Chapter 5. Food group and nutrient intakes at baseline in the Multiple Risk Factor Intervention Trial1 2

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1 hpter 5 Food group nd nutent intkes t bseline in the Multiple Risk Fctor Intervention Tl1 2 Jenne L Tillotson, Glenn E Brtsch, Dine Gorder, Gregory A Grndits, nd Jereih Stler ABSTRAT This chpter reltes food nd nutent intkes t bseline to other fcets of reported dietry behvior, jor sk fctors, nd sociodeogrphic chrctestics of en in the Multiple Risk Fctor Intervention Tl Intkes of totl ft (384% of energy), sturted ftty cids ( 142%), nd dietry cholesterol (492 g/d) were siilr to ounts seen in the first nd second tionl Helth nd uttion Exintion Surveys in the l97s nd were generlly lower thn findings fro studies in the 196s There were inverse reltions between totl seru cholesterol nd intkes of totl ft, sturted nd onounsturted ftty cids, nd dietry cholesterol These prdoxicl ssocitions were lrgely ttbutble to findings in the 21% of en who reported following specil diet, indicting tht use of such diet increses with sevety of hypercholesterolei Ft intke ws directly relted to nuber of els per week eten wy fro hoe, nd to cigrette soking Ptterns of food nd nutent intke were siilr for en strtified by bseline blood pressure nd ntihypertensive tretent Intke of totl energy nd percentges fro vous dietry fts decresed with ge, s did use of sucrose nd cffeine White en consued ore diry products thn did other ethnic groups, wheres blck en consued ore eggs, sugrs, nd sweets Asins hd the highest intke of cerel foods Those with ore eduction te less highft et products, ore fruit, nd ore polyunsturted oils, but lso ore highft diry products nd less breds nd cerels; they lso drnk ore lcohol A J lin utr 1997;65(suppl):228S57S KEY WORDS Food nd nutent intkes, crdiovsculr sk fctors, sociodeogrphic chrctestics ITRODTIO This chpter descbes the selfreported dietry intke of prticipnts in the Multiple Risk Fctor Intervention Tl (MRFIT) t bseline, ie, just before the en were rndoly ssigned into the tl Associtions re exined between bseline bioedicl, deogrphic, nd socil vbles nd intke of food groups nd nutents METHODS groups Dietry fts re referred to here siply s sturted (SFA), onounsturted (MFA), or polyunsturted (PFA) ftty cid In tbles with nutent intkes, stndrd nutent coposition noenclture is used Becuse use of vitin nd inerl suppleents ws not scertined in MRFIT, reported icronutent intkes reflect only ounts consued fro foods opsons of dietry vbles by bseline sociodeogrphic nd other fctors were de with nlysis of covnce These fctors were ge, rce, eduction, tl sttus, nuber of puttively stressful life events (chnges or probles with helth, work, fily, or other res of life in the previous yer), Jenkins Activity Survey (JAS) score (2, 3), nuber of lcoholic dnks consued per week, body ss index (BMI), percentge of els eten wy fro hoe, ntihypertensive ediction sttus, nuber of cigrettes soked per dy, distolic blood pressure (DBP), nd seru cholesterol concentrtion Ech fctor ws ctegozed into ppropte intervls, nd djusted en nutent or food group ount ws clculted fter djustent for the other vbles In ddition, for continuous vbles (eg, ge) the slope fro the corresponding ultiple liner regression ws clculted nd is displyed with the t sttistic (slope/se of slope) nd P vlue For vbles with just two ctegoes (eg, red or not red), the djusted en difference is presented For fctors with ultiple ctegoes tht re not ordered (eg, ethnicity: white, blck, Asin, or other), the F sttistic is given, testing whether there re differences ong the groups, nd dt on pirwise cornpsons re lso reported Soe nlyses were lso conducted for subgroups, eg, reltion between dietry vbles nd seru cholesterol ws ssessed seprtely for those consuing or not consuing specil diets In this cse P vlue for the interction is lso given Except for jor sk fctors (seru cholesterol, DBP, nd cigrettes soked), which becuse of the selection of the cohort re odertely correlted (4), other fctors considered re only slightly correlted Thus, in generl, djusted ens re siilr to undjusted ens Only djusted ens re reported Downloded fro by guest on 1 oveber 218 Reported food group nd nutent intke dt re bsed on 24h dietry recll interviews conducted with MRFIT prticipnts ieditely before they were rndoly ssigned into the tl As noted in hpter 3 (1), tbles on food consuption re bsed on clssifiction of ech food into 1 of 2 jor food I Fro Jcksonville, FL; the Division of Biosttistics, School of Public Helth, niversity of Minnesot, Minnepolis; nd the Deprtent of Preventive Medicine, orthwestern niversity, hicgo 2 Address repnt requests to GA Grndits Division of Biosttistics, niversity of Minnesot, 2221 niversity Avenue, SE Minnepolis, M S A J lin uir 1997;65(suppl): Pnted in SA to 1997 Aecn Society for linicl uttion

2 FOOD AD TRIET ITAKES AT BASELIE 2295 RESLTS Sury of food group nd nutent intkes nd other vbles At bseline, MRFIT en reported consuing 24% of their energy fro ets, 1 1% fro diry products, 14% fro breds nd cerels, nd 7% fro fruit nd vegetbles (Tble 1) Men reported energy intke ws just > 24 kcl (1 42 ): 38% fro totl ft, 14% fro SFA, nd 6% fro PFA (Tble 2) Dietry cholesterol intke verged 1 88 g/l kcl Sury sttistics for sociodeogrphic nd other vbles esured t bseline re given in Tble 3 Distbution of seru cholesterol by soking sttus nd distolic blood pressure t entry nd percentge consuing specil diet by seru cholesterol concentrtion As noted in hpter 4 (4), use of threefctor cobined sk score to ssess eligibility for the tl resulted in cholesterol distbution tht ved by soking sttus nd DBP (Tble 4) onsokers hd higher cholesterol concentrtions t the first screening visit (2656 g/dl) thn did sokers (2468 g/dl) Aong sokers, those with lower DBP hd higher cholesterol concentrtions thn did those with higher DBP These differences re relevnt for both bseline dietry ptterns nd subsequent responses of en in the specil intervention (SI) group to nuttionl recoendtions Also relevnt is tht 2 1 % of en t bseline were consuing specil diet prescbed by their personl physicins, with the highest percentge in the subgroup with highest blood cholesterol concentrtions (Tble 5) TABLE 1 Percentge of energy t bseline fro ech of the food groups for en in the Multiple Risk Fctor Intervention Tl i±sdn utent Percentge of energy 1) Met: low nd ediuft 14 ± 11 2) Met: highft 137 ± 138 3) Diry: lowft 22 ± 49 4) Diry: ediuft 37 ± 64 5) Diry: highft 51 ± 74 6) Eggs 2 ±41 7) Breds nd cerels 142 ± 95 8) Fruit 39 ± 58 9) egetbles 29 ± 38 1) Legues 3 ± 19 11) Bked goods nd desserts: lowft 4 ± 16 12) Miscellneous: lowft 7 ± 24 13) Miscellneous: cceptble ft 7 1 ± 92 14) Fts nd oils: polyunsturted 33 ± 51 15) Fts nd oils: onounsturted 12 ± 31 16) Fts nd oils: sturted 34 ± 44 17) rckers nd sncks: uncceptble ft 24 ± 47 18) Bked goods nd desserts: highft 83 ± 18 19) Sugrs nd sweets: lowft 55 ± 64 2) Alcoholic beverges 94 ± 126 % TABLE 2 utent ounts t bseline for en in the Multiple Risk Fctor Intervention Energy (kcl) (Id) Tl utent Protein (% of energy) Totl ft (% of energy) SFA (% of energy) PFA (% of energy) MFA (% of energy) holesterol (g) holesterol (g/boo kcl) Keys score2 rbohydrtes (% of energy) Strch (% of energy) Sucrose (% of energy) Other (% of energy) Totl fiber (g) Wtersoluble Insoluble (g) (g) Alcohol (% of energy) ffeine (g) itin A (I) (3rotene Retinol (,Lg) itin E (g) itin D (g) itin (g) Thiine Riboflvin icin (g) (g) (g) Folic cid (1Lg) (;tg) itin B6 (g) itin B12 (Lg) lciu Phosphorus Potssiu Sodiu Iron (g) Mgnesiu opper Zinc (g) (g) (g) (g) (g) (g) (g) Aount ± ± ± ± ± ± ± ± ± ± ± ± 73 8 ± ± ± ± 3 68 ± 5 72 ± ± ± ± ± ± ± ± ± 8 21 ± ± ± ± 8 86 ± ± ± ± ± ± ± ± ± 114 i ± SD n = SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Keys score = (2S P) + l5#{235}, where S nd P re the percentges of totl energy fro SFA nd PFA, respectively, nd is cholesterol intke in g/l kcl (5) Specil diet sttus nd food group nd nutent intkes t bseline Although infortion collected t bseline did not llow precise descption of the kinds of specil diets used, dt in Tble 6 nd Tble 7 indicte tht soe en consuing such diets de efforts to chieve ft nd energycontrolled dietry pttern Those reporting use of specil diet te reltively ore ediuft nd lowft et products, ore lowft diry products, ore fruit nd vegetbles, nd ore polyunsturted fts nd oils thn did nondieters (Tble 6) se of highft et products, sturted fts nd oils, highft bked products, nd sugrs ws significntly lower in dieters Dieters Downloded fro by guest on 1 oveber 218

