Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: The INTERMAP Study

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1 (2003) 17, & 2003 Nture Publishing Group All rights reserved /03 $ ORIGINAL ARTICLE Nutrient intkes of middle-ged men nd women in Chin, Jpn, United Kingdom, nd United Sttes in the lte 1990s: The INTERMAP Study BF Zhou 1, J Stmler 2, B Dennis 3, A Mog-Sthlberg 2, N Okud 4, C Robertson 5, L Zho 1, Q Chn 5 nd P Elliott 5 for the INTERMAP Reserch Group 1 Deprtment of Epidemiology, Fu Wi Hospitl nd Crdiovsculr Institute, Chinese Acdemy of Medicl Sciences, Beijing, People s Republic of Chin; 2 Deprtment of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicgo, IL, USA; 3 Deprtment of Biosttistics, Collbortive Studies Coordinting Center, University of North Crolin t Chpel Hill, Chpel Hill, NC, USA; 4 Deprtment of Helth Science, Shig University of Medicl Science, Otsu, Jpn; 5 Deprtment of Epidemiology nd Public Helth, Fculty of Medicine, St Mry s Cmpus, Imperil College, London, UK The purpose of the study ws to compre nutrient intkes mong Chinese, Jpnese, UK, nd US INTER- MAP smples, nd ssess possible reltionships of dietry ptterns to differentil ptterns of crdiovsculr diseses between Est Asin nd Western countries. Bsed on common Protocol nd Mnuls of Opertions, high-qulity dietry dt were collected by four stndrdized 24-h dietry reclls nd two 24-h urine collections from 17 popultion smples in Chin (three smples), Jpn (four smples), UK (two smples), nd USA (eight smples). There were bout 260 men nd women ged yers per smpleftotl N ¼ Qulity of dietry interview nd dt entry were monitored nd enhnced by extensive systemtic ongoing qulity control procedures t locl, country, nd interntionl level. Four dtbses on nutrient composition of foods from the four countries were updted nd enhnced (76 nutrients for ll four countries) by the Nutrition Coordinting Center, University of Minnesot, in coopertion with Country Nutritionists. The men body mss index ws much higher for Western thn Est Asin smples. Mcronutrient intkes differed mrkedly cross these smples, with Western diet higher in totl ft, sturted nd trns ftty cids, nd Keys dietry lipid score, lower in totl crbohydrte nd strch, higher in sugrs. Bsed on extensive published dt, it is resonble inference tht this pttern reltes to higher verge levels of serum totl cholesterol nd higher mortlity from coronry hert disese in Western thn Est Asin popultions. The rurl Chinese diet ws lower in protein, especilly niml protein, in clcium, phosphorus, selenium, nd vitmin A. Dietry sodium ws higher, potssium lower, hence N/K rtio ws higher in the Asin diet, especilly for Chinese smples. This pttern is known to relte to risks of dverse blood pressure level nd stroke. At the end of the 20th century, Est Asin nd Western diets remin significntly different in mcro- nd micronutrient composition. Both dietry ptterns hve spects tht cn be regrded, respectively, s dverse nd protective in reltion to the mjor dult crdiovsculr diseses. In both Asin nd Western countries, public efforts should be trgeted t overcoming dverse spects nd mintining protective ptterns for prevention nd control of crdiovsculr diseses. (2003) 17, doi: /sj.jhh Keywords: dietry ptterns; mcronutrients; micronutrients; interntionl popultion study Introduction INTERMAP is bsic epidemiologicl investigtion iming to clrify unnswered questions on the role of dietry fctors in the etiology of unfvourble Correspondence: Dr J Stmler, Deprtment of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Suite 1102 (D335), 680 North Lke Shore Drive, USA. E-mil: jstmler@northwestern.edu blood pressure ptterns. Its generl im isfby mens of n interntionl coopertive multismple cross-sectionl popultion study of men nd women ged yers in four countries (Chin, Jpn, UK, US)Fto dvnce knowledge on influence of dietry fctors on BP of individuls. For this purpose, 4680 prticipnts were recruited in from 17 popultion smples diverse in ethnic nd sociodemogrphic bckground in the four countries (three Chinese, four Jpnese, two UK,

