Conclusions In the context of low SFAs , high-MUFA diets in isocaloric substitution for high-CHO diets did not affect blood pressure in individuals with and without hypertension .
Context Current dietary guidelines for cardiovascular disease risk management recommend restricting intake of saturated fatty acids ( SFAs ) .
However , the optimal macronutrient profile , in the context of a low-SFA diet , remains controversial .
The blood-pressure effect of replacing SFAs in diets with monounsaturated fatty acids ( MUFAs ) compared with carbohydrate has not been quantified to date .
Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study
BACKGROUND The relationship between macronutrients and cardiovascular  disease and mortality is controversial . Most available data are from European and North American population s where nutrition excess is more likely , so their applicability to other population s is unclear . METHODS The Prospect i ve Urban Rural Epidemiology ( PURE ) study is a large , epidemiological cohort study of individuals aged 35 - 70 years ( enrolled between Jan 1 , 2003 , and March 31 , 2013 ) in 18 countries with a median follow-up of 7·4 years ( IQR 5·3 - 9·3 ) . Dietary intake of 135 335 individuals was recorded using vali date d food frequency question naires . The primary outcomes were total mortality and major cardiovascular events ( fatal cardiovascular disease , non-fatal myocardial infa rct ion , stroke , and heart failure ) . Secondary outcomes were all myocardial infa rct ions , stroke , cardiovascular disease mortality , and non-cardiovascular disease mortality . Participants were categorised into quintiles of nutrient intake ( carbohydrate , fats , and protein ) based on percentage of energy provided by nutrients . We assessed the associations between consumption of carbohydrate , total fat , and each type of fat with cardiovascular disease and total mortality . We calculated hazard ratios ( HRs ) using a multivariable Cox frailty model with r and om intercepts to account for centre clustering . FINDINGS During follow-up , we documented 5796 deaths and 4784 major cardiovascular disease events . Higher carbohydrate intake was associated with an increased risk of total mortality ( highest [ quintile 5 ] vs lowest quintile [ quintile 1 ] category , HR 1·28 [ 95 % CI 1·12 - 1·46 ] , ptrend=0·0001 ) but not with the risk of cardiovascular disease or cardiovascular disease mortality . Intake of total fat and each type of fat was associated with lower risk of total mortality ( quintile 5 vs quintile 1 , total fat : HR 0·77 [ 95 % CI 0·67 - 0·87 ] , ptrend<0·0001 ; saturated fat , HR 0·86 [ 0·76 - 0·99 ] , ptrend=0·0088 ; monounsaturated fat : HR 0·81 [ 0·71 - 0·92 ] , ptrend<0·0001 ; and polyunsaturated fat : HR 0·80 [ 0·71 - 0·89 ] , ptrend<0·0001 ) . Higher saturated fat intake was associated with lower risk of stroke ( quintile 5 vs quintile 1 , HR 0·79 [ 95 % CI 0·64 - 0·98 ] , ptrend=0·0498 ) . Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infa rct ion or cardiovascular disease mortality .  INTERPRETATION High carbohydrate intake was associated with higher risk of total mortality , whereas total fat and individual types of fat were related to lower total mortality . Total fat and types of fat were not associated with cardiovascular disease , myocardial infa rct ion , or cardiovascular disease mortality , whereas saturated fat had an inverse association with stroke . Global dietary guidelines should be reconsidered in light of these findings . FUNDING Full funding sources listed at the end of the paper ( see Acknowledgments )
Conclusions In the context of low SFAs , high-MUFA diets in isocaloric substitution for high-CHO diets did not affect blood pressure in individuals with and without hypertension .
Context Current dietary guidelines for cardiovascular disease risk management recommend restricting intake of saturated fatty acids ( SFAs ) .
However , the optimal macronutrient profile , in the context of a low-SFA diet , remains controversial .
The blood-pressure effect of replacing SFAs in diets with monounsaturated fatty acids ( MUFAs ) compared with carbohydrate has not been quantified to date .