Vitamin E intake and cardiovascular diseases in the EPIC-Potsdam Study [Elektronische Ressource] / Zorabel Cordero Gonzalez. Betreuer: Heiner Boeing

De
VITAMIN E INTAKE AND CARDIOVASCULAR DISEASES IN THE EPIC-POTSDAM STUDY vorgelegt von der Ärztin und Chirurgin, Magister in Ernährung Zorabel Cordero Gonzalez aus der Bolivarischen Republik Venezuela von der Fakultät VII – Wirtschaft und Management der Technischen Universität Berlin zur Erlangung des akademischen Grades Doktorin der Gesundheitswissenschaften/Public Health -Dr. P.H.- Genehmigte Dissertation Promotionsausschuss: Vorsitzende: Prof. Dr. Ulf Stahl Gutachter: Prof. Dr. Heiner Boeing Gutachter: Prof. Dr. Reinhard Busse Tag der wissenschaftlichen Aussprache: 31.03.2010 Berlin 2011 D83 CONTENT TABLE OF CONTENT INDEX OF TABLES................................................................................................................5 INDEX OF FIGURES..............................................................................................................8 INDEX OF ABBREVIATIONS..............................................................................................9 1. INTRODUCTION ............................................................................................. 11 1.1 Cardiovascular diseases and public health relevance .......................................... 11 1.1.1 Definition and global epidemic ........................................................................... 11 1.1.2 Impact of cardiovascular diseases in Europe on the economy ....
Publié le : samedi 1 janvier 2011
Lecture(s) : 23
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Source : D-NB.INFO/1014756529/34
Nombre de pages : 152
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VITAMIN E INTAKE AND CARDIOVASCULAR DISEASES
IN THE EPIC-POTSDAM STUDY


vorgelegt von der
Ärztin und Chirurgin, Magister in Ernährung



Zorabel Cordero Gonzalez
aus der Bolivarischen Republik Venezuela



von der Fakultät VII – Wirtschaft und Management der Technischen Universität Berlin
zur Erlangung des akademischen Grades



Doktorin der Gesundheitswissenschaften/Public Health
-Dr. P.H.-
Genehmigte Dissertation



Promotionsausschuss:

Vorsitzende: Prof. Dr. Ulf Stahl
Gutachter: Prof. Dr. Heiner Boeing
Gutachter: Prof. Dr. Reinhard Busse



