JACC
HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK
QUICK SEARCH:   [advanced]


     

J Am Coll Cardiol, 2002; 39:49-56
© 2002 by the American College of Cardiology Foundation
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Liu, S.
Right arrow Articles by Manson, J. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Liu, S.
Right arrow Articles by Manson, J. E.

CLINICAL STUDY

A prospective study of dietary fiber intake and risk of cardiovascular disease among women

Simin Liu, MD, ScD*||,*, Julie E. Buring, ScD*{ddagger}§, Howard D. Sesso, ScD*§, Eric B. Rimm, ScD{dagger}§||, Walter C. Willett, MD, DrPH{dagger}§|| and JoAnn E. Manson, MD, DrPH*{dagger}§

* Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
{dagger} Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
{ddagger} Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts, USA
§ Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
|| Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA

Manuscript received March 19, 2001; revised manuscript received September 10, 2001, accepted September 10, 2001.

* Reprint requests and correspondence: Dr. Simin Liu, Division of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Avenue East, Boston, Massachusetts 02215, USA.
simin.liu{at}channing.harvard.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
OBJECTIVES: This study was designed to examine the hypothesis that higher intake of dietary fiber is inversely related to the risk of cardiovascular disease (CVD) and myocardial infarction (MI) in a large prospective cohort of women.

BACKGROUND: Although dietary fiber has been suggested to reduce the risk of coronary disease, few prospective studies have examined the association between the types and amounts of dietary fiber and CVD risk, particularly among women.

METHODS: In 1993, we used a semi-quantitative food frequency questionnaire to assess dietary fiber intake among 39,876 female health professionals with no previous history of CVD or cancer. Women were subsequently followed for an average of six years for incidence of nonfatal MI, stroke, percutaneous transluminal coronary angioplasty, coronary artery bypass graft or death due to CVD confirmed by medical records or death certificates.

RESULTS: During 230,006 person-years of follow-up, 570 incident cases of CVD were documented, including 177 MIs. After adjustment for age and randomized treatment status, a significant inverse association was observed between dietary fiber intake and CVD risk. Comparing the highest quintile of fiber intake (median: 26.3 g/day) with the lowest quintile (median: 12.5 g/day), the relative risks (RR) were 0.65 (95% confidence interval [CI]: 0.51, 0.84) for total CVD and 0.46 (95% CI: 0.30, 0.72) for MI. Additional adjustment for CVD risk factors reduced the RRs to 0.79 (95% CI: 0.58, 1.09) for total CVD and 0.68 (95% CI: 0.36, 1.22) for MI. The inverse trends across categories generally remained, although they were no longer statistically significant. Inverse relations were observed between both soluble and insoluble fiber and risk of CVD and MI, and among those who had never smoked and those with body mass index <25.

CONCLUSIONS: A higher intake of dietary fiber was associated with a lower risk of CVD and MI, although the association was not statistically significant after further adjusting for multiple confounding factors. Nevertheless, these prospective data generally support current dietary recommendations to increase the consumption of fiber-rich whole grains and fruits and vegetables as a primary preventive measure against CVD.

Abbreviations and Acronyms
  BMI
  body mass index
  CABG
  coronary artery bypass graft
  CI
  confidence interval
  CVD
  cardiovascular disease
  FFQ
  food frequency questionnaire
  MI
  myocardial infarction
  RR
  relative risk or rate ratio (hazard ratio)
  SFFQ
  semiquantitative food frequency questionnaire
  WHS
  Women’s Health Study

Dietary fiber refers to a variety of plant-based non-starch polysaccharides and lignins that are resistant to human digestion. Evidence from several epidemiologic studies suggests a strong inverse association between intake of dietary fiber and risk of coronary disease, with high intake associated with 20% to 40% reductions in risk (1–10). Experimental studies demonstrate that increased intake of dietary fiber reduces plasma cholesterol. However, a meta-analysis of 67 trials involving 2,990 participants indicates that 1 g of soluble fiber lowers low-density lipoprotein (LDL) cholesterol by 2.2 mg/dl. This effect was observed mainly among dyslipidemic patients for intakes two to three times the general recommended daily intake (20 to 25 g) (11). Such a modest effect on serum cholesterol cannot account for the substantial reductions in coronary risk observed in epidemiologic studies. Moreover, in the only randomized intervention study designed to examine whether increased intake of dietary fiber reduces the risk of myocardial infarction (MI) (12), patients with existing coronary heart disease advised to increase fiber intake did not have lower reinfarction rates over a two-year follow-up period.

