The long awaited PURE study is out and the results will put the supporters of diets low in all types of fats into a carbohydrate-fueled tailspin. According to the large cohort Prospective Urban Rural Epidemiology (PURE) study, higher fat diets that include both saturated and unsaturated fats are associated with a lower risk of mortality. And replacing said fats with high carbohydrate intakes (above 60% energy) is associated with higher risk mortality.
The news, presented in Barcelona Aug. 29, 2017 at the European Cardiology Congress 2017 in 
Barcelona and published in Lancet, shows the world has a significant health problem: too many people consume too many simple carbohydrates and too few fats. Why? Many take advice from European and North American health advisories, which may not be relevant to moderate and low-income populations.
The study included people aged 35-70 years old from 18 countries across various regions including the Middle East, South America, Africa, China, North America and Europe, and South Asia and looked at the links between diet, cardiovascular disease and death. Participants’ completed follow-up visits with the research team at least every three years to record information on cardiovascular disease (ie, fatal and non-fatal heart attacks, stroke and heart failure) and death for 7.4 years. The team analysed rates of cardiovascular events (for example, heart attack, stroke, heart failure), cardiovascular deaths and and non-cardiovascular deaths.
PURE Study Suggests Carb Reduction and Increased Fat Intake
The study, being presented at the European Society of Cardiology Congress 2017, found that on average, globally, people’s diets consisted of over 60% energy from carbohydrates and 24% energy from fats, suggesting that rather than focusing on reducing fat intake in diets, guidelines should instead focus on reducing carbohydrate intake, particularly in low- and middle-income countries where carbohydrate intake was highest.
Additionally, while current guidelines recommend reducing saturated fat intake to below 10%, the study found that very low intake of saturated fats (below 3%) was associated with a higher risk of mortality, compared to diets with a higher intake of saturated fats of up to 13%.
“For the first time, our study provides a global look at the realities of people’s diets in many countries and gives a clearer picture of people’s fat and carbohydrate intake,” says lead author Dr. Mahshid Dehghan, McMaster University, Canada. “The current focus on promoting low-fat diets ignores the fact that most people’s diets in low and middle income countries are very high in carbohydrates, which seem to be linked to worse health outcomes. In low- and middle-income countries, where diets sometimes consist of more than 65% of energy from carbohydrates, guidelines should refocus their attention towards reducing carbohydrate intake, instead of focusing on reducing fats.”
The best diets will include a balance of carbohydrates and fats – approximately 50-55% carbohydrates and around 35% total fat, including both saturated and unsaturated fats. Our study did not look at trans fats, typically from processed foods, and the evidence is clear that these are unhealthy,” says Dehghan.
Here is what the PURE study found:
- Globally, the average diet consisted of 61.2% carbohydrates, 23.5% fat (including 8% saturated fats, 8.1% monounsaturated fats, and 5.3% polyunsaturated fats), and 15.2% protein.
- However, this balance varied by region: on average, carbohydrate intake was highest in China (67%), South Asia (65.4%) and Africa (63.3%); total fat intake was highest in North America and Europe (30.5%), Middle East (30.3%), and Southeast Asia (29.2%).
- High carbohydrate diets were common, with more than half of the people in the study eating a high carbohydrate diet (at least 60% of energy from carbohydrates), and about a quarter deriving 70% of their daily calories from carbohydrates.
- Half of the people involved derived less than 7% of their energy from saturated fats, and three-quarters (75%) ate less than 10% from saturated fats.
Cardiovascular Disease Outcomes
- During the study, 5796 people died (including 1649 from cardiovascular disease and 3809 from non-cardiovascular disease) and 4784 had a major cardiovascular disease event (2143 heart attacks and 2234 strokes)
- Diets high in carbohydrates (average of 77% energy from carbohydrates) were associated with a 28% higher risk of death, compared with low carbohydrate diets (46% energy from carbohydrates) [7.2 deaths per 1000 people years, compared with 4.1]. Rates of major cardiovascular events remained similar for low and high carbohydrate diets.
- Comparatively, diets with high total fat intake (35.3% energy from fat) were associated with a 23% lower risk of death, compared with low fat diets (11.0% energy from fat) [4.1 deaths per 1000 people years in people, compared with 6.7].
- Rates of major cardiovascular events remained similar for low and high fat diets.
- The trends were similar when looking at saturated fats, with very low intake (below 3%) associated with a higher risk of mortality, compared to diets with a higher intake of saturated fats of up to 13%.
- Similarly, diets with very low intake of mono and polyunsaturated fats (3.6% and 2.2%) were associated with a higher risk of mortality, compared to diets with higher intakes (13% and 9.1%).
“Despite there being no association between low carbohydrate intake and health outcomes, this does not provide support for very low carbohydrate diets – less than 50% energy. A certain amount of carbohydrate is necessary to meet energy demands during physical activity and so moderate intakes, of around 50-55% of energy, are likely to be more appropriate than either very high or very low carbohydrate intakes,” explained Dehghan.
The study authors note that existing global guidelines recommend that 50-65% of a person’s daily calories come from carbohydrates, and less than 10% from saturated fats, but this is mostly based on evidence from North America and Europe, and it is unclear how applicable it is to other countries.
Drs Christopher Ramsden and Anthony Domenichiello, National Institute on Aging, USA, commented on this advice, saying, “The relationships between diet, cardiovascular disease, and death are topics of major public health importance, and subjects of great controversy … The PURE study is an impressive undertaking that will contribute to public health for years to come. Initial PURE findings challenge conventional diet-disease tenets that are largely based on observational associations in European and North American populations, adding to the uncertainty about what constitutes a healthy diet. This uncertainty is likely to prevail until well-designed randomised controlled trials are done.”
The authors note some limitations, including that the diet measures used were based on when the study began. Additionally, the study did not look at the specific types of foods the nutrients were derived from, but the will assess this in future analyses.