2 624 nd eight US smples). Four 24-h dietry reclls nd two timed 24-h urine specimens were collected for ech prticipnt with extensive stndrdized qulity control. 1,2 This report compres verge nutrient intkes mong Chinese, Jpnese, UK, nd US men nd women t the country level, with focus on possible reltionships of contrsting dietry ptterns to differentil ptterns of crdiovsculr diseses between Est Asin nd Western countries. Methods Study smples nd prticipnts Nutrient intkes of middle-ged men nd women At ech locl centre in the four countries, popultion-bsed smple of pproximtely 260 persons ws rndomly selected from the trget popultion (eg, community, villge, city block, workplce); bout 65 persons were rndomly selected from ech of four ge gender subgroupsf men nd women, ged nd yers. Extensive efforts were mde to recruit high proportion of those invited to prticipte. Only one person ws llowed from ech fmily to void the effect of similr dietry ptterns mong persons within one fmily. Substitute prticipnts were similrly selected to replce persons who did not stisfctorily complete full dt collection. Dietry recll methods nd qulity control Four stndrdized 24-h dietry reclls were collected for ech prticipnt on two pirs of successive dys bout 3 6 weeks prt. One of the dietry reclls ws for dy just fter weekend of no work or dy off, to include effect of possible vrition in diet during dys off. At ech recll, done by trined nd certified interviewers, dt were obtined on use of nutritionl supplements. Two of the dietry reclls included collection of dt on dily lcohol intke during the preceding 7 dys. Stndrdiztion nd qulity control of dietry interviews involved the following procedures: 2 1. Centrl trining nd certifiction for ll dietry interviewers. 2. Dry run before strt of field work, with surveillnce by interntionl nd country nutritionists. 3. Use of stndrd food models, clibrted utensils, scles, pictures, etc. to help quntify mounts of foods consumed; collection of informtion from cooks in fmily or resturnt when prticipnt did not cook the mel. 4. Monitoring of interviewers during field work ndffor Chin, Jpn, UK, where hrd copy of the recll ws mde nd then codedfdily locl recoding of 10% of reclls; lso, tpe recording of ll interviews nd review of rndomly selected tpes by Site Nutritionists ccording to stndrd protocol, feedbck to the interviewer, nd timely correction of ny problems found. 5. Recoding of 10% of rndomly selected dietry records by the Country Nutritionist, timely feedbck to the locl centres, nd correction of problems. Coded dietry dt were entered twice into the computer by two seprte trined stff members, checked for comprbility, discrepncies djudicted, nd finl corrections mde. Nutrient intkes of prticipnts were clculted bsed on the specil food tble for ech country. Ech food tble ws compiled on the bsis of ntionl food tble for ech country nd ws mde comprblefbsed on stndrds for qulity control of interntionl dtbsesfby the Nutrition Coordinting Center, Minnepolis, Minnesot. 