Comparison of predictive performance of various fatty acids for the risk of cardiovascular disease events and all-cause deaths in a community-based cohort


      • We investigate fatty acids on the risk of cardiovascular and all-cause death events.
      • Trans fat and saturated fat were predictors for all-cause death risk.
      • EPA was inversely related to all-cause death.



      The issue of whether saturated fats and trans fats are superior predictors of all-cause death and cardiovascular disease than n-3 polyunsaturated fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), remains a matter of contention. Furthermore, few studies have examined the relationship between fatty acids and the outcomes of cardiovascular disease (CVD) in Asian populations. The aim of this study was to compare the effectiveness of various plasma fatty acids as predictors for all-cause death and CVD events in an ethnic Chinese population.


      This study assembled a community-based prospective cohort, comprising 1833 participants (60.6 ± 10.5 yrs, 44.5% women) who underwent a comprehensive evaluation of fatty acids in blood using gas chromatography. None of the subjects had a history of CVD at the time of recruitment.


      A total of 568 individuals died and 275 individuals developed CVD during the follow-up period (median of 9.6 years; interquartile range of 8.9–10.5 years). Following adjustment for established cardiovascular risk factors, the relative risk of all-cause death in the highest quartile, compared with the lowest quartile, was 1.33 for saturated fats (95% confidence interval [CI], 1.01–1.75, test for trend, P = 0.015), 1.71 for trans fats (95% CI, 1.27–2.31, test for trend, P = 0.0003), 0.77 for EPA (95% CI, 0.59–1.00, test for trend, P = 0.048), and 0.89 for DHA (95% CI, 0.68–1.18, test for trend, P = 0.354). Similar patterns were observed for CVD events. Trans fats presented the largest area under the receiver operator characteristic curve (0.740, 95% CI, 0.716–0.766) for the prediction of all-cause death. A mutually adjusted two-marker model indicated that saturated fats and trans fats were significant predictors of all-cause death and CVD; however, the other fatty acids were not. In addition, trans fats presented the greatest improvement in net reclassification for all-cause death (7.7%, P = 0.003), followed by EPA (3.8%, P = 0.033). Saturated fats presented the greatest improvement in net reclassification for CVD events (5.6%, P = 0.039).


      Our data provides strong evidence to support that plasma saturated fats and trans fats can predict all-cause death and CVD more effectively than other fatty acid markers.