Different types or sources of dietary fiber may vary in their physiologic effects. For example, soluble fiber may be primarily responsible for the cholesterol-lowering effect of dietary fiber (11), and insoluble fiber may reduce risk by slowing intestinal absorption of foods or by reducing clotting factors (13). However, a comprehensive evaluation of the effects of different types of fiber has not been conducted in most previous studies. To examine the hypothesis that a greater intake of dietary fiber reduces risk of cardiovascular disease (CVD) or MI, we used prospective data from the Women’s Health Study (WHS) over a six-year period to assess the relationship between total dietary fiber, soluble and insoluble fiber, and fiber sources on risk of CVD or MI.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Study population.   The WHS is a randomized, double-blind, placebo-controlled trial designed to evaluate the balance of benefits and risks of low-dose aspirin and vitamin E in the primary prevention of CVD and cancer among 39,876 female health professionals who were without heart disease, stroke or cancer (other than non-melanoma skin cancer) at baseline. Detailed information on diet was provided by 39,310 (99%) of the randomized participants, who completed a semi-quantitative food frequency questionnaire (SFFQ) at baseline in 1993 (14). We further excluded those subjects with more than 70 blanks in their SFFQ and with energy intake <2,514 kJ (600 kcal) or >14,665 kJ (3,500 kcal), leaving a final sample of 38,480 (96%) for the current analysis.

Assessment of dietary fiber intake.   A validated 131-item SFFQ was administered to all participants. For each food, a standard unit or portion size was specified, and participants were asked how often, on average, during the previous year they had consumed that amount. Nine responses were possible, ranging from "never" to "six or more times per day." In addition to the structured questions on food intake, participants also reported the specific brands and types of cold breakfast cereals they commonly used. Dietary fiber intake was computed by multiplying the frequency of consumption of each food item by the fiber content of the specific portions, accounting for the type and brand of breakfast cereal. The dietary fiber content of foods was obtained from the Harvard Food Composition Database, which is derived from US Department of Agriculture sources (15) and from manufacturers using the Association of Official Analytical Chemists’ method (16–18). We adjusted fiber intake for total energy intake using the residual method (19). In populations of nurses and health professionals, this SFFQ has demonstrated reasonably good validity as a measure of long-term average dietary intakes (20–22). The Pearson correlation coefficient between total dietary fiber assessed by SFFQ and diet records was 0.60 (10).

Outcomes.   The primary end point for this analysis was incident CVD, which included MI, stroke, percutaneous transluminal coronary angioplasty, coronary artery bypass graft (CABG) and fatal CVD that occurred during the six-year period between the return of the 1993 questionnaire and March 31, 2000. Diagnoses were confirmed by a committee of cardiologists and one neurologist. For MI, we used criteria proposed by the World Health Organization: symptoms plus either typical electrocardiographic changes or elevation of cardiac enzymes (23). A diagnosis of stroke was made if the patient had a new neurologic deficit lasting more than 24 h, computed tomography or magnetic resonance imaging scans were available in the majority of cases. Reported percutaneous transluminal coronary angioplasty or CABG was confirmed by hospital records. Cardiovascular deaths were confirmed through medical records, autopsy reports and death certificates. Mortality follow-up was virtually 100% complete.