3 235 TILLOTSO El AL TABLE 3 Sociodeogrphic nd other vbles t bseline for en in the Multiple Risk Fctor Intervention Study ble lue Age (y) 464 ± 6 Ethnicity (%) White 899 Blck 72 Asin 1 Eduction (y) 137 ± 33 Percentge red (%) 899 Percentge sokers (%) 637 igrettes soked/d for sokers 34 ± 153 Distolic blood pressure ( Hg) 97 ± 88 Seru cholesterol (g/dl) ± 366 Percentge on specil diet (%) 212 Percentge of els eten wy fro hoe (%) 32, Alcoholic dnks/wk 126 ± 124 JAS score3 9 ± 96 uber of life events4 38 ± 38 BMI (kg/2) 277 ± 35 Percentge tking ntihypertensive ediction 193 I ± SD 2 To convert to SI units (ol/l), ultiply by Jenkins Activity Survey (2, 3) 4 Defined s chnges or probles with helth, work, fily, or other res of life in the previous yer lso reported consuing on verge lost 2 kcl (837 kj)/d less thn nondieters (Tble 7) Dieters reported lower intkes of totl ft, SFA, MFA, cholesterol, sucrose, nd cffeine, long with higher intkes of protein nd siple crbohydrtes other thn sucrose Although these differences were significnt (P < 1) with the lrge MRFIT sple size, in bsolute ounts they were odest itin intke ws greter for dieters, but bsolute intkes of ost B vitins, clciu, phosphorus, iron, nd gnesiu were sller TABLE 5 Percentge of en in the Multiple Risk Fctor Intervention Tl consuing specil diet t bseline by cholesterol concentrtion t the first screening v151t1 Firstscreen cholesterol (g/dl)2 Percentge TABLE 4 Frequency distbution of seru cholesterol for en in the Multiple Risk Fctor Intervention Tl ccording to soking sttus nd distolic blood pressure (DBP) t the first screening visit Firstscreen cholesterol (g/dl) onsokers2 < [ [2393] [2781] [2521] [168] [14191 Totl diet % 2l2[l2866] [17221, n in brckets 2 To convert to SI units (olll), ultiply by 2586 oronry hert disese sk fctor sttus nd food group nd nutent intkes t bseline Seru cholesterol Food group nd nutent intkes were coputed for en in six strt of bseline seru totl cholesterol, rnging fro < 22 g/dl to 3 g/dl, nd seprtely for the sury strtu 22 g/dl (Tbles 8li) Reported use of lowft diry products ws higher wheres use of eggs nd ediuft diry products ws lower in prticipnts with higher seru cholesterol concentrtions (Tble 8) orrespondingly, there ws n inverse ssocition of totl ft, SFA, nd cholesterol intkes with seru cholesterol (Tble 9) Agin, lthough these differences cross the subgroups were significnt (P < 1) with the lrge MRFIT sple size, in bsolute ounts they were odest The lesser use of soe diry products by en with higher seru cholesterol concentrtions sees to be reflected in significnt negtive ssocitions of intkes of clciu nd phosphorus with seru cholesterol, but gin these differences re sll Sokers All en DBP < 95 DBP 95 Totl DBP < 95 DBP 95 Totl % on Downloded fro by guest on 1 oveber 218 < [164] 44 [98] 316 [1882] 242 [198] 44 [99] 192 [245] 167 [2144] [771] 129 [288] 224 [ [1622] 129 [288] 198 [215] 186 [2393] [1l41] 196(438] 22(122] 2[I64] 196[439] 22[2342] 216 [2781] [l18] 231 [517] 138[ [1341] 231 [517] 189[24] 196 [2521] l69[789] 185[4l4] 68[45] l[8l9] l85[415] ll2[1l93] 125 [168] [627] 215 [482] 52 [31] 97 [792] 215 [482] 88 [ [14191 Totl 1 [4672] 1 [2237] 1 [5957] 1 [8194] 1 [224] 1 [1 626] 1 [12 866] [458] 956 [ [475] 758 [6214] 956 [2141] 88 [8581] 833 [1 722] n in brckets Men seru cholesterol vlues (gldl) for ech group were s follows: nonsokers, 2656; sokers with DBP < 95, 27 19; sokers with DBP 95, 2374; ll sokers, 2468; ll with DBP < 95, 2718; ll with DBP 95, 2498; nd ll en, 2536 To convert to SI units (ol/l), ultiply by All but three nonsoking en hd DBP 95 Hg

4 FOOD AD TRIET ITAKES AT BASELIE 23 1 S TABLE 6 Adjusted percentges of energy fro ech food group by specil diet sttus for en in the Multiple Risk Fctor Intervention Tl Food group On diet (n 2678) o diet (n = 9875) Difference (diet no diet) P % ofenergy % of energy I) Met: low nd ediuft < 1 2) Met: highft <1 3) Diry: lowft < 1 4) Diry: ediuft ) Diry: highft ) Eggs ) Breds nd cerels ) Fruit < 1 9) egetbles ) Legues ii) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted < 1 /5) Fts nd oils: onounsturted ) Fts nd oils: sturted < 1 /7) rckers nd sncks: uncceptble ft I ) Bked goods nd desserts: highft < 1 19) Sugrs nd sweets: lowft < 1 2) Alcoholic beverges , Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus Tbles 1 nd 1 1, with dt given for those consuing nd not consuing specil diets seprtely, crry these nlyses step further In prticulr, Tble 1 1 shows tht uch of the difference in dietry lipid intke cross seru cholesterol subgroups ws ttbutble to those consuing specil diets Thus, there were significnt differences between dieters nd nondieters in slopes for reltion of seru cholesterol to intkes of totl ft, SFA, nd Keys score, ie, slopes were significntly steeper (ore negtive) for dieters thn for nondieters Distolic blood pressure nd hypertensive sttus Reported food group nd nutent intkes were coputed for five strt relted to DBP nd ntihypertensive tretent sttus t bseline nd for ll hypertensive en cobined (Tble 12 nd Tble 13) There were few significnt differences in food ptterns cross these strt Men tking ntihypertensive ediction reported the highest fruit intke There ws significntly lower intke of lcohol nd significntly higher intke of potssiu nd cffeine for nonhypertensive en copred with hypertensive en (Tbles 12 nd 13) Despite only one 24h recll per n, these nlyses lso indicte inverse reltions to DBP of totl fiber, vitin A, (3crotene, vitin, iron, nd gnesiu (Tble 13) [see lso hpter 12 (6)] These differences were odest in degree igrette soking nonsokers Sokersespecilly hevy sokers (> 4 cigrettes/d)chose highft over lowft et products, ediuft over lowft diry products, nd eggs, nd included less fruit nd vegetbles in their food ptterns (Tble 14) They lso used significntly lrger quntities of sturted fts nd oils, refined sugrs, nd lcoholic beverges Averge reported energy intkes were 2kcl (837 kj)/d higher for hevy sokers thn for nonsokers (Tble 15) Sokers reported higher intkes of ost dietry lipids (totl ft, SFA, MFA, nd cholesterol) nd lower intkes of totl crbohydrte, other siple crbohydrtes, nd dietry fiber (Tble 15) These differences were generlly odest in degree Men dily cffeine intke for sokers (75 g) ws higher thn for nonsokers (496 g); cffeine intke ws progressively higher by nuber of cigrettes soked per dy A lower intke of fruit nd vegetbles by sokers ws reflected in significntly lower intke of crotene nd vitin Averge intkes of boflvin, nicin, clciu, phosphorus, potssiu, iron, gnesiu, nd zinc were higher with greter dily use of cigrettes, becuse of soewht higher intke of et, diry, nd egg products by sokers However, bsolute differences between sokers nd nonsokers for these icronutents were generlly sll Body ss index nd food group nd nutent intkes t bseline Downloded fro by guest on 1 oveber 218 Reported food group nd nutent intkes were coputed for en not soking t bseline nd for three subgroups of cigrette sokers, on the bsis of nubers of cigrettes soked per dy, s well s for ll cigrette sokers cobined (Tble 14 nd Tble 15) Food preferences of cigrette sokers t bseline were different in ny respects fro those reported by Reported food group nd nutent intkes were coputed for five strt bsed on entry BMI (kg/rn2), fro < 24 to 32 (Tbles 1619) There ws significnt direct grded reltion between BMI nd reported dily intke of ets, eggs, nd polyunsturted fts nd oils, nd significnt inverse reltion between BMI nd reported dily intke of ediuft diry

5 232S TILLOTSO El AL TABLE 7 Adjusted en nutent ounts t bseline by specil diet sttus for en in the Multiple Risk Fctor Intervention Tl utent On diet (n 2678) o diet (n 9875) Difference (diet no diet) Energy (kcl) <1 (Id) Protein (% of energy) < 1 Totl ft (% of energy) < 1 SFA (% of energy) < 1 PFA (% of energy) MFA (% of energy) < 1 holesterol (g) < 1 holesterol (g/1 kcl) Keys score < 1 rbohydrtes (% of energy) Strch (% of energy) Sucrose (% of energy) < 1 Other (% of energy) < 1 Totl fiber (g) Wtersoluble (g) I Insoluble (g) Alcohol (% of energy) ffeine (g) < 1 itin A (I) (3rotene (tg) Retinol (Lg) itin E (g) itin D (g) itin (g) Thiine (g) < 1 Riboflvin (g) < 1 icin (g) <1 Folic cid (;Lg) itin B6 (g) itin Bl2 (pg) lciu (g) < 1 Phosphorus(g) <1 Potssiu (g) Sodiu (g) < 1 Iron (g) < 1 Mgnesiu (g) < 1 opper (g) Zinc (g) , Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2 products, highft bked goods nd desserts, sugrs, sweets, nd lcoholic beverges (Tble 16) orrespondingly, en with higher BMIs hd significntly higher intkes of protein nd of ll dietry lipids s percentge of totl energy, nd reported significntly lower consuption of ll dietry crbohydrtes nd lcohol (Tble 17) These reltions of BMI to food nd nutent ptterns tended to be siilr for en consuing or not consuing specil diets (Tbles 18 nd 19) Mel consuption wy fro hoe nd food group nd nutent intkes t bseline Reported food group nd nutent intkes were coputed for four strt rnging fro % to > 5% of els eten wy fro hoe This vble ws significntly relted to dietry intke ptterns Those who ore frequently te outside the hoe reported significntly greter use of highft ets nd sturted fts nd oils, s well s lower use of lowft diry products, breds nd cerels, fruit, nd vegetbles (Tble 2) This ws reflected in significntly higher en intkes of totl ft, SFA, nd MFA long with lower intkes of crbohydrtes nd dietry fiber (Tble 21) Intke of ny icronutents ws lso lower with greter nuber of els eten wy fro hoe Alcohol use nd food group nd nutent intkes t bseline Most en (> 9%) reported dnking t lest one lcoholic dnk per week Reported food group nd nutent intkes were Downloded fro by guest on 1 oveber 218

