(2003) 17, 623 630 & 2003 Nture Publishing Group All rights reserved 0950-9240/03 $25.00 www.nture.com/jhh 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 40 59 yers per smpleftotl N ¼ 4680. 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, 623 630. doi:10.1038/sj.jhh.1001605 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 40 59 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 1997 1999 from 17 popultion smples diverse in ethnic nd sociodemogrphic bckground in the four countries (three Chinese, four Jpnese, two UK,
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 40 49 nd 50 59 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 40 59 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 48.1 49.6 nd 48.6 49.2 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 5.9 7.0%, with omeg-3 polyunsturted ftty
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 574 416 266 1103 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 571 423 235 1092 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) 2278 428 2347 532 2470 635 2609 694 Totl protein (%kcl) 15.8 2.3 12.6 2.0 15.6 3.2 15.5 3.2 Animl protein (%kcl) 8.9 2.5 2.8 2.6 9.5 3.4 10.2 3.3 Vegetble protein (%kcl) 6.9 1.1 9.8 1.4 6.1 1.4 5.0 1.5 Totl ft (%kcl) 23.7 4.8 20.5 6.2 33.0 6.5 33.3 6.7 SFA (%kcl) 6.1 1.6 5.2 2.0 12.0 3.4 10.8 2.8 MFA (%kcl) 8.6 2.1 8.3 2.8 11.2 2.5 12.4 2.8 PFA (%kcl) 6.2 1.5 5.9 2.2 6.4 1.9 7.0 2.2 Omeg-3 PFA (%kcl) 1.3 0.4 0.6 0.4 0.7 0.3 0.7 0.3 Omeg-6 PFA (%kcl) 4.8 1.3 5.4 2.2 5.6 1.8 6.3 2.1 Trns FA (%kcl) 0.3 0.2 0.2 0.4 1.6 4.1 2.0 0.8 Cholesterol (mg/dy) 446 175 218 201 299 145 348 176 Cholesterol (mg/1000 kcl) 195 67 94 86 120 48 133 59 Keys dietry lipid score 28.7 5.9 18.8 10.2 39.9 11.3 36.6 9.7 PFA/SFA 1.1 0.3 1.3 0.6 0.6 0.3 0.7 0.3 Totl vilble crb. (%kcl) 52.3 7.7 61.8 11.5 46.6 7.2 48.4 8.1 Strch (%kcl) 35.5 8.0 54.3 11.5 25.8 5.3 22.5 5.7 Totl fibre (g/dy) 15.5 4.8 30.5 9.9 29.1 9.8 21.5 8.5 Estimted totl sugrs (%kcl) 15.8 3.9 7.1 4.6 17.9 5.2 24.3 8.0 Alcohol (%kcl) 8.2 7.2 5.1 8.0 4.7 6.1 2.7 4.8 Energy (kcl/dy) 1798 325 1733 443 1827 419 1876 474 Totl protein (%kcl) 16.1 2.3 12.2 1.8 16.1 3.1 15.6 3.2 Animl protein (%kcl) 8.8 2.4 2.2 2.1 10.1 3.1 10.1 3.2 Vegetble protein (%kcl) 7.3 1.1 10.1 1.2 6.1 1.4 5.3 1.6 Totl ft (%kcl) 26.1 4.9 19.5 6.0 32.5 6.5 32.6 7.1 SFA (%kcl) 7.1 1.8 4.8 2.1 12.2 3.3 10.6 2.9 MFA (%kcl) 9.4 2.2 7.8 2.8 10.8 2.4 12.0 3.0 PFA (%kcl) 6.6 1.4 5.7 2.2 6.1 1.8 6.9 2.2 Omeg-3 PFA (%kcl) 1.4 0.4 0.5 0.4 0.7 0.2 0.8 0.3 Omeg-6 PFA (%kcl) 5.2 1.3 5.2 2.1 5.4 1.7 6.3 2.0 trns FA (%kcl) 0.5 0.3 0.2 0.3 1.3 0.6 1.9 0.8 Cholesterol (mg/dy) 359 139 146 152 220 105 244 121 Cholesterol (mg/1000 kcl) 199 67 84 85 121 49 130 58 Keys dietry lipid score 31.1 6.5 17.2 10.6 40.8 10.6 35.9 9.8 PFA/SFA 1.0 0.3 1.4 0.6 0.6 0.2 0.8 0.3 Totl vilble crb. (%kcl) 56.2 6.4 68.1 6.8 48.3 6.8 50.5 8.0 Strch (%kcl) 35.6 6.5 58.6 8.4 25.1 4.9 23.0 5.6 Totl fibre (g/dy) 15.8 4.8 26.1 8.5 21.4 6.4 16.7 6.4 Estimted totl sugrs (%kcl) 19.3 4.2 8.9 5.0 20.2 5.8 25.7 7.3 Alcohol (%kcl) 1.5 3.2 0.2 0.9 3.0 4.8 1.3 3.4 SFA, sturted ftty cids; MFA, monounsturted ftty cids; PFA, polyunsturted ftty cids; FA, ftty cids. 1.35 (2 SFA PFA)+1.5 CHOL 1/2, where CHOL is dietry cholesterol in mg/1000 kcl.