Data analysis.   Each participant accumulated follow-up time beginning at baseline and ending in the month of diagnosis of a CVD end point or censoring (death from causes other than CVD, percutaneous transluminal coronary angioplasty or CABG, or March 2000, whichever came first). We considered dietary fiber intake as both a continuous variable (g/day) and a categorical variable (in quintiles). We calculated incidence rates of CVD for five categories of dietary fiber intake at baseline by dividing the number of incident cases by the person-years of follow-up. The rate ratio was then calculated by dividing the rate among women in each specific intake quintile by the rate among women in the lowest quintile of intake (reference). We used Cox proportional-hazards models to estimate the rate ratios (described as relative risks, RRs) and 95% confidence interval (CI) of developing CVD, adjusting for age (in years); smoking; exercise; alcohol intake; use of postmenopausal hormones; body mass index (BMI, kg/m2); use of multivitamin or vitamin C supplements; history of hypertension, high cholesterol or diabetes mellitus; parental history of MI before age 60; dietary variables including total energy intake and randomized assignments. Tests of linear trend across increasing quintiles of dietary fiber intake were conducted by assigning the medians of intakes in quintiles (servings/day) treated as a continuous variable.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
At baseline, women with higher dietary fiber intake were older, were less likely to be current smokers and were more likely to exercise, use postmenopausal hormones, use supplements of multivitamins or vitamin C or have a history of high cholesterol than women with low dietary fiber intake. High fiber intake was also associated with a lower BMI (Table 1). History of diabetes, history of hypertension and parental history of MI before age 60 did not differ significantly across quintiles of intake.


View this table:
[in this window]
[in a new window]
  		Table 1 Baseline Distributions of Cardiovascular Risk Factors According to Quintiles of Energy-Adjusted Dietary Fiber Intake

 
There was an approximately 1.5-fold difference in total dietary fiber intake between the highest and lowest quintiles of the study population (median: 26.3 g/day in the highest quintile vs. 18.2 g/day in the lowest quintile) (Table 1). Women in the highest quintile of dietary fiber had a lower intake of total and saturated fats and a lower dietary glycemic index (a measure of carbohydrate quality), but a higher intake of dietary protein, carbohydrate and folate than women who consumed less fiber. Table 2 describes the correlations between different types and sources of dietary fiber. All the fiber fractions were correlated with each other, and a particularly strong correlation was observed for soluble and insoluble fibers (r = 0.80, p < 0.001) (Table 2). In general, dietary fiber intake was positively associated with intake of whole-grain products but inversely associated with intake of refined-grain products.


View this table:
[in this window]
[in a new window]
  		Table 2 Energy-Adjusted Correlations Among Different Types and Sources of Dietary Fiber

 
During an average of six years of follow-up (230,006 person-years), 570 incident cases of CVD were confirmed. A significantly smaller number of CVD cases occurred in the highest quintile of intake than in the lowest quintile of intake (99 cases vs. 140 cases) (Table 3). The age and randomized treatment-adjusted RR of CVD was 0.65 (95% CI: 0.51, 0.84; p for linear trend = 0.001) comparing the highest and lowest quintiles. In multivariate models, smoking was the strongest confounding factor. A similar but attenuated trend was observed after adding smoking to the model (RR: 0.82; 95% CI: 0.63, 1.07) and after adjustment for known CVD risk factors and dietary variables including folate, fat, protein and total energy intake (RR: 0.79; 95% CI: 0.57, 1.09) (Table 3). After adjustment for the same covariates and considering dietary fiber intake as a continuous variable, the relative risk of CVD was 0.83 (95% CI: 0.69, 1.01) for each 10-g increment in daily intake of dietary fiber. The magnitude of the inverse relationship between dietary fiber intake and MI risk was stronger than that between fiber intake and CVD risk (Table 4). Compared with the lowest quintile of intake, the age- and treatment-adjusted RR of MI for the highest quintile of intake was 0.46 (95% CI: 0.30, 0.72; p for linear trend = 0.0005). As with CVD, an inverse though no longer statistically significant trend was observed after further adjustment for known CVD risk factors and dietary variables (for highest vs. lowest quintile, RR: 0.68; 95% CI: 0.39, 1.22; p for trend = 0.13).


