Original article
Nutritional factors and metabolic variables in relation to the risk of coronary heart disease: A case control study in Armenian adults
Ezatollah Fazeli Moghadam
a, Artashes Tadevosyan
b, Ebrahim Fallahi
c, Reza Goodarzi
d,*
aNutritionalHealthResearchCenter,LorestanUniversityofMedicalSciences,Khorramabad,Iran
bDSCPublicHealthDepartment,YerevanStateMedicalUniversity,Yerevan,Armenia
cNutritionDepartment,FacultyofHealthandNutrition,LorestanUniversityofMedicalSciences,Khorramabad,Iran
dImamHospitalofBorujerd,LorestanUniversityofMedicalSciencesandHealthServices,Borujerd,Iran
ARTICLE INFO
Keywords:
Dietaryfactors Coronaryheartdisease Metabolicsyndrome Vitamins
Armenia
ABSTRACT
Introduction:Dietaryfactorscanaffectthecoronaryheartdisease(CHD).Resultsofpreviousstudieson theassociationbetweenthedietandCHDarenotconsistentindifferentcountries.Therewerenodataon thisassociationinArmenia.
Objective:Aimsofthiscase-controlstudyweretoevaluatetheassociationbetweennutritionalfactors andCHDamongArmeniansinYerevan.
Methods:During2010and2011,werandomlyselected320CHDpatientswithadiagnosisofCHDless than6 monthsand320subjectswithoutCHD(30yearsold)fromthehospitalsandpolyclinicsin Yerevan.Dietaryintakeswith135fooditemsovertheprevious12monthswereevaluatedusingasemi- quantitativefoodfrequencyquestionnaire.
Results:AfteradjustingforsomeCHDriskfactorshigherintakesofpolyunsaturatedfattyacids(PUFA)and monounsaturatedfattyacids(MUFA)wereassociatedwithareducedriskofCHD,whilethisassociation wasnotwitnessedforsaturatedfattyacids(SFA).Inaddition,findingsindicatedaninverserelation between vitamins (E, B6 and B12, folic acid) and fiber with CHD. In this population, smoking, hypertension,andmetabolicsyndrome(MetS)weresignificantlymorecommonamongpatientswith CHD.
Conclusion: Theintake ofvitaminsE,B6 andB12,folicacid,PUFA,MUFAandfiberappearedtobe predictorsofCHD,independentlyofotherriskfactors.
ã2016DiabetesIndia.PublishedbyElsevierLtd.Allrightsreserved.
1.Introduction
Dietaryintakesarerecognizedtoplayprominentrolesinthe preventionand treatment of coronaryheart disease(CHD) [1].
Awarenessofdietarychangesasastrategyisthemostusefulfor bothprimaryandsecondarypreventionofcoronaryrisks[2].The studyof therelationship betweendietaryfactors and CHDhas beenfocusedlargelyforalmosthalfacentury[3].Inprospective cohortstudiesdietaryriskfactorssuchashighsaturatedfattyacids (SFAs) [4–6],trans-fatty acid[7], low in marine omega-3 fatty acids, fiber, legume [8], vegetable and fruit have been well- established[3,9].Inaddition,duringthepastdecade,innumerous studiesdietaryfactorshavebeenassociatedwithCHDriskssuchas theblood pressure[10,11], waist-to-hipratio [11], dyslipidemia [12], and metabolic risk factor [13,14]. Despite decades of
interesting researches, the association between dietary fat, particularly, its quantity and quality, and the risk of CHD is a subject ofdebate. Inlinewiththe sameargument, prospective cohortstudieshaveinvestigatedtheassociationbetweentheCHD incidenceandintakeoftotaldietaryfatwithdiscrepantfindings [4,15].
EvidencethatthedietaryintakeofBvitaminsisaprotectiverisk factorforcardiovasculardisease(CVD)remainslimited.TheJapan PublicHealthCenter-basedProspectiveStudyindicatedthatCHD was inversely associated with the dietary intake of folic acid, vitaminB6andvitaminB12afteradjustmentfortheageandsex [16].
Epidemiologicalstudieshavenotbeenentirelyconsistentwith regard to the relationship between the intake of antioxidant vitaminsandCVD[17].Also,thepreventiveeffectofantioxidant supplementationoncardiovasculareventsinhumansisunproven [16,18,19]. However; few studies have examined the potential effectofthemixtureofthesevitamins[16,20].Thecombinationof multipledietaryfactorsismorepowerfulthanasinglefactor[21].