3 The utomted Nutrition Dt System (NDS) from the Nutrition Coordinting Center ws used for dietry interviews t US centres; reported foods nd beverges consumed were entered in detil directly into computer. Results Complete dt sets were collected for 4680 people ged yers, 2359 men nd 2321 women from 17 smples (four smples from Jpn, three from Chin, two from UK, nd eight from US) (Tble 1). Men ges of men nd women were in the rnge nd yers with smll differences cross countries. Averge yers of eduction were mrkedly lower for prticipnts from the three rurl Chinese smples, only 6.5 yers for men nd 4.3 yers for women. US smples hd the highest verge yers of eduction, 15.4 for men nd 14.5 for women. For both men nd women, men body mss index (BMI) levels of Asin smples were much lower thn those of Western smples, for exmple, 22.4 nd 23.7 kg/m 2 for men from Chin nd Jpn, respectively, nd 27.7 nd 29.1 kg/m 2 for men from UK nd US, respectively. Intke of energy, mcronutrients, cholesterol, fibre US men nd women reported the highest verge totl energy intke; Asin smples, lower thn Western smples (Tble 2). There were mrked differences in mcronutrient composition between Asin nd Western smples, reflecting differences in overll dietry pttern. Totl ft provided 23.7 nd 20.5% of totl clories for Jpnese nd Chinese men; 26.1 nd 19.5% for women. For UK nd US smples, per cent of clories from totl ft rnged between 32.5 nd 33.3%. Energy provided by sturted ftty cids for Asin men nd women rnged from 4.8 to 7.1%, but for Western smples from 10.6 to 12.2%. Per cent polyunsturted ftty cids ws similr cross the four countries, in the rnge %, with omeg-3 polyunsturted ftty

3 Nutrient intkes of middle-ged men nd women Tble 1 Number of prticipnts, verge ge, yers of eduction, nd BMI, by country nd gender 625 Vrible Jpn PR Chin UK US Number of prticipnts Age (yers) 49.5 (5.3) b 48.1 (6.0) 49.6 (5.6) 49.0 (5.4) Eduction (yers) 12.4 (2.1) 6.5 (2.4) 13.1 (3.2) 15.4 (3.1) BMI (kg/m 2 ) 23.7 (2.7) 22.4 (2.7) 27.7 (3.9) 29.1 (5.1) Number of prticipnts Age (yers) 49.2 (5.3) 48.9 (5.6) 48.6 (5.6) 49.2 (5.4) Eduction (yers) 11.6 (2.0) 4.3 (2.9) 12.2 (2.9) 14.5 (2.9) BMI (kg/m 2 ) 23.2 (3.1) 23.9 (3.7) 27.2 (5.3) 28.7 (6.6) Averge. b Stndrd devition. Tble 2 Intke of energy, mcronutrients, cholesterol, fibre, lcohol Vrible Jpn PR Chin UK US Men s.d. Men s.d. Men s.d. Men s.d. Energy (kcl/dy) Totl protein (%kcl) Animl protein (%kcl) Vegetble protein (%kcl) Totl ft (%kcl) SFA (%kcl) MFA (%kcl) PFA (%kcl) Omeg-3 PFA (%kcl) Omeg-6 PFA (%kcl) Trns FA (%kcl) Cholesterol (mg/dy) Cholesterol (mg/1000 kcl) Keys dietry lipid score PFA/SFA Totl vilble crb. (%kcl) Strch (%kcl) Totl fibre (g/dy) Estimted totl sugrs (%kcl) Alcohol (%kcl) Energy (kcl/dy) Totl protein (%kcl) Animl protein (%kcl) Vegetble protein (%kcl) Totl ft (%kcl) SFA (%kcl) MFA (%kcl) PFA (%kcl) Omeg-3 PFA (%kcl) Omeg-6 PFA (%kcl) trns FA (%kcl) Cholesterol (mg/dy) Cholesterol (mg/1000 kcl) Keys dietry lipid score PFA/SFA Totl vilble crb. (%kcl) Strch (%kcl) Totl fibre (g/dy) Estimted totl sugrs (%kcl) Alcohol (%kcl) SFA, sturted ftty cids; MFA, monounsturted ftty cids; PFA, polyunsturted ftty cids; FA, ftty cids (2 SFA PFA)+1.5 CHOL 1/2, where CHOL is dietry cholesterol in mg/1000 kcl.

4 626 cid (PFA) higher for Jpnese ( %) thn others ( %). Owing to lower SFA for Asin smples, PFA/SFA rtio for Asin smples ws higher thn for Western smples ( compred to ). Dietry cholesterol intke ws highest for Jpnese nd lowest for Chinese smples. Keys dietry lipid score ws lowest for the Chinese, nd lower for Jpnese thn Western smples, despite higher Jpnese cholesterol intke. Per cent energy from crbohydrte of Asin smples ws higher thn for Western smples (Tble 2). Chinese smples hd highest intke of totl crbohydrte (62 68%), strch (54 59%), fiber, nd lowest intke of sugrs (7 9%), in contrst to 24 26% for US prticipnts. Intke of totl protein ws lowest for Chinese smples (12 13%, compred to bout 16% for other smples) (Tble 2). This reflected low Chinese niml protein intke (2 3%, compred to 9 10% for other smples). Alcohol intke, uniformly higher on verge for men thn women, ws highest for Jpnese men (8.2%), in contrst to 2.7% for US men (Tble 2). Intke of minerls Nutrient intkes of middle-ged men nd women Men dily intke of