View this table:
[in this window]
[in a new window]
  		Table 3 Adjusted Relative Risk (95% CI) of CVD* According to Quintiles of Dietary Fiber Intake, the Women’s Health Study, 1993–1999

 

View this table:
[in this window]
[in a new window]
  		Table 4 Adjusted Relative Risk (95% CI) of MI According to Quintiles of Dietary Fiber Intake, the Women’s Health Study, 1993–1999

 
We further examined the relations of specific types of fiber with risk of CVD or MI. Overall, insoluble fiber and its subfractions (lignin and cellulose) were more strongly associated with a reduced risk of CVD or MI than was soluble fiber. The multivariate RRs comparing two extreme quintiles of insoluble fiber intake were 0.78 (0.57 to 1.06) for CVD risk (Table 3) and 0.74 (0.42 to 1.30) for MI risk (Table 4). However, neither of these inverse trends was statistically significant at the conventional p = 0.05 level.

Diabetes, hypertension, hypercholesterolemia and other high-risk conditions for CVD such as obesity and cigarette smoking may lead to changes in dietary fiber intake and may thus bias the association between dietary fiber intake and CVD risk (14,24,25). To better control for information bias and confounding, we examined the association between dietary fiber intake and CVD risk in three subgroups of the cohort: 1) participants who reported no history of hypertension, hypercholesterolemia or diabetes at baseline; 2) those with BMI <25 and 3) never smokers. Overall, the inverse association between dietary fiber intake and CVD risk became stronger in these subgroups, and statistically significant for women who never smoked or who had a BMI <25 (Table 5).


View this table:
[in this window]
[in a new window]
  		Table 5 Adjusted Relative Risk (95% CI) of CVD* According to Quintiles of Dietary Fiber Intake Among Subgroups of Women, the Women’s Health Study, 1993–1999

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
In this six-year prospective cohort of female health professionals ≥45 years, we found a modest but not statistically significant inverse association between intake of dietary fiber intake and risk of CVD. This inverse association appeared to be stronger for MI than for overall CVD, and was also stronger among those who were not overweight or who were never smokers.

Dietary fiber and coronary heart disease.   These results are generally consistent with those of other studies evaluating the association between dietary fiber intake and risk of coronary heart disease (1–10). Several of these studies found an approximate 10% to 30% reduction in risk associated with an increment of 10 g/day of intake. In the Health Professionals Follow-up Study, with 734 cases of MI among 43,757 men followed for six years, a 19% reduction in MI risk associated with a 10 g increase in dietary fiber intake was observed (7). In the Nurses’ Health Study, Wolk et al. (10) followed 68,782 women for 10 years and found an identical relative risk of 0.81, but with much narrower 95% confidence interval. In the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study, Pietinen and colleagues followed 21,930 male Finnish smokers for six years and reported a significant reduction in both coronary morbidity and mortality associated with increased intake of dietary fiber (8). In all three of those studies, a stronger association was observed between cereal fiber and CHD risk than between vegetable or fruit fiber and CHD risk. We observed a similar inverse association between total dietary fiber intake and CVD risk, but did not observe an inverse trend for cereal fibers (Table 3). However, cautions need to be exercised when interpreting results for types of fiber, given the high correlation between types of dietary fibers. Moreover, the composition data regarding types of fiber are sparse and vary from different sources because the methodology used to characterize various fiber fractions remains to be standardized.

Alternative explanations.   Although our results, and those of other observational studies, may indicate a true benefit from high intake of dietary fiber, they may also be explained by other heart-healthy lifestyle and dietary factors associated with a greater intake of dietary fiber. After adjusting for multiple CVD risk factors and dietary variables such as intake of total energy and total fat, most inverse trends in the current study still remained, although they were no longer statistically significant at the conventional p = 0.05 levels. Excluding participants who were overweight or ever smoked, which allows for better control of residual confounding, generally revealed a stronger inverse association between dietary fiber intake and CVD risk in this cohort. However, these estimates had wider 95% CIs, reflecting a loss of statistical power in these subgroup analyses.