6 FOOD AD TRIET ITAKES Al BASELIE 233S S Ifl S Ifl fl > ( i r 1 c,,, o Q (O OO OO O O r1r1 % rj #{149};AI o oooio o F t OOO OOOO vv OO O rn c1 1 orcc rr I I I I I I n r o r rn fl In! 2 c,) I I I I I I I I E rr r4 n e1 r ei o c r I( Al11 2 LI!, _ s :i o r 1 n Q\ r ir t O r1 r1 1, r i ci 1 r1 r #{149} ooi c r Q) I r r r4 n r 1 r e r1 *f? 5 r ; 9 B \ i t E b ( OO\ r r1 r r oo c_ill 2 e 1: b c OO r O #{176}Qi #{176}#{176} #{176} 2 r1 r r1 r \ II 2 S >, ) e,, ) = () z b1 I, _ z > E : i J: ) E c o O, b1 #{149} cr &s <,,,,, r1 Downloded fro by guest on 1 oveber 218

7 234S TILLOTSO El AL TABLE 9 Adjusted en nutent ounts t bseline by seru cholesterol concentrtion for en in the Multiple Risk Fctor Intervention Tl Energy Seru cholesterol (g/dl) Test: < 22 vs 22 < utent (n = 285) (n 2339) (n = 2714) (n 2467) (n 1566) (n 1382) (n 1468) Slope t P t P (kcl) (Id) Protein (% of energy) Totl ft (% of energy) < SFA (% ofenergy) < PFA (% of energy) MFA (% ofenergy) < holesterol (g) < < 1 holesterol (g/l kcl) < < 1 Keys score < < 1 rbohydrtes (% of energy) I Strch (% ofenergy) Sucrose (% of energy) Other (% of energy) Totl fiber (g) Wtersoluble (g) Insoluble (g) Alcohol (% of energy) ffeine (g) itin A (l) fjrotene (g) Retinol (/Lg) itin E (g) itin D (g) itin (g) Thiine (g) Riboflvin (g) < icin (g) Folic cid (,Lg) itin B6 (g) itin B12 (Lg) lciu (g) < Phosphorus (g) < Potssiu (g) Sodiu (g) Iron (g) Mgnesiu (g) opper (g) Zinc (g) , Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, els eten wy fro hoe, specil diet, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus To convert to SI units (olil), ultiply by 2586 SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA onounsturted ftty cid 2 Eqution for Keys score given in Tble 2 coputed for five strt bsed on reported nuber of lcoholic dnks consued per week (Tble 22 nd Tble 23); proportion of energy fro lcohol rnged fro en of 1% to 15% (Tble 23) Food ptterns were relted to use of lcoholic beverges (Tble 22) Percentges of energy fro diry products, breds nd cerels, nd fruit were lower for those with higher lcohol intkes, s were percentges fro sugrs nd sweets nd desserts By definition, s the percentge of energy fro lcoholic beverges increses, percentges of energy fro soe other sources ust decrese However, these energy fro other siple crbohydrtes ws higher ong hevier dnkers, due in prt to crbohydrtes in beer nd wine Intke of cffeine ws inversely relted to lcohol intke Reported intkes of soe vitins (E, D, nd thiine) nd of clciu nd iron were lower s lcohol intke incresed; differences were odest in degree Intkes of severl other icronutents (nicin, folic cid, vitin B6, phosphorus, gnesiu, nd copper) were positively relted to lcohol use, to soe extent reflecting the vitin nd inerl contents of beer nd wine sources did not include ets or eggs, which were consued in siilr ounts cross the strt of reported lcohol intke Sociodeogrphic chrctestics nd food group nd Tble 23 shows significnt direct reltion between hevy nutent intkes t bseline dnking nd energy intke As for percentges of totl energy fro vous cronutents, dietry protein intke ws Age slightly lower s lcohol consuption incresed All dietry As shown in Tble 24, older prticipnts reported higher lipids were inversely relted to lcohol intke, s were totl intkes of low nd ediuft ets, fruit, nd vegetbles s crbohydrte, strch, nd sucrose However, percentge of well s lower consuption of highft et products, highft Downloded fro by guest on 1 oveber 218

8 FOOD AD TRIET ITAKES Al BASELIE 235S 111 I1 f 4 % t i_o O O OO ( O I1 1 o O e L o, I I I I I < F O E O E E 2 r Al o,o (1 II r II z II 1:: r r or4 r4 II A, cc o c1 c II r4 II I I r1 OO O O I I I I I I I I I I \O rnc O ( Ir, fsn_zc;o O n z, ei r o o O(4Or 4 t o ei, i rn e r s n It r r ir i, O F ) : r I1 t t oo r i 4 O r4 4 O eir o r v \ r r ( 1 r, c 1 r4 ei E I! Downloded fro by guest on 1 oveber 218 r i,noo ei r r i, ro #{128} 2 I b I 9 bj #{149} is c,,, t; I c R & S, r 1,, O z 2

9 236S TILLOTSO El AL O 5 I r ir oo rn fl r r fl r I, f,, e Q II II I I IIIIIIIIIIIIII I t : :,, _, i 4 t r4 I, F III I II T III I III I O E E O O Al II II r1 II (1 II o II OI r II Al 1 11, rn c 4 1 r r (n (fl r r r c r e r r o r1 r ( \or1 r r 1 (4 r1 r 1 r1 e 1 r Q O c r1 n ro \ rr1 r1 ( r c( rnrn1, r r4 f ei ir q Qc O r o r1r rc r o Oc r1 oc r, e o in o \ r r1 O,, ci,,, n oo u,, I o it in I,, o oo o r r r s #{149}O, O O O4 >, O ti > O F Downloded fro by guest on 1 oveber 218 z E2

10 FOOD AD TRIET ITAKES Al BASELIE 237S TABLE 12 Adjusted en percentges of energy fro ech food group by distolic blood pressure (in Hg) nd ntihypertensive drug use for en in the Multiple Risk Fctor Intervention Tl Test: hypertensive vs ot on ediction nonhypertensive On < ediction Food group (n 4749) (n 229) (n 1626) (n 1464) (n 2424) F P Hypertensive3 t P % ofenergy % ofenergv % of energy I) Met: low nd ediuft ) Met: highft ) Diry: lowft ) Diry: ediuft ) Diry: highft ) Eggs ) Breds nd cerels ) Fruit < ) egetbles ) Legues II) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted ) Fts nd oils: onounsturted ) Fts nd oils: sturted ) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft ) Sugrs nd sweets: lowft ) Alcoholic beverges < < 1 Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, seru cholesterol, els eten wy fro hoe, specil diet sttus, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, nd BMI 2 p vlue copng five blood pressure nd ediction groups 3 Hypertensive distolic blood pressure 9 or on ntihypertensive ediction sncks, nd sugrs Older prticipnts lso reported greter use of egg products These findings re reflected in nutent intke dt (Tble 25) Thus, reported intke of energy nd sucrose ws less with incresing ge Averge reported energy intkews lost 45 kcl ( Id) lower in the oldest (5557 y) copred with the youngest (3539 y) group Intke of protein, other siple crbohydrtes, nd dietry fiber ws positively ssocited with ge Intke of B vitins nd ll inerl nutents ws less in older prticipnts Agerelted differences in nutent coposition were odest in degree Ethnicity MRFIT prticipnts were predoinntly white (91% of the cohort) Of nonwhite en, 7% were blck, 1% were of Asin ogin, nd 19% were of other ethnic ogins There were significnt differences ong ethnic groups in consuption of ost food groups, lthough differences were generlly odest in degree (Tble 26) Both blck nd Asin subgroups reported lower en energy intke thn did whites (Tble 27) orrespondingly, there were significnt differences ong the in intkes of ost cronutents nd of ny icronutents, for exple, blcks reported lower intkes of fiber, clciu, potssiu, nd gnesiu nd higher intkes of sucrose (Tble 27) Eduction The MRFIT cohort ws de up of en with wide rnge of eductionl bckgrounds Prticipnts with ore yers of eduction reported significntly greter use of lowft et nd lowft diry products, fruit, nd polyunsturted fts nd oils, but lso ore highft diry products (Tble 28) Intke of highft et products, sturted fts nd oils, highft bkery products, nd sugrs ws negtively ssocited with eductionl level, s ws intke of breds nd cerels se of eggs did not differ by eductionl level se of lcoholic beverges ws progressively higher with eductionl level, fro 72% of energy for en in the lowest strtu of eduction to > 1 1 % for en in the two highest strt These trends were reflected in nutent intke, with energy fro SFA, MFA, totl crbohydrte, strch, nd sucrose inversely ssocited with eductionl level Intke of PFA, other siple crbohydrtes, nd lcohol Downloded fro by guest on 1 oveber 218

11 238S TILLOTSO El AL TABLE 13 Adjusted en nutent ounts t bseline by distolic blood pressure (in Hg) nd ntihypertensive drug use for en in the Multiple Risk Fctor Intervention Tl Test: hypertensive vs ot on ediction On nonhypertensive < ediction utent (n = 4749) (n = 229) (n = 1626) (n 1464) (n 2424) F P Hypertensive3 : P Energy (kcl) () Protein (% ofenergy) Totl ft (% of energy) SFA (% of energy) PFA (% of energy) MFA (% ofenergy) holesterol (g) holesterol (g/l kcl) Keys score rbohydrtes (% of energy) Strch (% of energy) Sucrose (% ofenergy) Other (% of energy) Totl fiber (g) Wtersoluble (g) Insoluble (g) I Alcohol (% of energy) < < 1 ffeine (g) < < 1 itin A (I) (3rotene (Lg) Retinol (;tg) itin E (g) itin D (g) itin (g) < Thiine (g) Riboflvin (g) icin (g) Folic cid (,tg) itin B6 (g) itin Bl2 (pg) lciu (g) Phosphorus(g) Potssiu (g) < < 1 Sodiu (g) Iron (g) Mgnesiu (g) opper (g) Zinc (g) I Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, seru cholesterol, els eten wy fro hoe, specil diet sttus, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, nd BMI SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 p vlue copng five blood pressure nd ediction groups 3 Hypertensive = distolic blood pressure 9 or on ntihypertensive ediction 4 Eqution for Keys score given in Tble 2 Downloded fro by guest on 1 oveber 218 ws positively ssocited with eduction Men vitin ptterns Mred en reported greter use of breds nd ceintke ws positively ssocited with eduction wheres intke rels nd lower intkes of fruit thn did single en (Tble 3) of severl B vitins ws negtively ssocited (Tble 29) orrespondingly, intke of strch ws higher nd tht of other Differences were generlly odest in degree siple crbohydrtes ws lower by red en (Tble 31) icin intke ws higher nd vitin intke lower for Mtl sttus red en Mred en reported significntly higher cf At bseline, 89% of MRFIT prticipnts were red Mr feine intke thn did single en Differences were generlly itl sttus pprently hd reltively little reltion to eting odest in degree