626 cid (PFA) higher for Jpnese (1.3 1.4%) thn others (0.5 0.8%). Owing to lower SFA for Asin smples, PFA/SFA rtio for Asin smples ws higher thn for Western smples (1.1 1.4 compred to 0.6 0.8). 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 2.2 3.1 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 28 40 mg/dy, compred to 77 191 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 427 555 for men nd 319 425 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) 4843 1302 5633 2454 3702 1180 4202 1436 Urinry N (mmol/dy) 211 57 245 107 161 51 183 62 Urinry K (mg/dy) 1920 519 1506 506 2912 852 2512 839 Urinry K (mmol/dy) 49.2 13.3 38.6 13.0 74.7 21.9 64.4 21.5 Urinry N/K (mmol/mmol) 4.5 1.3 6.8 3.0 2.3 0.9 3.1 1.2 Dietry C (mg/dy) 605 224 356 150 1013 354 882 402 Dietry Mg (mg/dy) 288 68 348 117 360 97 364 115 Dietry Fe (mg/dy) 11.4 3.0 18.4 5.9 14.8 4.4 19.4 7.8 Dietry Se (mcg/dy) 191 79 40 14 110 41 153 78 Dietry P (mg/dy) 1232 285 1000 306 1556 439 1488 454 Urinry N (mg/dy) 4278 1221 4839 2084 2929 913 3272 1110 Urinry N (mmol/dy) 186 53 210 91 127 40 142 48 Urinry K (mg/dy) 1891 541 1475 488 2378 582 1982 697 Urinry K (mmol/dy) 48.5 13.9 37.9 12.5 61.0 14.9 50.8 17.9 Urinry N/K (mmol/mmol) 4.1 1.2 6.0 2.7 2.2 0.8 3.1 1.3 Dietry C (mg/dy) 607 219 256 115 843 246 699 313 Dietry Mg (mg/dy) 250 58 271 100 276 67 273 87 Dietry Fe (mg/dy) 9.9 2.5 13.5 4.4 11.1 3.0 14.4 5.1 Dietry Se (m g/dy) 151 63 28 10 77 25 109 37 Dietry P (mg/dy) 1037 243 762 258 1209 279 1100 329
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) 2859 1918 2667 2229 2375 1899 4025 3754 Retinol (mg/dy) 427 899 125 215 553 542 510 581 Vitmin A (IU/dy) 6187 4284 4865 3796 5801 3654 8420 6641 Vitmin C (mg/dy) 126 81 80 41 87 56 121 85 Vitmin E (mg/dy) 10.4 3.0 12.4 5.0 11.2 5.1 11.4 5.4 b-crotene (mg/dy) 3100 2106 2210 1868 2018 1451 3858 3785 Retinol (mg/dy) 319 428 71 109 374 294 425 464 Vitmin A (IU/dy) 6229 3720 3921 3157 4611 2566 7860 6618 Vitmin C (mg/dy) 132 71 75 40 85 53 100 65 Vitmin E (mg/dy) 9.6 3.4 9.3 3.8 8.0 3.4 8.6 4.2 -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. 4 17 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), 18 20 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 1970. 21 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
Nutrient intkes of middle-ged men nd women 628 Tble 5 CHD nd stroke mortlity rte ge-stndrdized, 1970, men nd women ged 35 74 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 385 141 180 120 Coronry hert disese 47 Not vilble for entire PRC popultion 164 240 252 Stroke 225 113 158 90 Age-stndrdized rte per 100 000 popultion. b Englnd nd Wles. c Scotlnd. Tble 6 CHD nd stroke mortlity rte ge-stndrdized, 1994 1998, men nd women ged 35 74 yers by country Cuse of deth Jpn 1997 PR Chin 1994 UK 1997 US 1998 Coronry hert disese 57 54 100 b 267 c 349 d 202 Stroke 79 230 251 57 80 42 Coronry hert disese 20 36 69 96 139 84 Stroke 41 151 170 44 59 33 Rurl. b Urbn. c Englnd nd Wles. d Scotlnd. nonftl myocrdil infrction plus CHD deth were 86 per 100 000 per yer for Chinese (Beijing) men ged 35 64 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 35 64 yers were 33, 174 nd 269, 116. 22 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
Nutrient intkes of middle-ged men nd women Tble 7 CHD CVD risk fctor level erly 1990s, men nd women ged 35 64 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 174 228 236 209 Systolic BP (mmhg) 131 135 133 129 Smoking (%) 64 29 41 23 BMI (kg/m 2 ) 24.1 26.3 26.8 26.9 Serum cholesterol (mg/dl) Not vilblefno MONICA smple 174 228 236 205 Systolic BP (mmhg) 130 129 126 119 Smoking (%) 9 25 41 19 BMI (kg/m 2 ) 24.5 25.6 26.9 26.6 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- HL50490-06 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. 090357003), 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: 591 608. 2 Dennis B et l. for the INTERMAP Reserch Group. INTERMAP: the dietry dtfprocess nd qulity control. J Hum Hypertens 2003; 17: 609 622. 3 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: 395 408. 4 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 25 88.
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