Misclassification of dietary fiber intake could have led to an underestimation of the association between dietary fiber intake and CVD risk in this study. During a six-year follow-up period, both the participants’ diets and the composition of food may have changed, leading to errors in assessing long-term dietary exposure of interest. Therefore, it is possible that the approximately 20% reduction in risk associated with high intake of dietary fiber that we observed may be a conservative estimate. Because changes in diet over time are usually a mix of true variation and measurement error, even perfect measures of intake at any particular point in time can be conceptualized as an imperfect measure of the true long-term average dietary exposure of interest. Thus, multiple measures of diet over time are important to reduce measurement error and to better capture the temporal relationship between dietary fiber intake and CVD risk. With the exception of the Nurses’ Health Study, however, all studies that have related a high intake of dietary fiber to lower risk of coronary disease included only a single measurement of diet. Even so, a remarkably consistent inverse relation has been shown among published studies (1–10). As shown in Figure 1, a pooled analysis of these published studies reveals a RR of 0.83 (95% CI 0.78–0.89) associated with 10-g increased in dietary intake. Nevertheless, publication bias is a concern, as it is possible that negative findings from other cohort studies may not have been reported.



View larger version (12K):
[in this window]
[in a new window]
  		Figure 1 The study by Kromhout et al. (2) was excluded in the pooled analysis because information on 95% confidence interval for relative risk cannot be calculated on the basis of the published report.

 
Aside from chance and biases, another explanation is that other characteristics of fiber-containing foods, rather than fiber itself, may be responsible for this inverse association. In the Iowa Women’s Health Study, Jacobs et al. (26) demonstrated a significant inverse relationship between whole-grain intake and death from ischemic heart disease, independent of dietary fiber. The age- and energy-adjusted relative risk of mortality from ischemic heart disease was 0.60 (95% CI: 0.45 to 0.81) for women in the highest quintile of whole-grain intake (median 22.5 servings per week) compared with those in the lowest quintile (median 1.5 servings per week) (26). In the Nurses’ Health Study, an increase in whole-grain intake of two servings/day was associated with a 25% lower risk of CHD independent of dietary fiber intake (9).

Potential mechanisms.   Proposed mechanisms for the biological actions of dietary fiber include increasing fecal excretion of cholesterol and decreasing hepatic cholesterol synthesis (27,28), although the cholesterol-lowering effect of fiber appears modest (11); increasing satiety (29) and insulin sensitivity (30) and lowering plasminogen activator inhibitor type 1 (31) and factor VII coagulation activity (13). Dietary fiber has also been shown to reduce glycemic response and circulating insulin concentrations in healthy adults (32), as well as in patients with hypercholesterolemia (30) or diabetes (33,34). Delaying carbohydrate absorption may be one mechanism for improvement in insulin sensitivity associated with greater intake of dietary fiber (35).

Conclusions.   In this cohort of apparently healthy middle-aged women, higher intake of dietary fiber was associated with a lower risk of CVD and MI, although the association appeared to be attenuated and was not statistically significant after further adjusting for multiple confounding factors. However, the modest number of end points, especially for MI, limited our ability to assess the potential beneficial effects of dietary fiber independent of other healthy lifestyle factors. Nevertheless, these findings generally support current dietary recommendations to increase the consumption of fiber-rich whole grains and fruits and vegetables as a primary preventive measure against CVD.


   Acknowledgments
 
We are indebted to the participants in the Women’s Health Study for their continuing exceptional cooperation, and to David Gordon, Marilyn Chown, Jean MacFadyen and Eduardo Pereira for their expert help in this project.