12 FOOD AD TRIET ITAKES AT BASELIE 239S TABLE 14 Adjusted en percentges of energy fro ech food group by nuber of cigreues soked per dy for en in the Multiple Risk Fctor Intervention Tl igrettes/d Test: sokers vs nonsokers All sokers Food group (n = 4547) (n = 837) (n = 365) (n = 3519) Slope t P (n = 86) t P % ofenergy % of energy I) Met: low nd ediuft < ) Met: highft ) Diry: lowft < ) Diry: ediuft < < 1 5) Diry: highft ) Eggs < 1 7) Breds nd cerels ) Fruit < <1 9) egetbles < < 1 1) Legues I 1) Bked goods nd desserts: lowft < /2) Miscellneous: lowft < ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted I ) Fts nd oils: onounsturted ) Fts nd oils: sturted < ) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft ) Sugrs nd sweets: lowft < < 1 2) Alcoholic beverges < , Mens were djusted for ge, rce, eduction, tl sttus, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus Jenkins Activity Survey score Scores fro the JAS for ssessing type AB behvior ved considerbly ong MRFIT prticipnts JAS scores were significntly relted to only few nuttionl trits, nd differences were odest in degree Men with positive JAS scores (type A behvior) reported significntly higher intkes of lcoholic beverges nd lower intkes of breds nd cerels thn did those with lower scores (Tble 32) Intkes of totl crbohydrte nd strch were negtively ssocited with JAS score, wheres intkes of cffeine nd potssiu were positively ssocited (Tble 33) Life events Prticipnts ved considerbly in hving expeenced puttively stressful jor life events, with 17% reporting none nd 24% reporting six or ore dung the preceding yer uber of life events showed little reltion to food group selection, except tht those in the highest ctegory of life events reported consuing ore sugrs nd sweets (Tble 34) Significnt positive ssocitions were found between nuber of life events nd intkes of energy; fiber; vitins D, E, nd B6; clciu; phosphorus; nd potssiu (Tble 35) Differences were generlly odest in degree DISSSIO Bseline nutent intke of the rndoized cohortoverll findings nd copson with intkes reported in other Aecn studies Averge bseline dietry intke vlues reported by MRFIT prticipnts were generlly coprble with those of other groups of iddleged Aecn en, eg, en in the tionl DietHert Study of 1963 (7); the S Deprtent of Agculture tionwide Food onsuption Surveys of 1965 (8), (9), nd 1985 (1); the dietry intke study conducted fro 1967 to 197 by the Fringh Hert Progr (1 1); the first ( ; tionl enter for Helth Sttistics, unpublished dt) nd second ( ) (tionl enter for Helth Sttistics, unpublished dt; 1 2, 1 3) tionl Helth nd uttion Exintion Surveys (HAES); nd the Lipid Reserch linics Progr Prevlence Study (dt collected ) (14) (Tble 36) Becuse of interstudy differences in spling cte nd dietry ethods (prticulrly for the tbultion of lcohol intke), copsons bsed on these dt re pproxite lerly, the MRFIT cohort of > 12 en, recruited in 18 S cities cross the country, reported intkes of both cro nd icronutents tht were Downloded fro by guest on 1 oveber 218

13 24S TILLOISO El AL TABLE 15 Adjusted en nutent ounts t bseline by nuber of cigrettes soked per dy for en in the Multiple Risk Fctor Intervention Tl Test: sokers vs igrettes/d nonsokers All sokers utent (n 4547) (n 837) (n 365) (n 3519) Slope t P (n 86) t P Energy (kcl) < <1 (Id) Protein (% of energy) < Totl ft (% of energy) < < 1 SFA (% of energy) < < 1 PPA (% of energy) MFA (% of energy) < < 1 holesterol (g) < < 1 holesterol (g/l kcl) < 1 Keys score < < 1 rbohydrtes (% of energy) < < 1 Strch (% of energy) Sucrose (% of energy) Other (% of energy) I 14 < < 1 Totl fiber (g) < 1 Wtersoluble (g) < 1 Insoluble (g) < < 1 Alcohol (% of energy) < ffeine (g) < < 1 itin A (I) (3rotene (Lg) < Retinol (/Lg) itin E (g) itin D (g) itin (g) < <1 Thiine (g) Riboflvin (g) < icin (g) < < 1 Folic cid (,Lg) itin B6 (g) < 1 itin B12 (Lg) lciu (g) < < 1 Phosphorus(g) < <1 Potssiu (g) < < 1 Sodiu (g) < Iron (g) < Mgnesiu (g) < < 1 opper (g) Zinc (g) < Mens were djusted for ge, rce, eduction, tl sttus, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2 generlly siilr to those of popultion sples of iddleged en studied dung the se tie peod This is the cse despite the specil fetures of the MRFIT en, ie, they were cohort selected becuse of high concentrtions of seru cholesterol, blood pressure, or cigrette use; dditionlly, they were volunteers, not popultionbsed sple As volunteers for tl ephsizing lifestyle interventions, it is resonble to infer tht they were ore helth conscious thn iddleged Aecn en in generl in the yers Despite these specil fetures, however, this cohort reported nutent ptterns siilr to those recorded for popultionbsed sples of S iddleged en in those yers, including the representtive sples studied in the S Deprtent of Agculture nd HAES surveys This ws the finding for ll cronutents, including dietry lipids, nd for ll icronutents, with en ounts for the ltter eeting the recoended dietry llownces for iddleged en (15, 16) Hence, the MRFIT expeence hs iplictions tht re brodly generlizble The dt in Tble 36 lso indicte tht the bseline cronutent findings for the MRFIT cohort reflect S trends in eting ptterns dung the 196s nd erly 197s, prticulrly ong ore helthconscious people Thus, dietry cholesterol nd percentges of energy fro totl ft nd SFA were ll odertely lower, nd PFA higher, for groups studied in the Downloded fro by guest on 1 oveber 218

14 FOOD AD TRIET ITAKES AT BASELIE 24 1S TABLE 16 Adjusted en percentges of energy fro ech food group by body ss index for en in the Multiple Risk Fctor Intervention Tl BMI (kg/2) < Food group (n = 1 176) (n 375) (n 4174) (n 1722) (n 1731) Slope t P % of energy 1) Met: low nd ediuft < 1 2) Met: highft < 1 3) Diry: lowft ) Diry: ediuft < 1 5) Diry: highft ) Eggs <1 7) Breds nd cerels ) Fruit ) egetbles ) Legues II) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted < 1 15) Fts nd oils: onounsturted ) Fts nd oils: sturted ) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft < 1 /9) Sugrs nd sweets: lowft < 1 2) Alcoholic beverges < 1, Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, nd ntihypertensive ediction sttus lte l96s The inference tht these findings reflected generl popultion trend is supported by dt over tie for popultion sples (eg, Fringh in copred with HAES I in ), nd by dt over tie for groups of volunteers for nuttion intervention tls (eg, the tionl DietHert Study in 1963 copred with MRFIT in ) (Tble 36) It is lso supported by dt fro nlyses of the cronutent content of foods nnully vilble to the S popultion dung these yers (172) nd by dt on popultion sples, indicting declining concentrtions of en seru cholesterol (2123) The dt lso indicte trend dung these yers of n incresing percentge of energy fro lcohol (Tble 36), which is lso consistent with dt on ntionl trends for Aecns dung these yers (24) As noted in hpter 3 (1), it ws nticipted in the MRFIT design tht dietry lipid ptterns t bseline would reseble those recorded for the tionl DietHert Study volunteers in the erly l96s (7); in fct, reported intkes of totl ft, SFA, nd cholesterol were lower nd intkes of PFA were higher (Tble 36) On the bsis of these dt plus the finding tht initil chnge in blood cholesterol in the SI group ws less thn the desired 1% reduction for en with cholesterol concentrtions 22 g/dl, the MRFIT dietry pttern for SI en ws odified in 1976; in prticulr, trgets for SFA nd cholesterol intkes were lowered (J Stler, unpublished dt, 1976; 25) Bseline nutent intkes of subgroups of the rndoized cohort Eligibility for MRFIT ws bsed on ultifctor score tht considered seru cholesterol concentrtion, DBP, nd cigrette use per dy ( 1) A n ws eligible bsed on vous cobintions of these sk fctors (4) Hence, the rndoized cohort ws heterogeneous for sk fctors In this chpter we exined dietry ptterns of subgroups bsed on these sk fctors, s well s on body ss, lcohol use, nd sociodeogrphic trits Differences in reported nutent intke were found, prticulrly cross strt of seru cholesterol, BMI, nd lcohol use; for sokers copred with nonsokers; nd (lbeit sll) cross certin ethnic nd sociodeogrphic strt Subgroups bsed on seru cholesterol concentrtion The higher the bseline seru cholesterol concentrtion of the MRFIT en, the lower their reported intke of totl ft, SFA, nd cholesterol (Tble 9) This crosssectionl finding ppers to be opposite tht expected, given extensive evidence tht both dietry SFA nd cholesterol increse seru cholesterol The explntion for this pprent prdox is siple: By the 197s, the generl S popultion hd for yers been exposed to helth eduction concerning reltions ong dietry lipids, seru cholesterol, nd coronry hert disese As consequence, ny dultsespecilly the ore helth conscioushd becoe wre of the sks of hypercholesterolei, hd their blood cholesterol esured, nd reduced their intke of SFA nd cholesterol For people with hypercholesterolei the consequence generlly is tht they shifted downwrd in the popultion distbution of seru cholesterol, but reined in the upper portion of tht distbution, reflecting the interply between environentl nd genetic fctors in detening seru cholesterol concentrtions They lso shifted downwrd in the popultion distbution of dietry SFA nd Downloded fro by guest on 1 oveber 218