sodiumfs mesured by timed 24-h urine collectionsfws higher in Asin thn Western smples, highest for Chinese smples (Tble 3). The opposite ws true for potssium intke. Hence the N/K rtio ws higher for Jpnese nd Chinese thn Western smples, highest for the Chinese (6.0 nd 6.8, compred to for Western smples). Clcium intke ws lower in Asin thn Western smples, especilly low for Chinese (only 356 nd 256 mg/dy for men nd women) (Tble 3). Mgnesium nd iron intke were lower for Jpnese smples. Phosphorus intke ws lower for Chinese smples. Chinese smples lso hd the lowest intke of selenium, only mg/dy, compred to for other smples. Intke of vitmins Concordnt with low niml protein intke, retinol intke of Chinese smples ws especilly low, 125 nd 71 mg/dy for men nd women, compred to for men nd for women from other smples (Tble 4). Correspondingly, intke of totl vitmin A ws lowest for Chinese smples. b- Crotene intke ws higher for US thn other smples. Vitmin C intke ws lower for Chinese nd UK thn other smples. Discussion The min findings cross countries nd regions from these INTERMAP in-depth dietry surveys of middle-ged nutrient intke ptterns in Chin, Jpn, UK, nd USA t the end of the 20th century were: (1) much higher men BMI, nd higher energy intke, for Western thn Est Asin smples; (2) higher verge intke of totl ft, sturted ft, Keys dietry Tble 3 Intke of minerls Minerl Jpn PR Chin UK US Men s.d. Men s.d. Men s.d. Men s.d. Urinry N (mg/dy) Urinry N (mmol/dy) Urinry K (mg/dy) Urinry K (mmol/dy) Urinry N/K (mmol/mmol) Dietry C (mg/dy) Dietry Mg (mg/dy) Dietry Fe (mg/dy) Dietry Se (mcg/dy) Dietry P (mg/dy) Urinry N (mg/dy) Urinry N (mmol/dy) Urinry K (mg/dy) Urinry K (mmol/dy) Urinry N/K (mmol/mmol) Dietry C (mg/dy) Dietry Mg (mg/dy) Dietry Fe (mg/dy) Dietry Se (m g/dy) Dietry P (mg/dy)

5 Nutrient intkes of middle-ged men nd women Tble 4 Intke of vitmins 627 Vitmin Jpn PR Chin UK US Men s.d. Men s.d. Men s.d. Men s.d. b-crotene (mg/dy) Retinol (mg/dy) Vitmin A (IU/dy) Vitmin C (mg/dy) Vitmin E (mg/dy) b-crotene (mg/dy) Retinol (mg/dy) Vitmin A (IU/dy) Vitmin C (mg/dy) Vitmin E (mg/dy) Tocopherol equivlents (ATE). lipid score in Western thn Est Asin smples; (3) higher intke of sodium nd lower intke of potssium in Est Asin thn Western smples, hence higher dietry N/K intke by Est Asins, especilly Chinese. Also, clcium nd phosphorus intkes were lower for Est Asins thn Westerners, with Chinese intkes of clciumflso selenium nd vitmin AFconspicuously lower. Three other findings, on the Jpnese smplesfone fvourble ( protective ), the other two unfvourblefwere higher intke of omeg-3 PFA, lmost certinly reflecting greter fish intke; higher intke of cholesterol, due probbly to greter egg consumption; nd for Jpnese men greter verge intke of lcohol. The three Chinese smples were ll rurl frmers, hence some of the nutrient intkes my hve been lower thn for popultions from more developed res of the country nd from urbn res. However, they were from widely dispersed res north to south in Chin, nd reflected trditionl dietry ptterns known to be typicl for the Chinese popultion. Similrly, the four Jpnese smples, two UK smples, nd eight US smples were not rndomly selected from their ntionl popultions. Agin, the dietry findings for them re concordnt with those from recent ntionl surveys nd from FAO food blnce sheet nlyses for ech of these three countries, 4 hence it is resonble to infer tht cross-country comprisons here of the high-qulity INTERMAP nutrient dt re generlly vlid for the countries nd regions. The differentil findings in nutrient intke ptterns of middle-ged Est Asin nd Western men nd women reported here re consistent with those from mny other studies in recent decdes Thus, while multiple phenomenffor exmple, economic development, globliztion (including