   Footnotes
 
The work reported in this paper was supported by grants PHS NO-CA47988, HL43851 and DK02767 from the National Institutes of Health.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Morris JN, Marr JW, Clayton DG. Diet and heart: a postscript. Br Med J. 1977;2:1307–1314[Medline]
  2. Kromhout D, Bosschieter EB, de Lezenne Coulander C. Dietary fiber and 10-year mortality from coronary heart disease, cancer and all causes: the Zutphen Study. Lancet. 1982;2:518–522[Medline]
  3. Kushi LH, Lew RA, Stare FJ, et al. Diet and 20-year mortality from coronary heart disease: the Ireland-Boston Diet-Heart study. N Engl J Med. 1985;312:811–818[Abstract]
  4. Khaw KT, Barrett-Connor E. Dietary fiber and reduced ischemic heart disease mortality rates in men and women: a 12-year prospective study. Am J Epidemiol. 1987;126:1093–1102[Abstract/Free Full Text]
  5. Fraser GE, Sabate J, Beeson WL, Strahan TM. A possible protective effect of nut consumption on risk of coronary heart disease: The Adventist Health Study. Arch Intern Med. 1992;152:1416–1424[Abstract]
  6. Humble CG, Malarcher AM, Tyroler HA. Dietary fiber and coronary heart disease in middle-aged hypercholesterolemic men. Am J Prev Med. 1993;9:197–202[Medline]
  7. Rimm EB, Ascherio A, Giovannucci E, Spiegelman D, Stampfer MJ, Willett WC. Vegetable, fruit, and cereal fiber intake and risk of coronary heart disease among men. JAMA. 1996;275:447–451[Abstract]
  8. Pietinen P, Rimm EB, Korhonen P, et al. Intake of dietary fiber and risk of coronary heart disease in a cohort of Finnish men: the Alpha-tocopherol, Beta-carotene Cancer Prevention Study. Circulation. 1996;94:2720–2727[Abstract/Free Full Text]
  9. Liu S, Stampfer M, Hu F, et al. Whole grain consumption and risk of coronary heart disease: results from the Nurses’ Health Study. Am J Clin Nutr. 1999;70:412–419[Abstract/Free Full Text]
  10. Wolk A, Manson JE, Stampfer MJ, et al. Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. JAMA. 1999;281:1998–2004[Abstract/Free Full Text]
  11. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr. 1999;69:30–42[Abstract/Free Full Text]
  12. Burr ML, Fehily AM, Gilbert JF, et al. Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet. 1989;2:757–761[Medline]
  13. Marckmann P, Sandstrom B, Jespersen J. Effects of total fat content and fatty acid composition in diet on factor VII coagulant activity and blood lipids. Atherosclerosis. 1990;80:227–233[CrossRef][Medline]
  14. Liu S, Manson J, Lee I, Cole S, Willett W, Buring J. Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. Am J Clin Nutr. 2000;72:922–928[Abstract/Free Full Text]
  15. US Department of Agriculture. Composition of foods—raw, processed, and prepared, 1963–1988: Agricultural Handbook No. 8 Series. Washington, DC: Department of Agriculture, Government Printing Office; 1989.
  16. Prosky L, Asp N, Furda I, DeVries JW, Schweizer TF, Harland BF. Determination of total dietary fiber in foods, food products and total diets: interlaboratory study. J Assoc Off Anal Chem. 1984;67:1044–1052
  17. Prosky L, Asp N, Furda I, DeVries JW, Schweizer TF, Harland BF. Determination of total dietary fiber and food products: collaborative study. J Assoc Off Anal Chem. 1985;68:677–679[Medline]
  18. Prosky L, Asp N, Schweizer T, DeVries J, Furda I. Determination of insoluble, soluble and total dietary fiber in foods and food products: interlaboratory study. J Assoc Off Anal Chem. 1988;71:1017–1021[Medline]
  19. Willett WC, Stampfer MJ. Total energy intake: implications for epidemiologic analyses. Am J Epidemiol. 1986;124:17–27[Free Full Text]
  20. Willett WC, Sampson L, Stampfer MJ, et al. Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol. 1985;122:51–65[Abstract/Free Full Text]
  21. Salvini S, Hunter DJ, Sampson L, et al. Food-based validation of a dietary questionnaire: the effects of week-to-week variation in food consumption. Int J Epidemiol. 1989;18:858–867[Abstract/Free Full Text]
  22. Willett WC. Nutritional Epidemiology. Second Edition. New York: Oxford University Press; 1998.
  23. Rose GA, Blackburn H. Cardiovascular survey methods: WHO Monograph Series No. 58. Second Edition. Geneva: World Health Organization; 1982.
  24. Liu S, Lee I, Ajani U, Cole S, Buring J, Manson J. Intake of vegetables rich in carotenoids and risk of coronary heart disease in men: the Physicians’ Health Study. Int J Epidemiol. 2001;30:130–135[Abstract/Free Full Text]
  25. Liu S, Manson JE, Stampfer MJ, et al. Whole grain consumption and risk of ischemic stroke in women: a prospective study. JAMA. 2000;284:1534–1540[Abstract/Free Full Text]
  26. Jacobs DR Jr, Meyer KA, Kushi LH, Folsom AR. Whole-grain intake may reduce the risk of ischemic heart disease death in postmenopausal women: the Iowa Women’s Health Study. Am J Clin Nutr. 1998;68:248–257[Abstract]
  27. Vahouny GV, Tombes R, Cassidy MM, Kritchevsky D, Gallo LL. Dietary fiber: V: Binding salts, phospholipids and cholesterol from mixed micelles by bile acid sequestrants and dietary fibers. Lipids. 1980;15:1012–1018[CrossRef][Medline]
  28. Jenkins DJ, Wolever TM, Rao AV, et al. Effect of blood lipids of very high intakes of fiber in diets low in saturated fat and cholesterol. N Engl J Med. 1993;329:21–26[Abstract/Free Full Text]
  29. Raben L, Christensen NJ, Madsen J, Holst JJ, Astrup A. Decreased postprandial thermogenesis and fat oxidation but increased fullness after a high-fiber meal compared with a low-fiber meal. Am J Clin Nutr. 1994;59:1386–1394[Abstract/Free Full Text]
  30. Hallfrisch J, Scholfield DJ, Behall KM. Diets containing soluble oat extracts improve glucose and insulin responses of moderately hypercholesterolemic men and women. Am J Clin Nutr. 1995;61:379–384[Abstract/Free Full Text]
  31. Sundell IB, Ranby M. Oat husk fiber decreases plasminogen activator inhibitor type 1 activity. Haemostasis. 1993;23:45–50[Medline]
  32. Fukagawa NK, Anderson JW, Hageman G, Young VR, Minaker KL. High-carbohydrate, high-fiber diets increase peripheral insulin sensitivity in healthy young and old adults. Am J Clin Nutr. 1990;52:524–528[Abstract/Free Full Text]
  33. Anderson JW, Zeigler JA, Deakins DA, et al. Metabolic effects of high-carbohydrate, high-fiber diets for insulin-dependent diabetic individuals. Am J Clin Nutr. 1991;54:936–943[Abstract/Free Full Text]
  34. Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ. Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. N Engl J Med. 2000;342:1392–1398[Abstract/Free Full Text]
  35. Jenkins DJ, Jenkins AL. Dietary fiber and the glycemic response. Proc Soc Exp Biol Med. 1985;180:422–431[Abstract]