Tag der wissenschaftlichen Aussprache: 31.03.2010


Berlin 2011

D83 CONTENT

TABLE OF CONTENT


INDEX OF TABLES................................................................................................................5
INDEX OF FIGURES..............................................................................................................8
INDEX OF ABBREVIATIONS..............................................................................................9
1. INTRODUCTION ............................................................................................. 11
1.1 Cardiovascular diseases and public health relevance .......................................... 11
1.1.1 Definition and global epidemic ........................................................................... 11
1.1.2 Impact of cardiovascular diseases in Europe on the economy ............................ 12
1.1.3 Cardiovascular diseases, atherosclerosis and antioxidants ................................. 13
1.2 Vitamin E, properties and relevance of vitamin E .............................................. 14
1.2.1 From chemical structures to physiological implications ...................................... 14
1.2.2 Vitamin E against atherosclerosis ........................................................................ 15
1.2.2.1 Antioxidant vs. Prooxidant function ............................................................ 15
1.2.2.2 Non-antioxidant functions ............................................................................ 16
1.2.3 Vitamin E metabolism .......................................................................................... 17
1.2.4 Vitamin E and antioxidant network ..................................................................... 18
1.3 Assessing of vitamin E intake ............................................................................. 19
1.3.1 Correlations with biological measures ................................................................. 19
1.3.2 Food sources of vitamin E .................................................................................... 22
1.4 Epidemiological evidences of relationship between vitamin E intake and
cardiovascular diseases ....................................................................................... 24
1.4.1 Cohort studies ....................................................................................................... 25
1.4.2 Metaanalysis of cohort studies and pooling of cohort studies ............................. 26
1.4.3 Randomized clinical trials .................................................................................... 30
1.5 What do we eat? Single nutrients vs. dietary patterns ......................................... 34
1.6 Aims and research questions ............................................................................... 36
2. MATERIAL AND METHODS ........................................................................ 37
2.1. The EPIC-Potsdam Study .................................................................................... 37
2.1.1 The EPIC-Study and the EPIC-Potsdam Study, a general description ................ 37
2.1.2 Baseline examination ........................................................................................... 38
2.1.2.1 Dietary assessment ....................................................................................... 38
2.1.2.2 Assessment of other characteristics .............................................................. 39
2
CONTENT
2.1.2.2.1 Socio-demographic, lifestyle and medical history ................................... 39
2.1.2.2.2 Anthropometry ......................................................................................... 39
2.1.3 Follow-up and case ascertainment ....................................................................... 40
2.2 Study design ........................................................................................................ 40
2.2.1 Exclusion criteria .................................................................................................. 40
2.2.2 Outcomes: case ascertainment and verified-cases ............................................... 41
2.2.3 Definition of nutrient variables ............................................................................ 41
2.3. Statistical analysis ............................................................................................... 42
2.3.1 Descriptive analysis .............................................................................................. 42
2.3.2 Energy adjustment and categorization ................................................................. 43
2.3.3 Stepwise linear regression deriving food groups to explain the variance in the
vitamin E intake .................................................................................................. 44
2.3.4 Stepwise linear regression deriving fat components to explain the variance in the
vitamin E intake .................................................................................................. 45
2.3.5 Reduced rank regression model deriving food groups rich in antioxidants ......... 45
2.3.6 Constructing food patterns ................................................................................... 46
2.3.7 Cox’s Proportional Hazard Model ....................................................................... 47
2.3.8 Covariates of the multivariate model ................................................................... 49
3. RESULTS ........................................................................................................... 51
3.1. Baseline description ............................................................................................ 51
3.1.1. Vitamin E intake distribution ............................................................................... 51
3.1.2. General characteristics of the study population across energy-adjusted vitamin E
intake ................................................................................................................... 53
3.1.3. Vitamin E and fat ................................................................................................. 58
3.1.4. Vitamin E and antioxidants .................................................................................. 59
3.1.5. Food sources of vitamin E .................................................................................... 60
3.1.6. Food patterns ........................................................................................................ 63
3.1.7. Characterization of the EPIC-Potsdam cohort across quintiles of food patterns . 72
3.2 Incidence of cardiovascular outcomes ................................................................ 79
3.3 Evaluation of risk for cardiovascular outcomes .................................................. 80
3.3.1 Association between vitamin E intake and cardiovascular outcomes .................. 80
3.3.1.1 Myocardial infarction ................................................................................... 80
3.3.1.2 Stroke ........................................................................................................... 82
3.3.1.3 Transient ischemic attack ............................................................................. 83
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CONTENT
3.3.2 Association between the food pattern rich in vitamin E and cardiovascular
outcomes .............................................................................................................. 84
3.3.2.1 Myocardial infarction ................................................................................... 84
3.3.2.2 Stroke ........................................................................................................... 85
3.3.2.3 Transient ischemic attack ............................................................................. 86
3.3.2.4 All cardiovascular events ............................................................................. 87
3.3.3 Association between the food pattern rich in antioxidant nutrients and
cardiovascular outcomes ..................................................................................... 89
3.3.3.1 Myocardial infarction ................................................................................... 89
3.3.3.2 Stroke ........................................................................................................... 90
3.3.3.3 Transient ischemic attack ............................................................................. 91
3.3.3.4 All cardiovascular events ............................................................................. 92
3.4 Other analyse ....................................................................................................... 94
4. DISCUSSION .................................................................................................... 95
4.1 Vitamin E and cardiovascular risk, comparison with previous studies ............... 95
4.2 Vitamin E, energy, fats and cardiovascular diseases .......................................... 98
4.3 Vitamin E, antioxidants and derived food intake patterns ................................ 102
4.4 Other perspective, from traditional biomarkers to inflammatory and genetic
biomarkers ......................................................................................................... 106
4.5 Strenghts and limitations ................................................................................... 109
4.6 Public health impact and future research .......................................................... 112
5. SUMMARY AND CONCLUSIONS .............................................................. 113
6. REFERENCES ................................................................................................ 116
7. APPENDIX ...................................................................................................... 143
4
CONTENT

