary pattern has been reported to be associated with inflammation and endothelial dysfunction (25,45), a possible biological mechanism that diet can affect cardiovascular health.

The traditional Iranian dietary pattern we identified was significantly associated with greater risk of dyslipidemia and having at least 1 risk factor of cardiovascular disease. This might be attributed to the higher carbohydrate content of this dietary pattern. The most prevalent components of dyslipidemia among Iranians, as in the current study, are low HDL and elevated serum triglyceride concentrations (20,46); both could be the result of high carbohydrate intake, particularly from refined sources. Data from the National Health Survey (47) have indicated that ~20% of the Iranian population have a serum total cholesterol concentration >6.24 mmol/L. Therefore, serum cholesterol might not be a major determinant of cardiovascular deaths among Iranians. The major characteristics of the traditional Iranian pattern of dependence on bread and rice and 66% of energy derived from carbohydrates (48) could explain, to some extent, the higher prevalence of dyslipidemia in this country.

Unlike most investigators, we did not find significant associations between the major dietary patterns and diabetes. van Dam et al. (7) found an increased risk of incident type 2 diabetes with Western dietary pattern among American men. This has also been reported among women (49). However, consistent with our study, both the Nurses' Health Study and the Health Professional Follow-up Study showed a marginally significant inverse association between the healthy (the so-called prudent) dietary pattern and the risk of incident diabetes (7,49). The lack of a significant association between the major dietary patterns and diabetes in our study is surprising and needs further investigations. Several factors may be involved, including a different definition of diabetes in our study compared with others, its lower prevalence compared with the other cardiovascular risks, inadequate sample size, and the cross-sectional design of the study.

Our study has several limitations. The major one is its cross-sectional design that precludes the determination of a cause and effect relationship. Therefore, the possible association needs to be tested directly in future investigations. However, due to budget limitations in these countries, such studies may not be conducted and the results published soon. However, identification of some intermediary factors such as unfavorable lipid profiles might lead to changes in diet in an attempt to ameliorate these conditions. However, residual confounding effects of these changes would tend to attenuate the risk estimates and therefore the true results would be even stronger than what we found.

Another limitation is that our study was confined to women. Men and women might have different eating patterns. However, due to consumption of most meals at home, it is likely that dietary patterns are similar in Iranian men and women. It has been argued that men and women have different lipid profiles so they must have different dietary patterns (50). This is possible, but it must be taken into account that dietary patterns are not the single determinant of serum lipid profiles. Other factors such as physical activity and smoking should also be considered. Lack of considering participants' dietary behaviors in our dietary pattern analysis, the limitations of an FFQ for assessing dietary intakes, and subjective decisions in the use of factor analysis must also be taken into account as other limitations of the study.

We cannot generalize our findings to the entire Iranian population, because teachers in our community have a higher socioeconomic status than the general Iranian population. However, participants in our study were selected from 4 large socioeconomically diverse districts of Tehran, covering a broad range of dietary habits. Further, dietary intakes of Tehrani people differ from those of people living in other small cities in the country. Overall, the diet of residents of Tehran, the largest city in the country, is more westernized. In small cities, the traditional Iranian pattern seems to be the major dietary pattern. However, due to different cultures in different parts of the country, this might not be true for all small cities. Overall, Iranians consume more energy from carbohydrates, typically from refined grains, whereas the contribution of fat and protein to their energy intake is less than that in developed countries.

In conclusion, the present findings demonstrate that eating patterns of the Middle Eastern populations might explain the higher prevalence of some cardiovascular risk factors in these areas. However, our findings need to be confirmed in other Middle Eastern countries.


   FOOTNOTES
 
1 Supported by the National Nutrition and Food Technology Research Institute of the Islamic Republic of Iran (P. 25/47/2337). Back

2 Author disclosures: A. Esmaillzadeh and L. Azadbakht, no conflicts of interest. Back

3 Abbreviations used: FPG, fasting plasma glucose; MET-h/wk, metabolic equivalent-h/wk; OR, odds ratio; WC, waist circumference. Back

Manuscript received 18 February 2008. Initial review completed 15 March 2008. Revision accepted 20 May 2008.


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 ABSTRACT
 Introduction
 Subjects and Methods
 Results
 Discussion
 LITERATURE CITED
 

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