15 2425 TILLOTSO El AL TABLE 17 Adjusted en nutent ounts t bseline by body ss index for en in the Multiple Risk Fctor Intervention Tl BMI (kg/2) utent (n < ) 2426 (n 375) 2729 (n 4174) 331 (n 1722) (n ) Slope t P Energy (kcl) (kj) Protein(%ofenergy) <1 Totl ft (% of energy) < 1 SFA (% of energy) < 1 PFA (% of energy) < 1 MFA(%ofenergy) <1 holesterol (g) < 1 holesterol (g/l kcl) < 1 Keys score < 1 rbohydrtes (% of energy) < 1 Strch (% of energy) < 1 Sucrose(%ofenergy) <1 Other (% of energy) Totl fiber (g) Wtersoluble (g) Insoluble (g) Alcohol (% of energy) < 1 ffeine (g) itina(i) (3rotene (;Lg) Retinol (Lg) itin E (g) itin D (g) itin (g) Thiine (g) Riboflvin (g) icin (g) Folic cid (;Lg) itin B6 (g) itin B12 (tg) lciu (g) Phosphorus(g) Potssiu (g) Sodiu (g) < 1 Iron (g) Mgnesiu (g) opper (g) Zinc (g) Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, nd ntihypertensive ediction sttus SFA, sturted ftty cid; PFA, polyunsturted fuy cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2 cholesterol intkes, but in this respect the shift ws often fro iddle to lower levels of the distbution When such chnges tke plce ong enough people in popultion, the result in prevlence survey cn be n inversion of the true reltion This is prticulrly likely when the survey involves not rndo sple of the popultion, but rther, s in MRFIT, group of helthconscious individuls knowingly volunteeng for n intervention tl ied t loweng seru cholesterol, nd selected in prt for their high seru cholesterol concentrtions The soundness of the foregoing explntion in ccounting for the prdoxicl reltion between bseline dietry lipids nd seru cholesterol is indicted by the MRFIT dt, which show tht this phenoenon is deved lrgely fro findings for the subgroup on specil diets t entry, nd the dt showing tht likelihood of being on specil diet ws positively relted to seru cholesterol concentrtion It is further borne out by the fct tht dung the yers of the tl, there ws the expected significnt positive reltion in MRFIT en between reduction in dietry SFA nd cholesterol nd reduction in seru cholesterol (26) Finlly, this explntion is consistent with findings of the Western Electc study (27) uttion dt collection in tht study involved two indepth diet histoes for ll en: the first done t bseline in nd the second done 1 y lter in At bseline, there ws significnt positive reltion between hbitul dietry lipid intke of individul en Downloded fro by guest on 1 oveber 218

16 FOOD AD TRIET ITAKES AT BASELIE 2435, In it n 2,fl t n n r r so in It o L c r O n n O OOO O O O O z I I I I I I I I I O I I i, 1 r fl f o OOOOOOO I I I I I I I I I I c O o 1W F c ir o c o AIII 2 i O _I Q_O #{149} 1r: i 1 O r f O, FJ & : o qo oo n :! o o c r Ir fl \ Q\Q j in fl I o Ifl If _ u _! O ir n c _ o ir o Al O It, : II, _q r,, 9 : g O r r, n I( fl II ro f 5 ;, O _ II rr niro rn O O r i; O O O OO O g t 2 Z i Ltt c i; R & S <,,,,,, I Downloded fro by guest on 1 oveber 218

17 2445 TILLOTSO El AL 1 t 9L oc t #{232} I I I I I I I I i ir?, o L t T I T III liii! B O O F O 11 5 O O E O O O Al II u u? Al : I II II II II II *, o I o o c r t c, \ In 1 o fl O \ / 1 r oo c r, r O n \ so O o c o o c o I( O OO O 1 O 1 c c r o o o O I/ c o O oo ooo in oo r u,, oou, fl i O c I, t I1 r so In oc ro r, oo t v \ _; < O O EO ) QO O I E 5 9_ 2 Downloded fro by guest on 1 oveber O z > tu Z D L, 5 F <> > > : < O

18 FOOD AD TRIET ITAKES Al BASELIE 2455 TABLE 2 Adjusted en percentges of energy in ech food group by percentge of els eten wy fro hoe for en in the Multiple Risk Fctor Intervention Study M els wy fro hoe (%) >5 Food group (n = 1696) (n = 4529) (n = 468) (n = 226) Slope t P % of energy I) Met: low nd ediuft ) Met: highft < 1 3) Diry: lowft < 1 4) Diry: ediuft ) Diry: highft ) Eggs ) Breds nd cerels < 1 8) Fruit < 1 9) egetbles < 1 1) Legues ) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted I ) Fts nd oils: onounsturted ) Fts nd oils: sturted < 1 17) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft ) Sugrs nd sweets: lowft ) Alcoholic beverges Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus nd their seru cholesterol concentrtion However, t 1 y this reltion ws ttenuted, lrgely becuse in the inte en with seru cholesterol concentrtions 3 g/dl in hd decresed their intke of SFA nd cholesterol Both the MRFIT nd the Western Electc findings re exples of n iportnt systetic error tht cn confound nd bis results of studies on reltions between diet nd other vbles, unless specil steps re tken to identify the proble nd control for it This proble exists currently not only for descptive crosssectionl studies on reltions between dietry lipids nd seru lipids in sples fro Aecn nd other helthconscious popultions, but lso for siilr studies on the reltion between slt intke nd blood pressure, becuse reduction in slt use hs lso tken plce differentilly in the popultion on the bsis of blood pressure (28) This proble of systetic error in crosssectionl studies of reltions between nuttionl nd other vbles is over nd bove probles of rndo esureent error in such studies In prticulr, it is seprte fro probles sing fro use of single 24h dietry recll to clssify individuls, with consequent high rtio of intr to intendividul vtion in dietry vbles nd consequent ttenution of correltion nd regression coefficients (4) Both of these probles cn be iportnt sources of difficulty leding to filure to show significnt true ssocitions in crosssectionl surveys Sokers nd nonsokers opred with nonsokers, cigrette sokers in the MR FIT cohort reported higher energy intke, higher percentges of energy fro totl nd sturted fts nd lcohol, greter cholesterol intke, nd lower intkes of fiber, crotene, nd vitin (Tble 15) These differences were generlly grded cross levels of cigrette use, ie, they were gretest for hevy sokers copred with nonsokers Although these differences were odest, they were significnt given the lrge MR FIT sple size Becuse the MRFIT cohort ws selected group of volunteers, it is not possible to stte definitively whether these unfvorble eting hbits pply to Aecn sokers in generl Reports copng dietry hbits of sokers nd nonsokers in the generl S popultion re scrce; soe dt fro the nited Kingdo were published in the 198s [see hpter 14 (29)] Findings re brodly consistent with the MRFIT dt Given the inverse reltion between socioeconoic sttus nd cigrette use, nd dt suggesting tht trends in reduction of dietry sturtes nd cholesterol hve tended to be sller in lower thn higher socioeconoic sttus strt, the finding of ore unfvorble nutent ptterns ong sokers thn nonsokers in is n nticipted one In generl, it is plusible to expect unfvorble lifestyles to cluster, eg, to record ore dverse eting nd dnking ptterns in continuing sokers t tie when knowledge ws lredy widespred bout the helth hzrds of soking The MRFIT expeence is consistent with this inference (29) Becuse cigrette users re t higher sk of such jor diseses s coronry hert disese, stroke, nd lung cncer, it ust be tter of concern for edicl cre nd public helth tht their dietry ptterns further enhnce sk For exple, coronry hert disese sk in sokers is incresed becuse of their higher intkes of SFA nd cholesterol copred with Downloded fro by guest on 1 oveber 218

19 2465 TILLOTSO El AL TABLE 21 Adjusted en nutent ounts t bseline by percentge of els eten wy fro hoe for en in the Multiple Risk Fctor Intervention Tl Energy Mels wy fro hoe (%) >5 utent (n = 1696) (n = 4529) (n = 468) (n = 226) Slope t P (kcl) (Id) Protein (% of energy) Totl ft (% of energy) < 1 SFA (% of energy) < 1 PFA (% of energy) MFA(%ofenergy) <1 holesterol (g) holesterol (g/1 kcl) Keys score < 1 rbohydrtes (% of energy) < 1 Strch (% of energy) < 1 Sucrose (% of energy) Other (% of energy) I < 1 Totl fiber (g) < 1 Wtersoluble (g) < 1 Insoluble (g) < 1 Alcohol (% of energy) ffeine (g) itina(i) (3rotene (Lg) Retinol (Lg) itin E (g) < 1 itin D (g) < 1 itin (g) < 1 Thiine (g) < 1 Riboflvin (g) < 1 icin (g) Folic cid (jig) < 1 itin B6 (g) < 1 itin B12 (pg) lciu (g) < 1 Phosphorus (g) < 1 Potssiu (g) < 1 Sodiu (g) Iron (g) < 1 Mgnesiu (g) < 1 opper (g) Zinc (g) Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2 nonsokers; dditionlly, sokers incresed sk of lung cncer nd other sokingrelted diseses y lso be further ggrvted by their dverse nuttionl puerns (3, 31) Lifestyle counseling of sokers needs to involve not only skillful pproches to xiize soking cesstion, but lso detiled recoendtions concerning eting nd dnking hbits, ied t iniizing the tendency to gin weight with soking cesstion, s well s iproving dietry cro nd icronutent coposition (29) Subgroups bsed on body ss index With its lrge sple size, MRFIT hd gret sttisticl power to explore two longstnding scientific questions confronting nuttion reserch in regrd to obesity: Is there reltion between energy intke nd overweight? Is nutent coposition of the diet relted to overweight? As to the first question, en in five BMI subgroups, rnging fro < 24 to 32, reported siilr djusted intkes of totl energy (Tble 17) This ws the cse both overll nd for en not consuing specil diets t bseline Whtever the precise role of energy intke in contbuting to positive energy blnce underlying weight gin nd obesity, it ws not expressed in higher en energy intkes for strt with greter BMI in this crosssectionl nlysis, which ws bsed on single 24h dietry recll for ech n It is probble tht this ethod is not ppropte: the 24h recll y not estite usul dietry intke of di Downloded fro by guest on 1 oveber 218