INDEX OF TABLES

Table 1. Non-antioxidant functions of vitamin E ..................................................................... 16
Table 2. Interaction among nutrients ........................................................................................ 18
Table 3. Dietary Reference Intake for vitamin E ..................................................................... 19
Table 4. Summary of correlations between vitamin E intake and biomarkers ........................ 21
Table 5. Foods with high content of vitamin E ....................................................................... 23
Table 6. Main food sources of vitamin E and % of contribution ............................................. 24
Table 7: Observational studies of dietary and supplemental vitamin E intake and
cardiovascular events .............................................................................................................. 27
Table 8. Metaanalysis and pooled analysis of cohort studies involving dietary and/or
supplemental vitamin E intake and risk for cardiovascular disease ......................................... 29
Table 9. Summary of primary prevention randomized clinical trials of vitamin E
supplementation and cardiovascular diseases .......................................................................... 32
Table 10. Summary of secondary prevention randomized clinical trials of vitamin E
supplementation and CVD ....................................................................................................... 33
Table 11. Summary of metanalysis results of randomised clinical trials ................................. 34
Table 12. Proposed score of antioxidants ................................................................................. 35
Table 13. EPIC-Potsdam cohort study instruments and requested type of exposure variables 38
Table 14. Description of the vitamin E intake of cohort population EPIC-Potsdam (n=25765)
at baseline, all and by gender ................................................................................................... 52
Table 15. General features of cohort population in EPIC-Potsdam (n=25765) across quintiles
of energy-adjusted vitamin E intake at baseline ....................................................................... 55
Table 16. General features of cohort population in EPIC-Potsdam (n=25765) across quintiles
of energy-adjusted vitamin E intake at baseline, by gender ..................................................... 56
Table 17. Main dietary features related to vitamin E intake in the cohort population EPIC-
Potsdam (n=25765) at baseline, all and by gender................................................................... 57
2
Table 18. Parameter estimates and percentage of the R in models with fat components relate
to vitamin E intake ................................................................................................................... 58
Table 19. Antioxidant intakes of cohort population in EPIC-Potsdam (n=25765) across
quintiles of the energy-adjusted vitamin E at baseline ............................................................. 59
Table 20. Pearson´s correlation coefficient matrix of antioxidant in the cohort population
EPIC-Potsdam (n=25765) at baseline ...................................................................................... 60
5
CONTENT
Table 21. Food groups contributing to alpha-tocopherol equivalent intake at baseline, EPIC-
Potsdam cohort (n=25765) ....................................................................................................... 61
2
Table 22. Partial R of main food groups to explain most the variance in energy-adjusted
vitamin E intake at baseline, EPIC-Potsdam cohort (n=25765) ............................................... 63
Table 23. Food patterns in the cohort population EPIC-Potsdam (n=25765), all and by gender
.................................................................................................................................................. 64
Table 24. Pearson´s correlation coefficient matrix of antioxidants (nutrients and scores) in the
cohort population EPIC-Potsdam (n=25765) at baseline ......................................................... 65
Table 25. Pearson´s correlation coefficient among antioxidant nutrients, food patterns and
food group intakes in the cohort population EPIC-Potsdam at baseline (n=25765) ................ 67
Table 26. Antioxidant nutrient intakes across quintiles of the food pattern rich in vitamin E
and the food pattern rich in antioxidants in the cohort population EPIC-Potsdam (n=25765) at
baseline ..................................................................................................................................... 69
Table 27. Food intake groups across quintiles of the food pattern rich in vitamin E in the
cohort population EPIC-Potsdam (n=25765) at baseline ......................................................... 70
Table 28. Food intake groups across quintiles of the food pattern rich in antioxidant nutrients
in the cohort population EPIC-Potsdam (n=25765) at baseline ............................................... 71
Table 29. General features of cohort population in EPIC-Potsdam (n=25765) across quintiles