of the food supply), ntionl nd interntionl public helth recommendtions for CHD-CVD prevention nd controlfhve influenced dietry trends in recent decdes, nd produced rpid trnsitions in Chin (nd other countries), importnt differences remin (lbeit blunted) cross Est Asin nd Western popultions. The foregoing summry sttements re pplicble lso to differences cross these popultions in incidence of the mjor crdiovsculr diseses. Prticulrly thought-provoking hve been the much higher mortlity rtes for coronry hert disese (CHD) in Western (eg, UK, USA) thn Est Asin (eg, Jpn) countries, ndfin contrstfthe much higher mortlity rtes for stroke in Est Asin thn Western countries. Tble 5 gives typicl dt on these findings, s of the yer Note tht CHD rtes were severlfold higher for UK nd US thn for Jpn, wheres stroke rtes were bout two to three times higher for Jpn thn for UK nd USA. From 1970 to the lte 1990s, these deth rtesffor both CHD nd strokefdecresed substntilly for ll three countries. 21 The CHD declines were 39 nd 57% for Jpnese men nd women, 46 nd 42% for UK men nd women, 64 nd 62% for US men nd women. The stroke declines were n extrordinry 80 nd 82% for Jpn, 58 nd 62% for UK, 65 nd 63% for USA. By the lte 1990s, Jpnese mortlity rtes from stroke were no longer grossly different from those for Western countries (Tble 6). 21,22 However, newly vilble dt for Chin show inordintely high stroke deth rtes for both men nd women from both rurl nd urbn popultions, not grossly dissimilr to those for Jpn in erlier decdes, nd three to six times higher thn for UK nd USA in the lte 1990s. For both Chin nd Jpn, in contrst, CHD deth rtes were still considerbly lower thn for UK nd USA, despite mrked decline in their CHD rtes during the ltter decdes of the 20th century. This persistence in the Est Asin-Western differentil in CHD hs been verified by dt on lrge popultion smples from the World Helth Orgniztion MONICA Study. In the lte 1980s nd erly 1990s, incidence rtes of

6 Nutrient intkes of middle-ged men nd women 628 Tble 5 CHD nd stroke mortlity rte ge-stndrdized, 1970, men nd women ged yers by country Cuse of deth Jpn PR Chin UK US Coronry hert disese 94 Not vilble for entire PRC popultion 509 b 634 c 652 Stroke Coronry hert disese 47 Not vilble for entire PRC popultion Stroke Age-stndrdized rte per popultion. b Englnd nd Wles. c Scotlnd. Tble 6 CHD nd stroke mortlity rte ge-stndrdized, , men nd women ged yers by country Cuse of deth Jpn 1997 PR Chin 1994 UK 1997 US 1998 Coronry hert disese b 267 c 349 d 202 Stroke Coronry hert disese Stroke Rurl. b Urbn. c Englnd nd Wles. d Scotlnd. nonftl myocrdil infrction plus CHD deth were 86 per per yer for Chinese (Beijing) men ged yers, in contrst to 593 nd 744 for two UK smples (Belfst, Glsgow, UK), nd 349 for the US smple (Stnford); corresponding rtes for women ged yers were 33, 174 nd 269, As is well known, the underlying pthology producing most clinicl CHD is severe coronry therosclerosis, usully of multiple rteries, nd its complictions, prticulrly thrombosis. The etiology of the modern epidemic of severe therosclerotic disese is dverse lifestyles, especilly dverse eting ptternsfpopultionwide diets high in totl ft, sturted ft, trns ft, cholesterol, clories (for level of energy expenditure), slt, nd often indequte in protective micronutrients nd fibre, nd excessive in lcohol. Prticulrly in this dietry context, cigrette smoking nd sedentry hbit ll too frequently dd insult to injury. Excess dietry lipid is of pivotl importnce, primrily becuse it produces rise in popultion verge serum cholesterol nd its therogenic frctions from youth through middle ge, with resultnt popultion high verge levels nd high rtes of dyslipidemi. These fundmentl generliztions hve been over the lst decdes derived from vst rry of concordnt evidence from reserch with every investigtive methodology (clinicl, pthologic, niml-experimentl, epidemiologic, nthropologic, etc). On the bsis of this knowledge, it is resonble inference tht the key fctor ccounting for persistent low CHD rtes for Chin nd Jpn is the low verge serum cholesterol tht hs previled throughout dulthood for both men nd women. 