* Correspondingauthor.
E-mailaddress:[email protected](R.Goodarzi).
http://dx.doi.org/10.1016/j.dsx.2016.06.013
1871-4021/ã2016DiabetesIndia.PublishedbyElsevierLtd.Allrightsreserved.
ContentslistsavailableatScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research &
Reviews
j o u r n a lh o m e p ag e : w w w . e l s e vi e r . c o m / l o c a t e / d s x
Recently,inareviewedstudyfromlargecohortstudiesinJapan, investigatorshavereportedthatadequatecontroloftotalenergy withrestrictionofSFAsfromanimalfoods,increasedintakeofn-3 polyunsaturated fatty acids (PUFAs) including fish, soybean products,fruitand vegetable togetherwiththe lowsalt intake areresponsibleforpromotingCHDprevention[2].Tothebestof ourknowledge,nopreviousstudyhaslookedattheassociation betweendietaryintakeofnutrientsandmetabolicvariablewith CHDinthe ArmeniaAdults. Theobjectiveof this study was to investigate nutritional factors and the metabolic variable in relationtotheriskofCHDinthispopulation.
2.Materialsandmethods 2.1.Participants
This observational case-control study was conducted from March 2010 to February 2011 in the Yerevan State Medical University(YSMU) hospitals and polyclinics, Patients aged30 yearsasthecasegroup(n=320)withestablishedCHDidentified bycardiologists and forcontrol (n=320) wereindividuals aged 30yearswithoutCHDwhoattendedforcheck-upin hospitals and polyclinics in Yerevan. Subjects with previous history of myocardial infraction (MI), admission for angiography, heart surgeryor angioplastyfor CHD, pregnantwomen, and patients withhistoryofsystemicdiseasesaccordingtothemedicalrecords wereexcluded.ThestudyprotocolwasapprovedbytheBioethics CommitteeoftheYSMUafterM.Heratsi.
2.2.Datacollection
Inthisstudy,aninformedconsentwasobtainedfromallstudy subjects.Researchassistantscollecteddataonfamilyhistoryof diabetes, heart diseases, hypertension, socioeconomic status, lifestylefactors(includingsmokinghabits,physicalactivity,and alcoholdrinking)andthedietaryintakefor eachsubject.Next, weightwasmeasuredbyusingdigitalscaleswhilesubjectswere wearinglightclothingandnoshoes.Heightwasmeasuredwitha tape measure while the subjects were in a standing position (withoutshoes) and the shoulderswere in a normal position.
Measurementswererecordedtothenearest100gand0.1cmfor weight and height respectively. Waist circumference was measuredwhilesubjectswerestandingwithasofttapemidway betweenthelowestribandtheiliacanditwasnotwrappedtoo tightortooloose.Thensystolicanddiastolicbloodpressurewas measuredtwice with a standardmercury sphygmomanometer after the participants sat for 15min; the means of the two measurements were considered to be the participant’s blood pressureatthetimeofhealthcheck-up.
2.3.Assessmentofthedietaryintake
Informationontheusualintakesoffoodsanddishesoverthe previous year was obtained using a semi-quantitative food frequencyquestionnaire (FFQ). Nutritionists and public health specialistsassisted in determining constructing a listof foods which ultimately consisted of approximately 135 foods and beverageitemswithastandardservingsizethatwascommonly consumedbyArmenians.BeforetheFFQwasimplementedinthe study, it was adapted to Armenian conditions and was field- tested on 50 individuals. Subjects were asked to select their frequencyofconsumptionandamountofeachfooditemduring theprevious12monthsbyusinghouseholdmeasures.Foreach subject,ameanintakeaccordingtogramsperdayofeachfood wascalculated.Then,totalenergyandnutrientsbasedondaily averages in both groups were calculated by Food Processor
Software,Ver.12.Itisworthmentionthatvitaminandmineral supplementswerenotincludedincomputingnutrientintakes.