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        • Yokoyama M.
        • Origasa H.
        • Matsuzaki M.
        • Matsuzawa Y.
        • Saito Y.
        • Ishikawa Y.
        • Japan EPAlisI
        • et al.
        Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis.
        Lancet. 2007; 369: 1090-1098
        • Siri-Tarino P.W.
        • Sun Q.
        • Hu F.B.
        • Krauss R.M.
        Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease.
        Am J Clin Nutr. 2010; 91: 535-546
        • Yamagishi K.
        • Iso H.
        • Yatsuya H.
        • Tanabe N.
        • Date C.
        • Kikuchi S.
        • et al.
        Dietary intake of saturated fatty acids and mortality from cardiovascular disease in Japanese: the Japan collaborative cohort study for evaluation of cancer risk (JACC) study.
        Am J Clin Nutr. 2010; 92: 759-765
        • The ORIGIN Trial Investigators
        N-3 fatty acids and cardiovascular outcomes in patients with dysglycemia.
        N Engl J Med. 2012; 367: 309-318
        • Marchioli R.
        • Levantesi G.
        Why do we still need large scale clinical trial: the case of n-3 PUFA.
        Front Physiol. 2012; 3: 202
        • Signorello L.B.
        • Buchowski M.S.
        • Cai Q.
        • Munro H.M.
        • Hargreaves M.K.
        • Blot W.J.
        Biochemical validation of food frequency questionnaire-estimated carotenoid, {alpha}-tocopherol, and folate intakes among African Americans and non-hispanic whites in the southern community cohort study.
        Am J Epidemiol. 2010; 171: 488-497
        • Wennberg M.
        • Vessby B.
        • Johansson I.
        Evaluation of relative intake of fatty acids according to the Northern Sweden FFQ with fatty acid levels in erythrocyte membranes as biomarkers.
        Public Health Nutr. 2009; 12: 1477-1484
        • Chien K.L.
        • Hsu H.C.
        • Su T.C.
        • Chang W.T.
        • Chen P.C.
        • Sung F.C.
        • et al.
        Constructing a point-based prediction model for the risk of coronary artery disease in a Chinese community: a report from a cohort study in Taiwan.
        Int J Cardiol. 2012; 157: 263-268
        • Chien K.L.
        • Su T.C.
        • Hsu H.C.
        • Chang W.T.
        • Chen P.C.
        • Sung F.C.
        • et al.
        Constructing the prediction model for the risk of stroke in a Chinese population: report from a cohort study in Taiwan.
        Stroke. 2010; 41: 1858-1864
        • Chien K.
        • Cai T.
        • Hsu H.
        • Su T.
        • Chang W.
        • Chen M.
        • et al.
        A prediction model for type 2 diabetes risk among Chinese people.
        Diabetologia. 2009; 52: 443-450
        • Lee Y.T.
        • Lin R.S.
        • Sung F.C.
        • Yang C.Y.
        • Chien K.L.
        • Chen W.J.
        • et al.
        Chin-Shan Community Cardiovascular Cohort in Taiwan: baseline data and five-year follow-up morbidity and mortality.
        J Clin Epidemiol. 2000; 53: 836-846
        • Wieland H.
        • Seidel D.
        A simple specific method for precipitation of low density lipoproteins.
        J Lipid Res. 1983; 24: 904-909
        • Chien K.L.
        • Chao C.L.
        • Kuo C.H.
        • Lin H.J.
        • Liu P.H.
        • Chen P.R.
        • et al.
        Plasma fatty acids and the risk of metabolic syndrome in ethnic Chinese adults in Taiwan.
        Lipids Health Dis. 2011; 10: 33
        • Grambsch P.M.
        • Therneau T.M.
        Proportional hazards tests and diagnostics based on weighted residuals.
        Biometrika. 1994; 81: 515-526
        • Hosmer Jr., D.W.
        • Lemeshow S.
        The multiple logistic regression model.
        Applied logistic regression. John Wiley & Sons, New York1989: 25-37
        • Hanley J.A.
        • McNeil B.J.
        A method of comparing the areas under receive operating characteristic curves derived from the same cases.
        Radiology. 1983; 148: 839-843
        • Greiner M.
        • Pfeiffer D.
        • Smith R.D.
        Principles and practical application of the receiver-operating characteristic analysis for diagnostic tests.
        Prev Vet Med. 2000; 45: 23-41
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Cook N.R.
        Use and misuse of the receiver operating characteristic curve in risk prediction.
        Circulation. 2007; 115: 928-935
        • Ridker P.M.
        • Buring J.E.
        • Rifai N.
        • Cook N.R.
        Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score.
        J Am Med Assoc. 2007; 297: 611-619
        • Pencina M.J.
        • D'Agostino R.B.S.