of the food pattern rich in vitamin E at baseline ...................................................................... 73
Table 30. General features of cohort population in EPIC-Potsdam (n=25765) across quintiles
of the food pattern rich in antioxidant nutrients at baseline ..................................................... 74
Table 31. General features of cohort population in EPIC-Potsdam (n=25765) across quintiles
of the food pattern rich in vitamin E at baseline, by gender .................................................... 76
Table 32. General features of cohort population in EPIC-Potsdam (n=25765) across quintiles
of the food pattern rich in antioxidant nutrients at baseline, by gender ................................... 77
Table 33. Cardiovascular outcomes cases and incidence in all cohort population EPIC-
Potsdam and by gender ........................................................................................................... 79
Table 34. Hazard ratios and 95% confidence intervals for myocardial infarction events across
quintiles of energy-adjusted vitamin E intake, EPIC-Potsdam cohort study, all subjects
(n=25765) ................................................................................................................................. 80
Table 35. Hazard ratios and 95% confidence intervals for myocardial infarction events across
quintiles of energy-adjusted vitamin E intake, EPIC-Potsdam cohort study, men (n=10085)
and women (n=15680) ............................................................................................................. 81
6
CONTENT
Table 36. Hazard ratios and 95% confidence intervals for stroke events across quintiles of
energy-adjusted vitamin E intake, EPIC-Potsdam cohort study, all subjects (n=25765) ........ 82
Table 37. Hazard ratios and 95% confidence intervals for transient ischemic attack events
across quintiles of energy-adjusted vitamin E intake, EPIC-Potsdam cohort study, all subjects
(n=25765) ................................................................................................................................. 83
Table 38. Hazard ratios and 95% confidence intervals for myocardial infarction events across
quintiles of the food pattern rich in vitamin E intake, EPIC-Potsdam cohort study, all subjects
(n=25765) ................................................................................................................................. 84
Table 39. Hazard ratios and 95% confidence intervals for stroke events across quintiles of the
food pattern rich in vitamin E intake, EPIC-Potsdam cohort study, men (n=10085) and
women (n=15680) .................................................................................................................... 85
Table 40. Hazard ratios and 95% confidence intervals for transient ischemic attack events
across quintiles of the food pattern rich in vitamin E intake, EPIC-Potsdam cohort study,
among all subjects (n=25765) .................................................................................................. 86
Table 41. Hazard ratios and 95% confidence intervals for cardiovascular events across
quintiles of the food pattern rich in vitamin E intake, EPIC-Potsdam cohort study, all subjects
(n=25756) ................................................................................................................................. 87
Table 42. Hazard ratios and 95% confidence intervals for cardiovascular events across
quintiles of the food pattern rich in vitamin E intake, EPIC-Potsdam cohort study, men
(n=10080) and women (n=15676) ........................................................................................... 88
Table 43. Hazard ratios and 95% confidence intervals for myocardial infarction events across
quintiles of the food pattern rich in antioxidant, EPIC-Potsdam cohort study, all subjects
(n=25765) ................................................................................................................................. 89
Table 44. Hazard ratios and 95% confidence intervals for stroke events across quintiles of the
food pattern rich in antioxidants, EPIC-Potsdam cohort study, all subjects (n=25765) .......... 90
Table 45. Hazard ratios and 95% confidence intervals for transient ischemic attack events
across quintiles of the food pattern rich in antioxidant, EPIC-Potsdam cohort study, all
subjects (n=25765) ................................................................................................................... 91
Table 46. Crude and adjusted hazard ratios and 95% confidence intervals for cardiovascular
events across quintiles of the food pattern rich in antioxidant, EPIC-Potsdam cohort study, all
subjects (n=25756) ................................................................................................................... 92
Table 48. Hazard ratios and 95% confidence intervals for cardiovascular events across
quintiles of the food pattern rich in antioxidant, EPIC-Potsdam cohort study, men (n=10080)
and women (n=15676) ............................................................................................................. 93
7
CONTENT
INDEX OF FIGURE