20 TABLE 22 FOOD AD TRIET ITAKES Al BASELIE 2475 Adjusted en percentges of energy fro ech food group by reported nuber of lcoholic dnks per week for en in the Multiple Risk Ftor Intervention Tl Dnks/wk Food group (n = 938) 17 (n 4695) 814 (n = 2863) 1521 (n = 227) 22 (n = 23) Slope z P % of energy I) Met:!ow nd ediuft 2) Met: highft 3) Diry: lowft 4) Diry: ediuft 5) Diry: highft 6) Eggs 7) Breds nd cerels 8) Fruit 9) egetbles JO) Legues 11) Bked goods nd desserts: lowft 12) Miscellneous: lowft 13) Miscellneous: cceptble ft 14) Fts nd oils: polyunsturted 15) Fts nd oils: onounsturted 16) Fts nd oils: sturted 17) rckers nd sncks: uncceptble ft 18) Bked goods nd desserts: highft 19) Sugrs nd sweets: lowft 2) Alcoholic beverges Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus Twentyone prticipnts reported not dnking lcoholic beverges by questionnire but reported dnking soe lcoholic beverges on the dietry recll TABLE 23 Adjusted en nutent ounts t bseline by reported nuber of lcoholic dnks per week for en in the Multiple Risk Fctor Intervention Tl Energy utent (n 938) Ii (n 4695) Dnks/wk 814 (n 2863) (n 227) (n 23) < 1 <1 < 1 17 < 1 < < 1 8 < < 1 <1 < 1 Slope t P (kcl) < 1 (Id) Protein (% of energy) < 1 Totl ft (% of energy) < 1 SFA (% ofenergy) <1 PFA (% of energy) < 1 MFA (% ofenergy) <1 holesterol (g) holesterol (gil kcl) < 1 Keys score <1 rbohydrtes (% of energy) <1 Strch(%ofenergy) <1 5ucrose (% of energy) < 1 Other (% of energy) <1 Totl fiber (g) < 1 Wtersoluble (g) < 1 Insoluble (g) < 1 Alcohol (% of energy) < 1 ffeine (g) <1 itin A (I) /3rotene (sg) Retinol (pg) itin E (g) < 1 itin D (g) < 1 itin (g) Thiine (g) < 1 Riboflvin (g) icin (g) < 1 Folic cid (sg) < 1 itin B6 (g) < 1 itin Bl2 (;Lg) lciu (g) Phosphorus (g) < 1 Potssiu (g) Sodiu (g) Iron (g) < 1 Mgnesiu (g) < 1 opper (g) <1 Zinc (g) Downloded fro by guest on 1 oveber 218 Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus Twentyone prticipnts reported not dnking lcoholic beverges by questionnire but reported dnking soe lcoholic beverges on the dietry recll SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2

21 2485 TILLOTSO El AL TABLE 24 Adjusted en percentges of energy fro ech food group by ge for en in the Multiple Risk Fctor Intervention Tl Age (y) Food group 3539 (n = 1981) 444 (n = 2838) 4549 (n 3483) 554 (n = 355) 55 (n = 1 196) Slope z P % of energy 1) Met: low nd ediuft 2) Met: highft 3) Diry: lowft 4) Diry: ediuft 5) Diry: highft 6) Eggs 7) Breds nd cerels 8) Fruit 9) egetbles 1) Legues II) Bked goods nd desserts: lowft 12) Miscellneous: lowft 13) Miscellneous: cceptble ft 14) Fts nd oils: polyunsturted 15) Fts nd oils: onounsturted 16) Fts nd oils: swrted 17) rckers nd sncks: uncceptble ft 18) Bked goods nd desserts: highft 19) Sugrs nd sweets: lowft 2) Alcoholic beverges I I Mens were djusted for rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus TABLE 25 Adjusted en nutent ounts t bseline by ge for en in the Multiple Risk Fctor Intervention Tl utent Energy (kcl) (Id) Protein (% of energy) Totl ft (% of energy) 5FA (% ofenergy) PFA (% of energy) MFA (% ofenergy) holesterol (g) holesterol (g/l kcl) Keys score2 rbohydrtes (% of energy) Strch (% of energy) Sucrose (% of energy) Other (% of energy) Totl fiber (g) Wtersoluble (g) Insoluble (g) Alcohol (% of energy) ffeine (g) itin A (I) rotene (ILg) Retinol (tg) itin E (g) itin D (g) itin (g) Thiine (g) Riboflvin (g) icin (g) Folic cid (sg) itin B6 (g) itin Bl2 (Lg) lciu (g) Phosphorus (g) Potssiu (g) Sodiu (g) Iron (g) Mgnesiu opper (g) Zinc (g) (g) 3539 (n = 1981) (n 2838) Age (y) 4549 (n 3483) (n 355) (n 1 196) I < 1 < < 1 3 < 1 <1 597 < 1 < < 1 4 < 1 37 Slope i P < 1 < < < 1 < 1 < 1 26 < < < 1 <1 < < < 1 < 1 < 1 < 1 < 1 <1 9 < 1 Downloded fro by guest on 1 oveber Mens were djusted for rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2

22 TABLE 26 FOOD AD TRIET ITAKES AT BASELIE 2495 Adjusted en percentges of energy fro ech food group by ethnicity for en in the Multiple Risk Fctor Intervention Tl Ethnic group P for copng White Blck Asin Other P Food group (n = I 1 39) (n = 882) (n 125) (n 237) F (df = 3) B/W A/W /W % of energy I) Met: low nd ediuft < 1 < ) Met: highft < ) Diry: lowft < 1 < ) Diry: ediuft < 1 < 1 < ) Diry: highft < 1 < 1 < ) Eggs < 1 < ) Breds nd cerels < < 1 < 1 8) Fruit < < 1 9) egetbles ) Legues < 1 < < 1 II) Bked goods nd desserts: lowft < ) Miscellneous: lowft < 1 < ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted ) Fts nd oils: onounsturted ) Fts nd oils: sturted < ) rckers nd sncks: uncceptble ft < 1 < ) Bked goods nd desserts: highft < < 1 19) Sugrs nd sweets: lowft < 1 < ) Alcoholic beverges < 1 1 < 1 167, Mens were djusted for ge, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus B, blck; W, white; A, Asin;, other TABLE 27 Adjusted en nutent ounts t bseline by ethnicity for en in the Multiple Risk Fctor Intervention Tl Ethnic group White Blck Asin Other P utent (n ) (n 882) (n 125) (n 237) F (df 3) B/W A/W /W Energy (kcl) < 1 < (Id) Protein (% of energy) Totl ft (% of energy) < < 1 SFA (% ofenergy) < 1 < 1 < 1 <1 PFA (% of energy) MFA (% ofenergy) < <1 holesterol (g) I holesterol (g/l kcl) < 1 < Keys score < 1 53 < 1 < 1 rbohydrtes (% of energy) < < 1 < 1 Strch (% of energy) < < 1 < 1 Sucrose (% ofenergy) < 1 < Other (% of energy) < 1 < 1 < Totl fiber (g) < 1 < Wtersoluble (g) < 1 < Insoluble (g) < 1 < Alcohol (% of energy) < 1 14 < ffeine (g) < 1 < < 1 itin A (l) rotene ()Lg) Retinol (pg) itin E (g) < 1 < itin D (g) 5_ < 1 < 1 < 1 4 itin (g) Thiine (g) < 1 < Riboflvin (g) < 1 < 1 < 1 < 1 icin (g) < 1 < < 1 Folic cid (glg) < itin B6 (g) < 1 < itin Bl2 (pg) lciu (g) < 1 < 1 < 1 6 Phosphorus (g) < 1 < 1 < 1 5 Potssiu (g) < 1 < 1 < 1 39 Sodiu (g) < 1 < Iron (g) < 1 < Mgnesiu (tug) < 1 < 1 5 < 1 opper (g) Zinc (g) < 1 < P for copng Downloded fro by guest on 1 oveber 218, Mens were djusted for ge, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus B, blck; W, white; A, Asin;, other; SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2

23 255 TILLOTSO El AL TABLE 28 Adjusted en percentges of energy fro ech food group by eduction level for en in the Multiple Risk Fctor Intervention Tl Eduction Food group < HS (n = 227) HS (n 2623) Trde Soe college (n 1368) (n = 397) ollege grd (n = 1681) Postgrd (n = 1757) Slope t P % of energy 1) Met: low nd ediuft ) Met: highft < 1 3) Diry: lowft < 1 4) Diry: ediuft < 1 5) Diry: highft < 1 6) Eggs ) Breds nd cerels < 1 8) Fruit 3_ < 1 9) egetbles ) Legues ) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted ) Fts nd oils: onounsturted ) Fts nd oils: sturted ) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft < 1 19) Sugrs nd sweets: lowft < 1 2) Alcoholic beverges <1, Mens were djusted for ge, rce, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus HS, high school; Postgrd, postgrdute TABLE 29 Adjusted en nutent ounts t bseline by eduction level for en in the Multiple Risk Fctor Intervention Tl utent < HS (n 227) HS (n 2623) Trde (n 1368) Eduction Soe college (n 397) ollege grd (n = 1681) Postgrd (n = 1757) Slope t P Energy (kcl) < 1 (kj) Protein (% of energy) Totl ft (% of energy) SFA (% of energy) < 1 PFA (% of energy) < 1 MFA (% of energy) < 1 holesterol (g) holesterol (g/boo kcl) Keys score < 1 rbohydrtes (% of energy) < 1 Strch (% of energy) < 1 Sucrose (% ofenergy) <1 Other (% of energy) <1 Totl fiber (g) Wtersoluble (g) Insoluble (g) Alcohol (% of energy) < 1 ffeine (g) itin A (L) rotene ()Lg) Retinol (eg) itin E (g) 9_i itin D (g) itin (g) < 1 Thiine (g) < 1 Riboflvin (g) < 1 icin (g) <1 Folic cid (Lg) itin B6 (g) itin Bl2 (,Lg) lciu (g) Phosphorus (g) Potssiu (g) Sodiu (g) < 1 Iron (g) Mgnesiu (g) opper (g) Zinc (g) Downloded fro by guest on 1 oveber 218, Mens were djusted for ge, rce, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus HS, high school; Postgrd, postgrdute; SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2