2.4.Statisticalanalysis
Thedatacollectedthroughthequestionnaire,clinicalexami- nations, laboratory findings, and dietary intakes were entered intothedatabase.Alldatawerestatisticallyanalyzedusingthe SPSS,version15.The qualitativedatawerecompared between cases andcontrols by using the Chi Square test. Comparisons between the two continuous variables were made using an independent sample t-test. The relation between intakes of nutrientsandtheCHDriskwas calculatedbytheunivariteand multiplelogisticregression,withfurthercontrolforpotentialrisk factorsincludinghypertension, metabolicsyndrome(MetS),the family history of CHD, physicalactivity status, smoking habits, waistcircumference,alcoholconsumption,andeducationstatusof the participants. All tests were 2-tailed and P<0.05 was consideredsignificant.
3.Results
Themeanandpercentagevaluesofvariouscofactorsamongthe casesandcontrolsareshowninTable1.ThemeanSDofagewere 57.2210.9 and 55.511.7years in case and control groups respectively. Although patientsin the case group wereslightly older, the statistical analysis did not reveal any significant differencesinagebetweengroups.Inourstudy,thepercentage ofcurrentsmokers,currentalcoholconsumers,thefamilyhistory ofCHDandMetS,usingNationalCholesterolEducationProgram- ThirdAdultTreatmentPanel[NCEP-ATP(III)]definition,modified byAmerican HeartAssociation/NationalHeart,Lung,and Blood Institute (AHA/NHLBI) [22], was significantly higher. Also, the caseshadsignificantlyhighermeansofwaistgirth(cm)thandid
Table1
DemographyandclinicalcharacteristicsofparticipantswithCHDandcontrols.
Variable CasesN=320) Controls(N=320)
Age(y) 57.22(10.9) 55.50(11.7) P>0.05
Mean(SD)
MaleSex 162(50.6) 141(44.1) P>0.05
N(%)
WaistGirth(cm) 102.19(13.2) 98.53(13.55) P<0.001 Mean(SD)
BMI(Kg/m2) 29.52(5.50) 29.38(5.51) P>0.05 Mean(SD)
Obese 137(42.8) 133(41.6) P>0.05
N(%)
CurrentSmokers 128(40) 67(20.9) P<0.0001
N(%)
CurrentAlcoholConsumers 175(54.7) 106(33.1) P<0.0001 N(%)
FamilyHistoryofCHD 45(14.1) 10(3.1) P<0.0001 N(%)
MetS 255(79.6) 222(69.4) P<0.005
N(%)
Hypertension 250(78.1) 206(64.4) P<0.0001
N(%)
thecontrolsubjectswhiletherewasnotasignificantdifference betweenobesityandthebodymassindex(BMI)inbothgroups.
Themeansofdailycalorie,fat,andvitaminsintakesamongthe casesandcontrolsarepresentedinTable2.Inthisstudy,thecases hadsignificantlylowertotalcalorie,protein,fat,PUFA,monoun- saturatedfattyacids(MUFAs),fiber,vitaminsE,B6,andfolicacid intakes.Themeandailyintakesofcarbohydrate,SFAs,vitaminC, and vitamin B12 didnot differ significantly between the both groups. Although the mean energy intake was lower, the cholesterolintakewashigherinthepatientswithCHDthanthat inthecontrols(358.8g/dvs.343.8g/d;p<0.05).Wereporteda significantdifferencebased onthemeanpercentagesofenergy fromPUFAsincasesand controls(7.79%vs.8.65%,respectively;
p<0.001). While there was not a significant difference in the percentof energy from SFAs and MUFAs betweenboth groups eitherthosewhohadCHDorthosewhodidnot.
The odds ratio (OR) and 95% CI of the highest and lowest quartileofthenutrientintakeassociatedwithCHDarereportedin Table 3. In the univariate logistic regression analysis, results showedthatdietaryintakesoftotalfat,PUFA,fiber,andvitaminsE wereinverselyassociatedwiththeriskofCHD.TheOR(95%CI)the inhighestvs.lowestquartileoftotalfatintakewas0.51(0.33–0.80) forCHD;forthehighestvs.lowestquartileofPUFAintakewas0.22 (0.14–0.35).Also,forthehighestvs.lowestquartileoffiber,and vitamins E intakes were 0.50(0.32–0.78) and 0.21(0.13–0.35), respectively. In contrast, participantsin thehighest quartileof cholesterolandvitaminAhadtheORof2.55(95%CI:1.62,3.99);
6.05(95%CI:3.71,9.87),respectively.Therewerenostatistically significantinteractionsforCHDbetweenquartilesofdietarySFAs, MUFAs,andvitaminCintakes.
