Dietary carbohydrate intake and mortality: reflections and reactions
Authors: Angela A Stanton
Journal: The Lancet Public Health (2018)

The Article by Sara Seidelmann and colleagues1Seidelmann SB Claggett B Cheng S et al.Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis.Lancet Public Health. 2018; 3: e419-e428Summary Full Text Full Text PDF PubMed Scopus (371) Google Scholar presents the analysis from the Atherosclerosis Risk in Communities study of adults aged 45–64 years over a median duration of 25 years, at six timepoints. The mean caloric intake by each adult was 1558–1655 kcal per day. I have several issues with this study. First, this analysis seems to ignore the fact that, after 25 years, participants are aged 70–89 years, which is older than the 2016 estimate of life expectancy by the US Centers for Disease Control and Prevention: 78·6 years. Second, the study does not stratify carbohydrate consumption by sex and age; these data are only available for the whole study. Third, more than 40% of the test population died during the 25 years. However, this study defined all-cause mortality with the implication that low carbohydrate diets were the only factor to cause early death in older people. There were more smokers and physically inactive participants in the group who had less than 37% of their calories from carbohydrates, both of which are known contributors to a shorter lifespan.2Inoue-Choi M Liao LM Reyes-Guzman C et al.Association of long-term, low-intensity smoking with all-cause and cause-specific mortality in the National Institutes of Health–AARP Diet and Health Study.JAMA Intern Med. 2017; 177: 87-95Crossref PubMed Scopus (121) Google Scholar Importantly, in a diet containing 1558 kcal, 37% carbohydrates is equal to 144 g. The US recommended daily allowance for carbohydrates3Otten JJ Helliwig JP Meyes LD Dietary reference intakes: the essential guide to nutrient requirements. The National Academies Press, Washington, DC2006Google Scholar is 130 g, which is lower than the low-carbohydrate diet defined in this research. 1655 kcal is considered to be a starvation diet,4Kalm LM Semba RD They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment.J Nutr. 2005; 135: 1347-1352Crossref PubMed Scopus (127) Google Scholar which is not feasible for participants to have maintained over 25 years. Also, data collection from memory is riddled with errors5Natarajan L Pu M Fan J et al.Measurement error of dietary self-report in intervention trials.Am J Epidemiol. 2010; 172: 819-827Crossref PubMed Scopus (67) Google Scholar and cannot be used to establish causality. Importantly, Seidelmann and colleagues did not update the carbohydrate exposures of participants that developed heart disease, diabetes, and stroke to reduce confounding from changes in diet that could arise from the diagnosis of metabolic diseases, which was the subject of the study. Removing the most important data for research invalidates the findings. Finally, a time-variable sensitivity analysis was selected from visits 1 and 3, and the cumulative average of carbohydrate intake was used to derive the conclusions of the study. Predicting nutrition consumption over 25 years from two datapoints is not reliable. I declare no competing interests. Dietary carbohydrate intake and mortality: reflections and reactionsI read Sara Seidelmann and colleagues study1 with interest, and there are several shortcomings that deserve attention. Although, the authors appropriately acknowledge the limitations of data collection by questionnaire, in their study, participants were expected to recall their food intake over 25 years, in detail, over two sessions. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: a prospective cohort study and meta-analysisBoth high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50–55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality. Full-Text PDF Open AccessHigh ambitions for health equity in the AmericasOn Oct 1, 2019, the Pan American Health Organization (PAHO) published Just Societies: Health Equity and Dignified Lives, the report of the Commission on Equity and Health Inequalities in the Americas—a Commission established by PAHO , chaired by Sir Michael Marmot, and tasked to analyse the effect of drivers influencing health, while proposing actions to address health inequalities in the region. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsEven if the Food Frequency Questionnaire had been robust and accurately reflective of what people had eaten during the whole 25-year study, a mean calorie intake of 1560–1660 kcal per day had been explained, and people had been allocated correctly to groups that reflected their actual carbohydrate consumption after a health diagnosis. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsThere are several problematic issues in the Article by Seidelmann and colleagues.1 First, the quality of the dietary data is weak, since they are based only on two samples. The food frequency questionnaire that they used appears not to have been independently validated, and it contained only 66 questions and excluded several popular items, such as pizza.1 Food was clearly underreported, as evidenced by a reported average energy intake of roughly 1500 kcal per day. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsIn their Article in The Lancet Public Health (September 2018), Sara Seidelmann and colleagues1 use data from a long-term prospective cohort study and do a meta-analysis of other related cohorts to assess the association between carbohydrate intake and mortality. Our main problem with this Article1 was regarding the confounders that are related to an individual's consumption of carbohydrates and to that individual's associated mortality. Some of these confounders were included as control variables, but since it is impossible to account for all possible confounders, some confounders necessarily went unobserved. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactions – Authors' replyWe appreciate the interest in our work. We found that in long-term observational studies, low carbohydrate dietary intake (<40% of total energy from carbohydrates) was associated with higher mortality when animal-based fat and protein were substituted for carbohydrate.1 However, when plant-based sources of fat and protein such as whole grains, legumes, and nuts are incorporated into low carbohydrate diets, they were associated with lower mortality. We fully acknowledge the limitations of observational studies, while recognising the difficulties associated with long-term randomised trials in the area. Full-Text PDF Open Access