24 FOOD AD TRIET ITAKES AT BASELIE 2515 TABLE 3 Adjusted en percentges of energy fro ech food group by tl sttus for en in the Multiple Risk Fctor Intervention Tl Mtl sttus Difference Mred ot red (red not Foodgroup (n ) (n 141) red) : P % of energy I) Met: low nd ediuft ) Met: highft ) Diry: lowft ) Diry: ediuft ) Diry: highft ) Eggs ) Breds nd cerels < 1 8) Fruit <1 9) egetbles ) Legues II) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted ) Fts nd oils: onounsturted ) Fts nd oils: sturted I 7) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft ) Sugrs nd sweets: lowft ) Alcoholic beverges I Mens were djusted for ge, rce, eduction, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus TABLE 31 Adjusted en nutent ounts t bseline by tl sttus for en in the Multiple Risk Fctor Intervention Tl Mtl sttus Difference Mred ot red (red not utent (n II 143) (n = 141) red) : P Energy (kcl) (Id) Protein (% of energy) Totl ft (% of energy) SFA (% ofenergy) PFA (% of energy) MFA (% of energy) holesterol (g) holesterol (g/l kcl) Keys score rbohydrtes (% ofenergy) Strch (% ofenergy) <1 Sucrose (% of energy) Other (% of energy) < 1 Totl fiber (g) Wtersoluble (g) Insoluble (g) Alcohol (% of energy) ffeine (g) _ < 1 itin A (I) nrotene (;sg) Retinol (pg) itin E (g) itin D (g) itin (g) Thiine (g) Riboflvin (g) icin (g) < 1 Folic cid (Lg) itin B6 (g) itin B12 (sg) lciu (g) Phosphorus (g) Potssiu (g) Sodiu (g) Iron (g) Mgnesiu (g) opper (g) Zinc (g) Downloded fro by guest on 1 oveber 218, Mens were djusted for ge, rce, eduction, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, nuber of life events, BMI, nd ntihypertensive ediction sttus SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted fuy cid 2 Eqution for Keys score given in Tble 2

25 2525 TILLOTSO El AL TABLE 32 Adjusted en percentges of energy fro ech food group by Jenkins Activity Survey (JAS) score for en in the Multiple Risk Fctor Intervention Tl JAS score <1 lto5 StoO OtoS 51 >1 Food group (n 2851) (n 225) (n 262) (n 2128) (n 1712) (n = 1775) Slope t P % of energy I) Met: low nd ediuft ) Met: highft ) Diry: lowft ) Diry: ediuft ) Diry: highft ) Eggs ) Breds nd cerels < 1 8) Fruit ) vegetbles ) Legues ) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted ) Fts nd oils: onounsturted ) Fts nd oils: sturted _S ) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft ) Sugrs nd sweets: lowft ) Alcoholic beverges < 1, Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, nuber of life events, BMI, nd ntihypertensive ediction sttus Higher JAS scores indicte possibly higher coronry diseseprone behvior (2, 3) TABLE 33 Adjusted en nutent ounts t bseline by Jenkins Activity Survey (JAS) score for en in the Multiple Risk Fctor Intervention Tl Energy JAS score < 1 1 to 5 5 to to 5 51 > 1 utent (n = 2851) (n 225) ( 262) (n 2128) (n 1712) (n = 1775) Slope : P (kcl) (Id) Protein (% of energy) Totl ft (% of energy) I SFA (% of energy) PFA (% of energy) MFA (% of energy) holesterol (g) holesterol (g/boo kcl) Keys score rbohydrtes (% of energy) < 1 Strch (% ofenergy) < 1 Sucrose (% of energy) Other (% of energy) Totl fiber (g) Wtersoluble (g) I insoluble (g) Alcohol (% of energy) < 1 ffeine (g) <1 itin A (l) rotene ( eg) Retinol (tg) itin E (g) 9_7 9_ itin D (g) itin (g) I Thiine (g) Riboflvin (g) I 267 icin (g) Folic cid (;g) itin B6 (g) itin B12 (pg) lciu (g) Phosphorus(g) Potssiu (g) < 1 Sodiu (g) [ron (g) Mgnesiu (g) opper (g) Zinc (g) Downloded fro by guest on 1 oveber 218 Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, nuber of life events, BMI, nd ntihypertensive ediction sttus Higher JAS scorns indicte possibly higher coronry disesepne behvior (2, 3) SFA, sturted ftty cid; PFA, polyunsturted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2

26 FOOD AD TRIET ITAKES Al BASELIE 2535 TABLE 34 Adjusted en percentges of energy fro ech food group by nuber of life events for en in the Multiple Risk Fctor Intervention Tl uber of life events Food group (n 2142) (n 384) (n = 359) (n 362) Slope : P % of energy I) Met: low nd ediuft ) Met: highft ) Diry: lowft ) Diry: ediuft ) Diry: highft ) Eggs ) Breds nd cerels ) Fruit 39 3_i ) egetbles ) Legues II) Bked goods nd desserts: lowft ) Miscellneous: lowft ) Miscellneous: cceptble ft ) Fts nd oils: polyunsturted ) Fts nd oils: onounsturted ) Fts nd oils: sturted ) rckers nd sncks: uncceptble ft ) Bked goods nd desserts: highft ) Sugrs nd sweets: lowft < 1 2) Alcoholic beverges Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet sttus, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, BMI, nd ntihypertensive ediction sttus Life events were defined s chnges or probles with helth, work, fily, or other res of life in the previous yer TABLE 35 Adjusted en nutent ounts t bseline by nuber of life events for en in the Multiple Risk Fctor Intervention Tl uber of life events utent (n 2142) (n 384) (n 359) (n 362) Slope : P Energy (kcl) < 1 (Id) Protein (% of energy) Totl ft (% of energy) SFA (% ofenergy) PFA (% of energy) MFA (% ofenergy) holesterol (g) holesterol (g/l kcl) Keys score rbohydrtes (% of energy) Strch (% of energy) Sucrose (% ofenergy) Other (% of energy) Totl fiber (g) < 1 Wtersoluble (g) < 1 Insoluble (g) < 1 Alcohol (% of energy) ffeine (g) itin A (L) rotene (sg) Retinol 4g) itin E (g) < 1 itin D (g) 4_ < 1 itin (g) Thiine (g) Riboflvin (g) icin (g) Folic cid (Lg) itin B6 (g) < 1 itin B12 (pg) lciu (g) < 1 Phosphorus (g) < 1 Potssiu (g) < 1 Sodiu (g) < 1 Iron (g) < 1 Mgnesiu (g) < 1 opper (g) Zinc (g) Downloded fro by guest on 1 oveber 218 Mens were djusted for ge, rce, eduction, tl sttus, cigrettes soked per dy, distolic blood pressure, seru cholesterol, specil diet Stts, els eten wy fro hoe, lcoholic dnks consued per week, Jenkins Activity Survey score, BMI, nd ntihypertensive ediction sttus Life events were defined s chnges or probles with helth, work, fily, or other res of life in the previous yer SFA, sturted ftty cid; PFA, polyunswrted ftty cid; MFA, onounsturted ftty cid 2 Eqution for Keys score given in Tble 2

27 254S TILLOISO El AL TABLE 36 opson of bseline nutent intke in the Multiple Risk Fctor Intervention Tl (MRFIT) with dt fro other studies of iddleged Aecn en, utent DHS y n 1196(7) SDA, 1965, 355 y n 171(8) Fringh, y n 859(11) HAES I, , 4554 y, n 631 MRFIT, , 3557 y n LR y n 1399 (14), HAES II , n 617(12, 13) SDA 1977, 355 y n 784 (9) Energy (kcl) Protein (% of energy) Totl ft (% ofenergy) SFA(%ofenergy) MFA (% ofenergy) PFA (% of energy) holesterol (g) Totl IIO (% ofenergy) Strch (% of energy) Sucrose(%ofenergy) Other HO (% ofenergy) Alcohol (% ofenergy) itin A (I) itin (g) Thiine (g) Riboflvin (g) icin (g) lciu (g) Phosphorus (g) Potssiu (g) Iron (g) DHS, tionl DietHert Study; SDA, S Deprtent of Agculture; HAES, tionl Helth nd uttion Exintion Survey; LR, Lipid Reserch linic; SFA, sturted ftty cid; MFA, onounsturted ftty cid; PFA, polyunsturted ftty cid; HO, crbohydrte For cells tht re blnk, dt were not vilble 2 Listed s percentge of energy fro other viduls with sufficient ccurcy, prticulrly for obese people who tend to underreport the ount of food they consue In contrst with this pprently negtive finding, MRFIT bseline dt yielded ultiple significnt reltions between BMI nd dietry nutent coposition The higher the BMI, the greter the percentges of energy fro dietry lipids nd protein, the greter the dietry cholesterol intke, nd the lower the percentges of energy fro crbohydrtes nd lcohol These findings were recorded both cross the entire cohort, for en consuing specil diets, nd for en not consuing specil diets Men with greter BMIs tended to consue diet of higher energy density thn did en with lower BMIs For ost overweight MRFIT en, the single ost iportnt food source of concentrted energy ws highft et It supplied greter percentge of totl energy (lost 16%) thn ny of the 19 other food groups Agin, it is not possible to sy definitively whether these findings in the selected MRFIT volunteers re representtive of the generl popultion of iddleged Aecn en However, few dt sets re vilble fro other studies, both observtionl nd interventionl, indicting tht energy density of hbitul diets y be fctor influencing energy blnce nd body weight (32) These findings lend support to the public helth recoendtion to reduce intke of totl ft, eg, fro 4% to 3% of energy, becuse highft foods re foods of high energy density They lso lend support to the clinicl recoendtion tht nuttionl counseling ied t sustined control of overweight should ephsize reduced intke of foods of high energy density, prticulrly highft foods lerly, if overweight is generlly ssocited with tendency to ingest greter ounts of such foods, s the MRFIT bseline dt indicte, these recoendtions re prticulrly relevnt The MRFIT finding of direct reltion between BMI nd dietry nutent coposition, prticulrly dietry lipid intke, poses the question of whether this nuttionl spect of overweight reltes to longter sks At lest four prospective popultion studies hve reported significnt reltions between dietry lipid, prticulrly dietry cholesterol, nd longter coronry sk, independent of BMI, seru cholesterol, blood pressure, nd cigrette use (33) oncordnt findings hve been reported by other investigtions (3437) These include dt fro the Atherosclerosis Risk in ounities popultion study showing n independent, direct reltion of dietry cholesterol to crotid wll thickness visulized sonogrphiclly (37) Also, the Western Electc Study found tht level of BMI odified the reltion of dietry cholesterol to longter coronry hert disese sk (38) Subgroups bsed on reported lcohol intke The subgroup with the highest lcohol intke, 22 dnks/ wk, reported higher energy intke (Tble 23) Becuse lcohol is source of energy, lost inevitbly significnt inverse ssocitions were recorded between nuber of dnks consued per week nd percentges of energy fro every cronutent, including ech of the dietry lipids Alcohol consuption nd intke of severl icronutents were lso inversely relted Alcohol intke ws lso inversely relted to cffeine consuption Further, lcohol intke ws directly relted to blood pressure nd to cigrette use, nd to highdensitylipoprotein cholesterol concentrtion These findings generlly gree with results reported in popultion studies involving iddleged en (3954) Evidence is vilble fro soe, but not ll, prospective popultion studies for shped reltion between hbitul lcohol intke nd coronry sk, ie, oderte dnkers (those ingesting 7l4 dnks/wk) y be t lower sk thn both nondnkers nd hevy dnkers (39, 4143, 4547, 49, 54, 55) o consensus exists s to whether this is n etiologiclly Downloded fro by guest on 1 oveber 218