Further control was made for hypertension, MetS, family history of CHD, physical activity status, smoking habits, waist circumference, alcohol consumption, and education status to investigatetherelationshipbetweensomenutritionalfactorsand theCHD.Inthemultiplelogisticregressions,theoutputindicated thatthePUFAs, MUFAs,fiber,vitaminsE,B6,B12,andfolicacid
weresignificantpredictorsforCHD.Therewas notasignificant relationshipbetweencholesterolandvitaminCwithCHD(Table4).
Theoddsratioswereestimatedaftertakingintoaccounttheeffect ofhypertension,MetS,andfamilyhistoryofCHD,physicalactivity status,smokinghabits,waistcircumference,alcoholconsumption, andeducationstatusoftheparticipants.
4.Discussion
Toourknowledge,thisisthefirststudytoassesstheassociation betweennutritionalfactorsandmetabolicvariableswithCHDin Armenia.Inthis case-controlstudy,theprevalenceofMetS and highbloodpressure(HBP)washighinbothgroups,thespecific sample of initially selected population who referred to the hospitalswithHBPandMetScomponents.
TheoddsratioindicatedthattheriskofCHDdecreasedbyabout 11%foreachadditionalgramperdayoffiber(Table4).30.2%ofthe casesand19.9%ofthecontrolswereinthelowestquartileoffiber consumption(OR:0.5;95%CI:0.32,0.78)(Table3).Consistently,a studyhasshownthatdietaryfiberintakewasinverselyassociated withseveralCVDriskfactors[11].
In the present study, it was observed that both cases and controlshadahighintakeofcholesterol(358.8g/dand343.8g/d, respectively) (Table 2).Although theintake ofcholesterol after adjusting for other risk factors, was not associated with CHD (Table 4; p>0.05), the odds ratio of subjects with cholesterol consumptioninthehighestquartile,comparedtothelowest,was 2.55(95%CI:1.62,3.99)(Table3).WealsofoundthatOR:1.91(95%
CI: 1.33, 2.75) based on the cholesterol300mg/day 75% and 60.6%ofthecasesandcontrolshadacholesterolintakemorethan 300mg/d(datanotshown).Acase-controlstudy,inIndonesia,has reported a consistent OR: 4.7 (95% CI: 2.3, 9.7) based on a cholesterol intake in thehighest quartile in comparison tothe lowest[23].
We observedaninverse associationbetweenthe PUFAs and MUFAswithCHD.Multiplelogisticregressionsindicatedthatfor Table2
Totaldailycalorie,fatandvitaminsintakeinpatientswithCHDandcontrols.
Nutrients(dailyintake) Casesmean(SD) Controlsmean(SD) Pvalue
Totalenergy(kcal) 1515.9(269) 1574(305.1) P=0.010
Carbohydrate(g) 150.6(36.4) 150.5(29.8) P=0.977
(%oftotalenergy) 39.7(9.6) 38.2(7.5)
Protein(g) 72.8(19.4) 76.8(25) P=0.026
(%oftotalenergy) 19.2(5.1) 19.5(6.3)
Totalfat(g) 69.1(11.4) 73.9(16.3) P=0.000
(%oftotalenergy) 41.(6.7) 42.2(9.3)
PUFA(g) 13.1(4.5) 15.1(5.6) P=0.000
(%oftotalenergy) 7.79(2.7) 8.65(3.2)
MUFA(g) 21.7(5.1) 22.9(6.4) P=0.013
(%oftotalenergy) 12.9(3) 13.1(3.7) P=0.500
SFA(g) 30.1(8) 30.7(8.8) P=0.329
(%oftotalenergy) 17.9(4.7) 17.6(5)
Cholesterol(g) 358.8(89.6) 343.8(100.1) P=0.047
DietaryFiber(g) 13.7(2.8) 14.6(3.6) P=0.000
Folicacidwithoutsupplements(mcg) 197.2(40.6) 204.9(49.2) P=0.031
VitaminEwithoutsupplements(mg) 9.9(2.8) 11.7(5.1) P=0.000
VitaminAwithoutsupplements(RE) 1252(204) 1178(193) P=0.000
VitaminCwithoutsupplements(mg) 61.8(18) 60.2(16) P=0.256
VitaminB6(mg) 1.3(0.24) 1.4(0.37) P=0.000
VitaminB12(mcg) 5.5(2.1) 5.8(2.8) P=0.120
everygPUFAsandMUFAsconsumption,theriskmaydecreaseby about11%and5%,respectively.Alsotheindividualsinthehighest quartileofconsumptionofPUFAsandMUFAshadabout78%and 30%lowerCHDwhencomparedtothosein thelowest quartile respectively.Thisresultisconsistentwiththefinding,ofprevious prospectivecohortstudies[4,24–26].Incontrast,intheSpanish cohortstudy,witharelativelyhighintakeoffish,noassociation wasfoundbetweenEPA,DHAandtotalomega-3fattyacidintake andriskofCHD[27].Likewise,Spainisacountrywithahighintake offish[26]andalowincidenceofCHD,whichmayexplain,atleast inpart,thelackofassociationbetweentotalomega-3fattyacid, EPAorDHAintakesandtheriskofCHDinthisstudy.