4,7,8,23,24 Thus, in the MONICA Study in the erly 1990s, men serum totl cholesterol level ws 174 for both men nd women in the Beijing smple, in contrst to the higher vlues for UK nd US smples (Tble 7). 21 Seril dt from the PRC-USA collbortive study indicte tht verge serum cholesterol levels of middle-ged Chinese rose during the 1990s, s diets becme richer nd BMI incresed. Similrly, dt from the Jpnese Hwii INTERLIPID Study, ncillry to INTERMAP, published in this specil number of the Journl of Humn Hypertension, indicte tht the decdeslong fvourble serum lipid levels of Jpnese middle-ged popultionsffor exmple s reported erlier by the Seven Countries nd the Ni-Hon-Sn StudiesFmy be on the wy out. 17,25 Especilly given the extrordinrily high smoking rtes for Chinese (Tble 7) nd Jpnese men, 17,23 26 the high verge blood pressures, nd the high rtes of high BP, the Est Asin serum lipid trend is to be regrded s wrning signl. In terms of underlying pthology, the sitution in regrd to stroke isfcompred to CHDFvriegted nd complex. Thus, only smll percentge of strokes, different from popultion to popultion, is due to therothrombotic disese of lrge rteries (extrcerebrl nd cerebrl) supplying the brin. Stroke lso results from hemorrhge t the bse of the brin (ruptured rteril neurysm) nd deep within the brin (ruptured microneurysm); from cerebrl ischemi due to the poorly understood degenertive lesion in smller rteries within the substnce of the brin (lcunr stroke), nd from embolism to brin (eg, from the hert, especilly with uriculr fibrilltion, due to rheumtic or therosclerotic disese; lso embolism from therothrombotic plques of rteries supplying brin). For ll the severl types of stroke, high blood pressure is prime risk fctor, nd cigrette smoking lso

7 Nutrient intkes of middle-ged men nd women Tble 7 CHD CVD risk fctor level erly 1990s, men nd women ged yers by country, MONICA study smples 629 Risk fctor Jpn PR Chin Beijing UK Belfst, Glsgow US Stnford Serum cholesterol (mg/dl) Not vilblefno MONICA smple Systolic BP (mmhg) Smoking (%) BMI (kg/m 2 ) Serum cholesterol (mg/dl) Not vilblefno MONICA smple Systolic BP (mmhg) Smoking (%) BMI (kg/m 2 ) BMI, body mss index. enhnces risk mrkedly. 27,28 On the other hnd, serum cholesterolfnot unexpectedlyfreltes to risk only of therothrombotic stroke, bsed on dt vilble to dte (evidence is sprse on its role in lcunr nd embolic stroke). In this context, the greter Est Asin intke of slt nd higher dietry N/K, especilly for Chin, loom lrge s probble contributors to upwrd slope of BP during dulthood resulting in high verge SBP/ DBP for the popultion from middle ge on nd high prevlence rtes of dverse SBP/DBP levels, despite low verge BMI. 9 11,16,17,29 35 For Chin, comprtively low intke of totl protein, especilly niml protein, nd of clcium my lso be fctors plying role in development of dverse SBP/DBP levels nd high risk of strokes. In this regrd, it is resonble inference tht decdes-long successful public helth efforts in Jpn to reduce slt intke nd improve protein nutrition nd dietry levels of protective micronutrients probbly contributed importntly to the drmtic sustined decline in stroke mortlity rtes of both men nd womenflong with efforts to detect, tret, nd control prevlent high BP. It is ironic tht incresing egg intke hs been key pproch to improvement in protein nutrition in Jpn (long with fish shellfish intke), with resultnt high cholesterol ingestion