28 FOOD AD TRIET ITAKES Al BASELIE 2555 significnt ssocition Dt fro soe, but not ll, of these studies re confounded by inclusion of exdnkers in the nondnker group, with resultnt bised infltion of sk for nondnkers A ore difficult proble is the ssessent of whether this reltion is confounded by differences between lifetie nondnkers nd oderte dnkers tht relte to longter sks but were not esured in studies done to dte Soe investigtors regrd the reltion s etiologiclly significnt nd hypothesize tht n lcoholrelted, higher highdensity Iipoprotein concentrtion is the echnis ccounting for lower coronry hert disese rtes in oderte dnkers copred with nondnkers (56) To our knowledge, little hs been wtten bout the possibilityposed by the nuttionl dt fro MRFIT nd other studies with siilr findingstht lower rtes of coronry hert disese in oderte dnkers y be due to their lower intke of totl ft, SFA, nd cholesterol, with consequent etbolic effects beyond ny influence on seru totl cholesterol (33) Also, little hs been reported on possible resons for the incresed crdiovsculr sk of hevy dnkers, including the dverse influences of lcohol on their blood pressure, their greter use of cigrettes, nd indequcies in their diets Although 16% of the MRFIT cohort reported consuing 22 dnks/wk t bseline (for this subgroup, lcohol provided 15% of totl energy), distbution of lcohol use ws truncted by the tl recruitent procedure, which included detiled esures to identify nd exclude proble dnkers nd hbitul consuers of lrge ounts of lcohol Subgroups bsed on percentge of els eten wy fro hoe Although n exclusion cteon for nuber of els eten wy fro hoe ws pplied t the second screening visit (1), onehlf of prticipnts rndoly ssigned into the study reported eting 3% of els wy fro hoe; 18% stted they te 5% of els wy Significnt positive reltions existed between frequency of els eten wy fro hoe nd percentge of energy fro totl ft, SFA, MFA, nd lcohol (Tble 2 1 ) This vble ws lso relted positively to dily intke of cholesterol, nd inversely to percentge of energy fro totl crbohydrte, strch, nd siple crbohydrtes other thn sucrose, to fiber intke, nd to intke of severl icronutents Although these differences cross subgroups were not lrge, they highlight specil conteporry proble, ie, iproving eting ptterns for those eting high percentge of els wy fro hoe As noted in hpter 3 (1), the MRFIT nuttion intervention progr for SI en ttepted to del with this proble SI prticipnts were given extensive counseling on how to enjoy eting wy fro hoe while following MRFIT dietry recoendtions Subsequent chpters of this onogrph give dt on reltions between this vble nd reported dherence to these recoendtions nd chnges chieved in dietry nutent coposition Abundnt dt re vilble showing tht eting out is cornon ong virtully ll strt of the S popultion urrently, sizble proportion of els eten wy fro hoe is consued in fst food resturnts, prticulrly by people of lower socioeconoic strt The food choices in these estblishents re generlly high in energy density, totl ft, SFA, cholesterol, nd slt (57) Therefore, ss eting in fst food resturnts nd the nture of the fre in these resturnts re key chllenges for ipleenting recoendtions for iproved eting ptterns in the S popultion Ethnic subgroups utent intke ptterns were brodly siilr cross the four ethnic groups identified in the MRFIT cohort (Tble 26) Thus, there ws nrrow rnge in subgroup ens for percentge of energy fro totl ft, SFA, MFA, nd PFA, reflecting coonlity of Aecn eting ptterns onetheless, there were significntlbeit slldifferences ong these subgroups, including for blcks copred with whites nd for Asins copred with whites These involved ost food groups, ost cronutents, nd severl icronutents It is likely tht ny of these differences re not idiosyncrtic to the MRFIT cohort, but rther reflect differences in eting ptterns existent in in S ethnic strt Do these differences relte to known differentil ptterns of blood pressure distbution (eg, between blcks nd whites) or to differentil ptterns of crdiovsculr sk? Although it sees useful t lest to pose such questions here, review of the literture nd discussion of the re beyond the scope of this onogrph Subgroups bsed on eductionl ttinent Dt hve been reported fro other studies indicting tht fvorble chnges in lifestyles nd in lifestylerelted sk fctors (ie, in eting, soking, nd exercise hbits, nd in seru cholesterol concentrtions) hve been greter in recent decdes ong oreeducted thn ong lesseducted Aecns (21, 23, 32) For dietry lipid intke, MRFIT findings were to degree concordnt, eg, with higher eductionl ttinent, percentge of energy fro SFA ws lower nd tht fro PFA ws higher (Tble 29) However, differences were sll, nd in other respects the pttern ws not consistent Thus, cholesterol intke per 1 kcl ws not significntly relted to eduction level Also, over the rnge of eductionl level, proportion of energy fro lcohol ws progressively nd substntilly higher, nd intke of totl crbohydrte nd strch lower This coplex pttern of cronutent intke cross eductionl subgroups reflected coplex nd contrdictory differences in ptterns of food group selection iewed overll, these dt suggest tht by the coronry prevention essge hd only to liited, prtil, nd inconsistent degree greter effect on eting behvior of iddleged Aecn en of higher eduction copred with those of lower eduction Agin, cution is clled for in giving credence to ny such generliztion, given tht the MRFIT cohort ws group of volunteers selected in specil wy nd not sple of the generl popultion OLSIOS Men dietry intke dt collected t bseline in MRFIT were coprble with dt collected in HAES I nd II, conducted fro 1971 to 1974 nd fro 1976 to 198, respectively, on rndo sples of iddleged Aecn en On the bsis of verge nutent intke dt, it ppers tht MRFIT prticipnts reported dietry intkes typicl of conteporry Aecn dietry ptterns nd were therefore ppropte for recruitent into the tl Men intkes of icronutents were lso coprble with intkes reported in surveys conducted in Downloded fro by guest on 1 oveber 218

29 256S TILLOISO El AL the 197s opred with dt collected by popultion studies nd tls in the lte 195s nd 196s, however, MRFIT prticipnts reported lower intkes of totl ft, SFA, MFA, nd dietry cholesterol, nd higher intke of PFA, possibly reflecting both generl popultion trends nd higher helth consciousness REFEREES 1 Dolecek TA, Stler J, ggiul AW, Tillotson JL, Buzzrd IM hpter 3 Methods of dietry nd nuttionl ssessent nd intervention nd other ethods in the Multiple Risk Fctor Intervention Tl In: Stler J, ggiul AW, utler JA, et l, eds Dietry nd nuttionl ethods nd findings: the Multiple Risk Fctor Intervention Tl (MRFIT) A J lin utr l997;65(suppl): 196S2lOS 2 Zyznski ST Jenkins D Bsic diensions within the coronryprone behvior pttern J hronic Dis l97;22: Jenkins D, Zyznski ST Rosenn RH Progress towrd vlidtion of coputerscored test for the type A coronryprone behvior pttern Psychoso Med 1971 ;33: Grndits GA, Brtsch GE, Stler J hpter 4 Method issues in dietry dt nlyses in the Multiple Risk Fctor Intervention Tl In: Stler J, ggiul AW, utler JA, et l, eds Dietry nd nuttionl ethods nd findings: the Multiple Risk Fctor Intervention Tl (MRFIT) A J lin utr l997;65(suppl):2l Keys A, Anderson if, Grnde F Seru cholesterol response to chnges in the diet Metbolis 1965;14: Stler J, ggiul AW, Grndits GA hpter 12 Reltion of body ss nd lcohol, nutent, fiber, nd cffeine intkes to blood pressure in the specil intervention nd usul cre groups in the Multiple Risk Fctor Intervention Tl In: Stler J, ggiul AW, utler JA, et l, eds Dietry nd nuttionl ethods nd findings: the Multiple Risk Fctor Intervention Tl (MRFI F) A J lin utr l997;65(suppl):338s65s 7 tionl DietHert Study Reserch Group The tionl DietHert Study finl report ircultion 1968;37(suppl I): S Deprtent of Agculture Household Food onsuption Survey Food nd nutent intke of individuls in the nited Sttes, spng 1965 Wshington, D: S Deprtent of Agculture, 1972 (Report 11) 9 S Deprtent of Agculture tionwide Food onsuption Survey utent intkes: individuls in 48 sttes, yer Hyttsville, MD: S Deprtent of Agculture, 1984 (Report 12) 1 S Deprtent of Agculture tionwide Food onsuption Survey ontinuing Survey of Food Intkes by Individuls Men 195 yers, 1 dy, 1985 Hyttsville, MD: S Deprtent of Agculture, 1986 (Report 853) 11 Knnel WE, Gordon T, eds The Fringh Studyn epideiologicl investigtion of crdiovsculr disese The Fringh Diet Study: diet nd the regultion of seru cholesterol Wshington, D: S Deprtent of Helth, Eduction nd Welfre, Public Helth Service, tionl Institutes of Helth, Block G, Dresser M, Hrtn AM, rroll MD utent sources in the Aecn diet: quntittive dt fro the HAES II survey I itins nd inerls A J Epideiol l985;l22:l Block G, Dresser M, Hrtn AM, rroll MD utent sources in the Aecn diet: quntittive dt fro the HAES II survey II Mcronutents nd fts A J Epideiol l985;l22: The Lipid Reserch linics popultion studies dt book ol II The prevlence studynutent intke Bethesd, MD: tionl Institutes of Helth, 1982 (IH publiction no 82214) 15 Food nd uttion Bord, tionl Reserch ouncil Recoended dietry llownces 9th ed Wshington, D: tionl Acdey Press, Food nd uttion Bord, tionl Reserch ouncil Recoended dietry llownces 1 ed Wshington, D: tionl Acdey Press, S Bureu of the ensus Sttisticl bstrct of the nited Sttes: 199 (1 1th edition) Tble 22,23,25 Wshington, D: S Bureu of the ensus, 199: S Bureu of the ensus Sttisticl bstrct of the nited Sttes: 1992 (1 12th edition) Tbles 25, 26, 28 Wshington, D: S Bureu of the ensus, 1992: Stler J In reply [to Popkin BM] Arch Intern Med 1994; 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