There was no association between the SFAs intake and incidence of CHD in ourstudy. Although it was reported in a
study thatonly long chainsSFAs wereassociated with a small increaseintherisk[24],theresultwassupportedbyotherstudies [4,23,28].
However,althoughtheresultshowedasignificantdifferencein thedietaryfatintakebetweenthecaseandcontrolgroups,ahigh totalfatintakecomparedtotherecommendationsmadebyAHA amongcasesandcontrolswasreported,41.06%and42.25%oftotal calories,respectively.Thehighfatdairyproducts,butterandlocal foodsincludingBozbash,PlavandDolma,andfriedfoodswerethe majorfoodsourceofthetotalfatintakeinthispopulationforboth groups.Thehigherintakeoftotalfat,SFAs,lowerintakeofMUFAs and PUFAs suggests a less healthy eating pattern among the ArmenianpopulationthatmaycontributetohigherCHD.
Multiple logistic regressions indicated that for every mcg consumptionofvitamin E,theCHDriskmaydecreasebyabout 14%. The individuals in thehighest quartile of consumption of vitaminEhadabout79%lowerCHDwhencomparedtothoseinthe lowestquartile.In thisstudy,unexpectedly,thebenefitofother antioxidantvitaminsincludingvitaminsAandCfortheCHDwas notconfirmed.
ThevitaminAintakerevealedthatithadapositiveassociation withCHD. In Saudipopulation, there was a similarassociation betweendietaryvitaminAandthecoronaryrisk[17].Inanearlier study,theuseofantioxidantsupplementsofvitaminEandbeta- carotenedidnothaveeffectsonthemajorcoronaryrisk[18,19].A significantinverseassociationwithCHDwasobservedforfolicacid andvitaminB6whilethesignificantinverseassociationwithCHD was marginal forvitamin B12. In 2008,Ishiharaet al. similarly reportedthatCHDwasassociatedwithfolicacid,vitaminsB6,and B12 [16,29].Anearlierstudy hasshown that individualsin the highestfifthofthefolicacidintakehada55%reductionofcoronary Table4
AdjustedoddsratioofCHDcalculatedfrommultiplelogisticregressionmodelsfor theassessedoftheeffectofdietaryfactorsoncoronaryrisk.
Dietaryfactors OR 95%CI Wald P-Value
Lower Upper
Calorie 0.999 0.998 1.000 10.37 0.001
Protein 0.988 0.98 0.996 8.29 0.004
TotalFat 0.940 0.961 0.986 17.20 0.000
PUFA(g/day) 0.911 0.868 0.955 14.65 0.000
MUFA 0.955 0.927 0.984 8.851 0.003
Cholesterol(mg/day) 1.001 1.000 1.003 2.585 0.108
Fiber(g/day) 0.895 0.846 0.946 15.238 0.000
VitaminE(mcg/day) 0.883 0.834 0.936 17.838 0.000 Folicacid(mcg/day) 0.995 0.991 0.999 6.262 0.012 VitaminB6(mg/day) 0.344 0.190 0.623 12.404 0.000 VitaminB12(mg/day) 0.927 0.860 0.999 3.898 0.048 VitaminC(mg/day) 1.002 0.992 1.012 0.107 0.744 Table3
Distributionofcasesandcontrolsinthehighestandlowestquartiles,theoddsratio(95%confidenceintervals)accordingtotheirnutrientsintakes.