nd its dverse effects on therogenic serum lipid frctions nd on CHD risk. Conclusion At the end of the 20th century, Est Asin nd Western diets remin significntly different in composition of mcro- nd micronutrients. Both Asin nd Western dietry ptterns hve spects, respectively, dverse nd protective in reltion to the mjor crdiovsculr diseses. Higher sturted ft, cholesterol, nd Keys score of trditionl Western diets hve dverse effects on serum lipids nd re ssocited with higher mortlity from CHD. Higher sodium chloride, lower potssium, higher N/K rtio, nd lower clcium of Asin diets hve dverse effects on blood pressure, nd pprently relte to higher mortlity from stroke, especilly hemorrhgic stroke. In both Asin nd Western countries, public efforts must be trgeted t overcoming dverse effects nd mintining protective effects of dietry ptterns for West nd Est, for prevention nd control of the crdiovsculr diseses. Acknowledgements This reserch ws supported by Grnt 2-RO1- HL from the US Ntionl Hert, Lung, nd Blood Institute, Ntionl Institutes of Helth, Bethesd, MD; by the Chicgo Helth Reserch Foundtion; nd by ntionl gencies in Chin, Jpn (the Ministry of Eduction, Science, Sports, nd Culture, Grnt-in-Aid for Scientific Reserch [A], No ), nd the UK. It is plesure to express pprecition to ll INTERMAP stff t locl, ntionl, nd interntionl centres for their invluble efforts; prtil listing of these collegues is given in Stmler et l. 1 References 1 Stmler J et l. for the INTERMAP Reserch Group. INTERMAP: bckground, ims, design, methods, nd descriptive sttistics (non-dietry). J Hum Hypertens 2003; 17: Dennis B et l. for the INTERMAP Reserch Group. INTERMAP: the dietry dtfprocess nd qulity control. J Hum Hypertens 2003; 17: Schkel SF et l. for the INTERMAP Reserch Group. Enhncing dt on nutrient composition of foods eten by prticipnts in the INTERMAP Study in Chin, Jpn, the United Kingdom, nd the United Sttes. J Food Comp Anl 2003; 16: Stmler J. Popultion studies. In: Levy RI, Rifkind BM, Dennis BH, Ernst ND (eds). Nutrition, Lipids, nd Coronry Hert DiseseFA Globl View. Rven Press: New York, 1979, pp

8 630 Nutrient intkes of middle-ged men nd women 5 Ntionl Diet-Hert Study Reserch Group. The Ntionl Diet-Hert Study Finl Report. Circultion 1968; 37(Suppl. I): I-1 I Inter-Society Commission for Hert Disese Resources, Atherosclerosis Study Group nd Epidemiology Study Group. Primry prevention of the therosclerotic diseses. Circultion 1970; 42: A55 A95. 7 Keys A. Seven Countries. Hrvrd University Press: Cmbridge, MA, Toshim H, Kog Y, Blckburn HJ, Keys A (eds). Lessons for Science from the Seven Countries Study: A 35-Yer Collbortive Experience in Crdiovsculr Disese Epidemiology. Springer-Verlg: Tokyo, WHO Expert Committee on the Prevention of Coronry Hert Disese. Prevention of coronry hert disese. World Helth Orgniztion Technicl Report Series No. 678, Genev, WHO Expert Committee on Prevention in Childhood nd Youth of Adult Crdiovsculr Diseses. Prevention in childhood nd youth of dult crdiovsculr disesesftime for ction: Report of WHO Expert Committee. World Helth Orgniztion Technicl Report Series No. 792, Genev, Ntionl Reserch Council (US). Committee on Diet nd Helth. Diet nd Helth: Implictions for Reducing Chronic Disese Risk. Committee on Diet nd Helth, Food nd Nutrition Bord, Commission on Life Sciences, Ntionl Reserch Council, Wshington, DC, People s Republic of Chin United Sttes Crdiovsculr nd Crdiopulmonry Epidemiology Reserch Group. Bseline survey, subsmple ( ), prt 2: nutrition. Dt Preview, US Deprtment of Helth nd Humn Services, Ntionl Institutes of Helth, Bethesd, MD, People s Republic of Chin United Sttes Crdiovsculr nd Crdiopulmonry Epidemiology Reserch Group. Bseline survey, subsmple ( ), prt 3: food intke. Dt Preview, US Deprtment of Helth