        • D' Agostino R.B.J.
        • Vasan R.S.
        Evaluating the added predictive ability of a new marker: from area under the roc curve to reclassification and beyond.
        Stat Med. 2008; 27: 157-172
        • Siri-Tarino P.W.
        • Sun Q.
        • Hu F.B.
        • Krauss R.M.
        Saturated fat, carbohydrate, and cardiovascular disease.
        Am J Clin Nutr. 2010; 91: 502-509
        • Mente A.
        • de Koning L.
        • Shannon H.S.
        • Anand S.S.
        A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease.
        Arch Intern Med. 2009; 169: 659-669
        • Leosdottir M.
        • Nilsson P.M.
        • Nilsson J.A.
        • Berglund G.
        Cardiovascular event risk in relation to dietary fat intake in middle-aged individuals: data from the malmo diet and cancer study.
        Eur J Cardiovasc Prev Rehabil. 2007; 14: 701-706
        • Boniface D.R.
        • Tefft M.E.
        Dietary fats and 16-year coronary heart disease mortality in a cohort of men and women in great britain.
        Eur J Clin Nutr. 2002; 56: 786-792
        • Jakobsen M.U.
        • O'Reilly E.J.
        • Heitmann B.L.
        • Pereira M.A.
        • Balter K.
        • Fraser G.E.
        • et al.
        Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies.
        Am J Clin Nutr. 2009; 89: 1425-1432
        • He K.
        • Merchant A.
        • Rimm E.B.
        • Rosner B.A.
        • Stampfer M.J.
        • Willett W.C.
        • et al.
        Dietary fat intake and risk of stroke in male US healthcare professionals: 14 year prospective cohort study.
        Br Med J. 2003; 327: 777-782
        • Mozaffarian D.
        • Rimm E.B.
        • Herrington D.M.
        Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women.
        Am J Clin Nutr. 2004; 80: 1175-1184
        • Gillman M.W.
        • Cupples L.A.
        • Millen B.E.
        • Ellison R.C.
        • Wolf P.A.
        Inverse association of dietary fat with development of ischemic stroke in men.
        J Am Med Assoc. 1997; 278: 2145-2150
        • Yamagishi K.
        • Iso H.
        • Date C.
        • Fukui M.
        • Wakai K.
        • Kikuchi S.
        • et al.
        Fish, omega-3 polyunsaturated fatty acids, and mortality from cardiovascular diseases in a nationwide community-based cohort of Japanese men and women the FACC (Japan Collaborative Cohort study for evaluation of cancer risk) study.
        J Am Coll Cardiol. 2008; 52: 988-996
        • Joensen A.M.
        • Overvad K.
        • Dethlefsen C.
        • Johnsen S.P.
        • Tjønneland A.
        • Rasmussen L.H.
        • et al.
        Marine n-3 polyunsaturated fatty acids in adipose tissue and the risk of acute coronary syndrome/clinical perspective.
        Circulation. 2011; 124: 1232-1238
        • Vedtofte M.S.
        • Jakobsen M.U.
        • Lauritzen L.
        • Heitmann B.L.
        Dietary alpha-linolenic acid, linoleic acid, and n-3 long-chain PUFA and risk of ischemic heart disease.
        Am J Clin Nutr. 2011; 94: 1097-1103
        • Jacobson T.A.
        • Glickstein S.B.
        • Rowe J.D.
        • Soni P.N.
        Effects of eicosapentaenoic acid and docosahexaenoic acid on low-density lipoprotein cholesterol and other lipids: a review.
        J Clin Lipidol. 2012; 6: 5-18
        • Nagata C.
        • Nakamura K.
        • Wada K.
        • Oba S.
        • Tsuji M.
        • Tamai Y.
        • et al.
        Total fat intake is associated with decreased mortality in Japanese men but not in women.
        J Nutr. 2012; 142: 1713-1719
        • Laake I.
        • Pedersen J.I.
        • Selmer R.
        • Kirkhus B.
        • Lindman A.S.
        • Tverdal A.
        • et al.
        A prospective study of intake of trans-fatty acids from ruminant fat, partially hydrogenated vegetable oils, and marine oils and mortality from CVD.
        Br J Nutr. 2012; 108: 743-754
        • Baer D.J.
        • Judd J.T.
        • Clevidence B.A.
        • Tracy R.P.
        Dietary fatty acids affect plasma markers of inflammation in healthy men fed controlled diets: a randomized crossover study.
        Am J Clin Nutr. 2004; 79: 969-973
        • Mozaffarian D.
        • Katan M.B.
        • Ascherio A.
        • Stampfer M.J.
        • Willett W.C.
        Trans fatty acids and cardiovascular disease.
        N Engl J Med. 2006; 354: 1601-1613
        • Chen C.L.
        • Tetri L.H.
        • Neuschwander-Tetri B.A.
        • Huang S.S.
        • Huang J.S.
        A mechanism by which dietary trans fats cause atherosclerosis.
        J Nutr Biochem. 2011; 22: 649-655