Variable CasesN(%) ControlsN(%) Oddsratio 95%CI
Fat(g/day)
1stquartile(<61.6g/d) 84(25.9) 79(24.4) 0.51 0.33–0.80
4thquartile(>79.5g/d) 57(17.6) 104(32.1)
PUFA(g/day)
1stquartile(<11.5g/d) 106(32.4) 61(18.7 0.22 0.14–0.35
4thquartile(>15.6g/d) 45(13.8) 115(35.2)
MUFA(g/day)
1stquartile(<18.4g/d) 83(25.8) 78(24.2) 0.7 0.45–1.08
4thquartile(>24.9g/d) 69(21.4) 92(28.6)
SFA(g/day)
1stquartile(<24.9g/d) 77(24) 84(26.2) 0.84 0.54–1.31
4thquartile(>34.1g/d) 70(21.8) 90(28)
Cholesterol(mg/day)
1stquartile(<294mg/d) 56(17.3) 106(32.7) 2.55 1.62–3.99
4thquartile(>409mg/d) 93(28.7) 69(21.3)
Fiber(g/day)
1stquartile(<11.8g/d) 97(30.2) 64(19.9) 0.5 0.32–0.78
4thquartile(>15.8g/d) 69(21.5) 91(28.3)
VitaminE(g/day)
1stquartile(<9.28mcg/d) 96(29.8) 64(19.9) 0.21 0.13–0.35
4thquartile(>11.8g/d) 40(12.4) 122(37.9)
VitaminA(RE/day)
1stquartile(<1092RE/d) 37(11.5) 124(38.6) 6.05 3.71–9.87
4thquartile(>1361RE/d) 103(32.1) 57(17.8)
VitaminC(mcg/day)
1stquartile(<49.6mcg/d) 37(11.5) 124(38.6) 0.87 0.56–1.36
4thquartile(>71mcg/d) 103(32.1) 57(17.8)
eventsas comparedtothosein thelowestfifth.A highdietary intakeofvitaminB6hadnosignificantassociationwhereastherisk ofCHDwas significantlyreduced in thosewho hada highB12 intake[20].
Inacasecontrolstudy,Meanplasmaleveloffolateinpatients withCADwaslowerthancontrolsubjects[30].Inanotherstudy, MeanserumlevelsofVitaminsB12andfolatewerelowerincases ofcoronaryatherosclerosisthancontrols[31].
SerumvitaminB12deficiencyandhyperhomocysteinemiaare relatedwithcardiovascularriskfactorsinpatientswithCHD[32].
However, in a systematic review, results identified a valid association of a few nutrients including folic acid, vitamins E andC,fiber,andtrans-fattyacidswithCHD[3].
Thecurrent study had several limitations. First, becausewe usedanFFQtoassessdietaryintakes,themisclassificationwasa majorconcern.Furthermore,caloriesarefrequentlyunderreported whendietarydataarecollectedbyFFQ.Thecaloricintakemayalso get underreported due to social desirability, particularly by overweightpeople[33,34].Second,itispossiblethatindividuals whohadalowintakeofvitaminsandfiberwereathigherriskof CHDduetootherunhealthyhabitsandbehaviors.Thelikelihoodof thiswasreduced,however,bythemultivariableadjustmentfora number of potential confounding variables including hyperten- sion,MetS,familyhistoryofCHD,physicalactivitystatus,smoking habits,waistcircumference,alcoholconsumption,andeducation status.Thefinalpotentiallimitationwasthedesignofthestudyas wehadtoassessMetSanditscomponentsincludingabdominal obesity, elevated blood glucose, dyslipidemia, and high blood pressureincaseandcontrolgroups,affectingonfoodpatterns.In ordertoeliminateselectionbias,subjectswithprevioushistoryof MI,admission for angiography,heart surgeryor angioplastyfor CHD, pregnant women, and patients with history of systemic diseaseswereexcludedfromthestudy.Theseexclusionsmayhave reduced the influence of such conditions subjects’ behavioral changes,especiallyfoodhabits.
5.Conclusion
Results of this case-control study showed that intakes of vitamins E, B6, B12, folic acid, and fiber are inversely and independently associated with the CHD.Thus, this association suggeststhatdietsrichinthesenutrientspreventtheriskofCHD.
Prospective cohort studies related to dietary habits and their nutrientsinArmenianpopulationarerecommended.
Acknowledgements
Authors are grateful to appreciate the staff at hospitals, subjects,andallthosewhohadacontributionandsupportedto carryoutthisresearch.
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