Figure 1. Correlation between non-adjusted and energy-adjusted vitamin E intake................53
Figure 2. Comparison of food patterns…………………........................................................78

8
CONTENT

INDEX OF ABBREVIATIONS
24HR 24-hour dietary recall
AI Adequacy Intake
AMI Acute Myocardial Infarction
AP Angina pectoris
ATBC The Alpha-Tocopherol Beta-Carotene Cancer Prevention Study
BMI Body-mass-index
DBP Diastolic blood pressure
CAD Coronary arterial disease
CHAOS Cambridge Heart Antioxidant Study
CHD Coronary heart disease
CI Confidence intervals
CPS-II Cancer Prevention Study-II
CSFII Continuing Survey of Food Intakes by Individuals
CV Cardiovascular
CVD Cardiovascular diseases
DRI Dietary Reference Intake
EPOZ-Study The Epidemiologic Study of Cardiovascular Risk Indicators
EPIC-Potsdam European Prospective Investigation into Cancer and Nutrition-Potsdam
EU European Union
FFQ Food-Frequency-Questionnaire
FP Food pattern
FPs Food patterns
FP-VE Food pattern rich in vitamin E
FP-AO Food pattern rich in antioxidants
FS Finnish Cohort Study
-CEHC -Tocopherol Metabolite GTM 2,7,8-trimethyl-2-( -carboxy-ethyl)-6-
hydroxychroman
GeNuS German Nutrition Survey
GISSI GISSI Prevenzione trial
HATS HDL-Atherosclerosis Treatment Study
HDL High density lipoprotein
HOPE Heart Outcomes Prevention Evaluation Study
HOPE-TOO Heart Outcomes Prevention Evaluation Study-The Ongoing Outcomes
HPFS Health Professionals Follow-up Study
HR Hazard risk
IHD Ischemic heart disease
IWHS Iowa Women’s Health Study
LIXIAN-1 Lixian Nutrition Intervention
LIXIAN-2 Lixian Nutrition Intervention 2
LDL Low-density-lipoproteins
MA Metanalysis
MI Myocardial infarction
MONICA Multinational MONItoring of trends and determinants in
CArdiovascular disease
MRC/BHF Heart Protection Study Collaborative Group
MRFIT The Multiple Risk Factor Intervention Trial
NHANES National Health and Nutrition Examination Surveys
NHS The Nurses’ Health Study
9

gbgCONTENT
NSS Nutrition Status Surveys
Oxi-LDL Oxidized-low-density-lipoproteins
PS Physician’ Health Study
PPP Primary Prevention Trial
PUFA Polyunsaturated fatty acids
RCT Randomized clinical trial
RCTs Randomised control trials
RDA Recommendation Dietary Allowance
RNOS Reactive-nitrogen-oxide-species
ROS Reactive-oxigen-species
SBP Systolic blood pressure
SHHS Scottish Heart Health Study
SPACE Secondary prevention with antioxidants of cardiovascular disease in
Endstage renal disease
ST Stroke
SU.VIMAX Supple´mentation en Vitamines et Minéraux Antioxydants
TIA transient ischemic attack
UK United Kingdom
WACS Women’s Antioxidant Cardiovascular Study
WHS Women’s Health Study
WHR Waist-to-hip ratio
ZS The Zutphen Study
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