nd Humn Services, Ntionl Institutes of Helth, Bethesd, MD, Pn WH, Ching BN. Plsm lipid profile nd epidemiology of therosclerotic diseses in TiwnF unique experience. Atherosclerosis 1995; 118: Zhou BF et l. for the PRC-USA Crdiovsculr nd Crdiopulmonry Reserch Group. The reltionship between dietry fctors nd serum lipids in Chinese urbn nd rurl popultions of Beijing nd Gungzhou. Int J Epidemiol 1995; 24: Stmler J et l. Dietry nd nutritionl methods nd findings: The Multiple Risk Fctor Intervention Tril (MRFIT). Am J Clin Nutr 1997; 65(1 Suppl): 183S 420S. 17 Ueshim H et l. for the INTERLIPID Reserch Group. Differences in crdiovsculr disese risk fctors between Jpnese in Jpn nd Jpnese Americns in Hwii: The INTERLIPID study. J Hum Hypertens 2003; 17: Zhou B et l. The reltionship of dietry niml protein nd electrolytes to blood pressure: study on three Chinese popultions. Int J Epidemiol 1994; 23: Chen XS. Nutrition trnsition nd the prevlence of chronic disese in Chin. In: Shetty P, Gopln C (eds). Diet, Nutrition nd Chronic Disese: An Asin Perspective. Smith-Gordon: London, Murt M. Seculr trends in growth nd chnges in eting pttern of Jpnese children. Am J Clin Nutr 2002; 72(Suppl): 1379S 1383S. 21 Dt from the World Helth Orgniztion, Genev, Switzerlnd. 22 Americn Hert Assocition Hert nd Stroke Sttisticl Updte. Americn Hert Assocition: Dlls, 2000, p People s Republic of Chin United Sttes Crdiovsculr nd Crdiopulmonry Epidemiology Reserch Group. An epidemiologicl study of crdiovsculr nd crdiopulmonry disese risk fctors in four popultions in the People s Republic of Chin: bseline report from the P.R.C. U.S.A. Collbortive Study. Circultion 1992; 85: Kuulsm K et l. for the WHO MONICA Project. Estimtion of contribution of chnges in clssic risk fctors to trends in coronry-event rtes cross the WHO MONICA Project popultions. Lncet 2000; 355: Reserch Committee on Serum Lipid Level Survey 1990 in Jpn. Current stte of nd recent trends in serum lipid levels in the generl Jpnese popultion. J Atheroscler Thromb 1996; 2: Dyer AR, Elliott P, Chn Q, Stmler J for the INTERMAP Reserch Group. Dietry intke in mle nd femle smokers, ex-smokers, nd never smokers: the INTERMAP Study. J Hum Hypertens 2003; 17: Neton JD et l. for the Multiple Risk Fctor Intervention Tril Reserch Group. Risk fctors for deth from different types of stroke. Ann Epidemiol 1993; 3: Dvis BR et l. Risk fctors for stroke nd type of stroke in persons with isolted systolic hypertension. Systolic Hypertension in the Elderly Progrm Coopertive Reserch Group. Stroke 1998; 29: Stmler J et l. INTERSALT study findings: public helth nd medicl cre implictions. Hypertension 1989; 14: Stmler R et l. on behlf of the INTERSALT Coopertive Reserch Group. Higher blood pressure in dults with less eduction: some explntory fctors. Findings of the INTERSALT Study. Hypertension 1992; 19: Elliott P et l. for the INTERSALT Coopertive Reserch Group. INTERSALT revisited: further nlyses of 24-hour sodium excretion nd blood pressure within nd cross popultions. BMJ 1996; 312: Stmler J. The INTERSALT Study: bckground, methods, findings, nd implictions. Am J Clin Nutr 1997; 65(2 Suppl): 626S 642S. 33 Dyer AR, Elliott P, Chee D, Stmler J. Urinry biochemicl mrkers of dietry intke in the INTER- SALT Study. Am J Clin Nutr 1997; 65: 1246S 1253S. 34 Hung Z et l. for the PRC-USA Crdiovsculr nd Crdiopulmonry Epidemiology Reserch Group. A north south comprison of blood pressure nd fctors relted to blood pressure in the People s Republic of Chin: report from the PRC USA Collbortive Study of Crdiovsculr Epidemiology. J Hypertens 1994; 12: Scks FM et l. for the DASH-Sodium Collbortive Reserch Group. Effects on blood pressure of reduced sodium nd the Dietry Approches to Stop Hypertension (DASH) diet. N Engl J Med 2001; 344: 3 10.