This article has been cited by other articles:


Home page
 Ann Fam MedHome page
D. E. King, A. G. Mainous III, B. M. Egan, R. F. Woolson, and M. E. Geesey
Effect of Psyllium Fiber Supplementation on C-Reactive Protein: The Trial to Reduce Inflammatory Markers (TRIM)
Ann. Fam. Med, March 1, 2008; 6(2): 100 - 106.
[Abstract] [Full Text] [PDF]

Home page
 AMERICAN JOURNAL OF LIFESTYLE MEDICINEHome page
M. B. Andon and J. W. Anderson
State of the Art Reviews: The Oatmeal-Cholesterol Connection: 10 Years Later
American Journal of Lifestyle Medicine, February 1, 2008; 2(1): 51 - 57.
[Abstract] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
Y. Ma, J. A Griffith, L. Chasan-Taber, B. C Olendzki, E. Jackson, E. J Stanek III, W. Li, S. L Pagoto, A. R Hafner, and I. S Ockene
Association between dietary fiber and serum C-reactive protein.
Am. J. Clinical Nutrition, April 1, 2006; 83(4): 760 - 766.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
D. Lairon, N. Arnault, S. Bertrais, R. Planells, E. Clero, S. Hercberg, and M.-C. Boutron-Ruault
Dietary fiber intake and risk factors for cardiovascular disease in French adults
Am. J. Clinical Nutrition, December 1, 2005; 82(6): 1185 - 1194.
[Abstract] [Full Text] [PDF]

Home page
 Diabetes CareHome page
S. Liu, Y. Song, E. S. Ford, J. E. Manson, J. E. Buring, and P. M. Ridker
Dietary Calcium, Vitamin D, and the Prevalence of Metabolic Syndrome in Middle-Aged and Older U.S. Women
Diabetes Care, December 1, 2005; 28(12): 2926 - 2932.
[Abstract] [Full Text] [PDF]

Home page
 J. Nutr.Home page
E. K. Kabagambe, A. Baylin, E. Ruiz-Narvarez, X. Siles, and H. Campos
Decreased Consumption of Dried Mature Beans Is Positively Associated with Urbanization and Nonfatal Acute Myocardial Infarction
J. Nutr., July 1, 2005; 135(7): 1770 - 1775.
[Abstract] [Full Text] [PDF]

Home page
 Diabetes CareHome page
Y. Song, P. M. Ridker, J. E. Manson, N. R. Cook, J. E. Buring, and S. Liu
Magnesium Intake, C-Reactive Protein, and the Prevalence of Metabolic Syndrome in Middle-Aged and Older U.S. Women
Diabetes Care, June 1, 2005; 28(6): 1438 - 1444.
[Abstract] [Full Text] [PDF]

Home page
 J. Appl. Physiol.Home page
C. K. Roberts and R. J. Barnard
Effects of exercise and diet on chronic disease
J Appl Physiol, January 1, 2005; 98(1): 3 - 30.
[Abstract] [Full Text] [PDF]

Home page
 Am J EpidemiolHome page
M. D. Holmes, S. Liu, S. E. Hankinson, G. A. Colditz, D. J. Hunter, and W. C. Willett
Dietary Carbohydrates, Fiber, and Breast Cancer Risk
Am. J. Epidemiol., April 15, 2004; 159(8): 732 - 739.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
M. A. Pereira, E. O'Reilly, K. Augustsson, G. E. Fraser, U. Goldbourt, B. L. Heitmann, G. Hallmans, P. Knekt, S. Liu, P. Pietinen, et al.
Dietary Fiber and Risk of Coronary Heart Disease: A Pooled Analysis of Cohort Studies
Arch Intern Med, February 23, 2004; 164(4): 370 - 376.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
H. Wu, K. M Dwyer, Z. Fan, A. Shircore, J. Fan, and J. H Dwyer
Dietary fiber and progression of atherosclerosis: the Los Angeles Atherosclerosis Study
Am. J. Clinical Nutrition, December 1, 2003; 78(6): 1085 - 1091.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
L. A. Bazzano, J. He, L. G. Ogden, C. M. Loria, and P. K. Whelton
Dietary Fiber Intake and Reduced Risk of Coronary Heart Disease in US Men and Women: The National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study
Arch Intern Med, September 8, 2003; 163(16): 1897 - 1904.
[Abstract] [Full Text] [PDF]

Home page
 JAMAHome page
D. Mozaffarian, S. K. Kumanyika, R. N. Lemaitre, J. L. Olson, G. L. Burke, and D. S. Siscovick
Cereal, Fruit, and Vegetable Fiber Intake and the Risk of Cardiovascular Disease in Elderly Individuals
JAMA, April 2, 2003; 289(13): 1659 - 1666.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
S. Liu, H. D Sesso, J. E Manson, W. C Willett, and J. E Buring
Is intake of breakfast cereals related to total and cause-specific mortality in men?
Am. J. Clinical Nutrition, March 1, 2003; 77(3): 594 - 599.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
W. S. Yancy Jr, E. C. Westman, P. A. French, and R. M. Califf
Diets and Clinical Coronary Events: The Truth Is Out There
Circulation, January 7, 2003; 107(1): 10 - 16.
[Full Text] [PDF]

Home page
 JAMAHome page
F. B. Hu and W. C. Willett
Optimal Diets for Prevention of Coronary Heart Disease
JAMA, November 27, 2002; 288(20): 2569 - 2578.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
W. D. Rosamond
Dietary fiber and prevention of cardiovascular disease
J. Am. Coll. Cardiol., January 2, 2002; 39(1): 57 - 59.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Liu, S.
Right arrow Articles by Manson, J. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Liu, S.
Right arrow Articles by Manson, J. E.

HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK