Risks and benefits of nonsugar sweeteners: conflicting evidence between observational studies and randomized controlled trials.

PURPOSE OF REVIEW: Recommendations on the use of nonsugar sweeteners are contradictory, even if they come from official sources. The aim is to review and discuss recent findings on the potential impact of nonsugar sweeteners on human health. RECENT FINDINGS: While randomized controlled trials (RCTs) with short duration and risk factors endpoints mostly show favourable effects on body weight and cardiometabolic parameters when nonsugar sweeteners are used to replaced sugar-sweetened products, observational studies mostly show a positive association between the consumption of nonsugar sweeteners and cardiometabolic diseases. The conflicting results may be explained by the heterogenous nature of nonsugar sweeteners but also likely is a consequence of serious weaknesses of available studies. SUMMARY: For more evidence-based recommendations for practice and policy, scientifically sound studies with long follow-up are required.

Does diet map with mortality? Ecological association of dietary patterns with chronic disease mortality and its spatial dependence in Switzerland.

We investigated the associations between dietary patterns and chronic disease mortality in Switzerland using an ecological design and explored their spatial dependence, i.e. the tendency of near locations to present more similar and distant locations to present more different values than randomly expected. Data of the National Nutrition Survey menuCH (n 2057) were used to compute hypothesis- (Alternate Healthy Eating Index (AHEI)) and data-driven dietary patterns. District-level standardised mortality ratios (SMR) were calculated using the Swiss Federal Statistical Office mortality data and linked to dietary data geographically. Quasipoisson regression models were fitted to investigate the associations between dietary patterns and chronic disease mortality; Moran's I statistics were used to explore spatial dependence. Compared with the first, the fifth AHEI quintile (highest diet quality) was associated with district-level SMR of 0·95 (95 % CI 0·93, 0·97) for CVD, 0·91 (95 % CI 0·88, 0·95) for ischaemic heart disease (IHD), 0·97 (95 % CI 0·95, 0·99) for stroke, 0·99 (95 % CI 0·98, 1·00) for all-cancer, 0·98 (95 % CI 0·96, 0·99) for colorectal cancer and 0·93 (95 % CI 0·89, 0·96) for diabetes. The Swiss traditional and Western-like patterns were associated with significantly higher district-level SMR for CVD, IHD, stroke and diabetes (ranging from 1·02 to 1·08) compared with the Prudent pattern. Significant global and local spatial dependence was identified, with similar results across hypothesis- and data-driven dietary patterns. Our study suggests that dietary patterns partly contribute to the explanation of geographic disparities in chronic disease mortality in Switzerland. Further analyses including spatial components in regression models would allow identifying regions where nutritional interventions are particularly needed.

Different dietary assessment methods, similar conclusions? Comparison of a country's adherence to food-based dietary guidelines as depicted in two population-based surveys using different dietary assessment methods.

OBJECTIVE: Different methods of dietary intake assessment are frequently used to assess a population's diet. In this study, we aimed to compare the adherence to Swiss food-based dietary guidelines as depicted in two Swiss population-based surveys using different methods of dietary assessment. DESIGN: Two population-based, cross-sectional surveys were compared. In the Swiss Health Survey (SHS), diet was assessed via a short set of questions on specific food groups, while in menuCH by two non-consecutive 24-h dietary recall interviews. SETTING: To compare the diet depicted in these surveys, we used the Swiss food-based dietary guidelines on vegetable, fruit, dairy product, meat and meat product, fish and alcohol. The weighted proportion of responders meeting these guidelines was calculated for both surveys and was compared overall and by selected characteristics. PARTICIPANTS: Residents of Switzerland, selected from a stratified random sample of the non-institutionalised residents, who agreed to participate in the respective survey. To ensure comparability between the surveys, the age of the study populations was restricted to 18-75 years. RESULTS: In menuCH, approximately 2 % of responders met ≥4 of the selected Swiss food-based dietary guidelines. In the SHS, using a cruder dietary assessment, the corresponding percentage was 20 %. In both surveys, more women and never smokers were meeting ≥4 food-based dietary guidelines compared to men and current or former smokers, respectively. CONCLUSIONS: Our study comparing the diet in two population-based, representative surveys detected large variations in guideline adherence depending on the dietary assessment method used.

Daily and meal-based assessment of dairy and corresponding protein intake in Switzerland: results from the National Nutrition Survey menuCH.

PURPOSE: Dairy contributes to daily protein and provides important minerals and vitamins. Using data of the National Nutrition Survey in Switzerland (menuCH), we aimed to describe intakes of dairy and its subcategories, to compare daily and per-meal dairy protein with total protein intake, and to investigate associations between energy-standardized dairy intake and sociodemographic, lifestyle and anthropometric factors. METHODS: From two 24-h dietary recalls, anthropometric measurements, and a lifestyle questionnaire from a representative sample (n = 2057, 18-75 years), we calculated daily and energy-standardized means and standard error of the means for dairy, its subcategories (milk, yoghurt and cheese), and compared daily and per-meal dairy protein with total protein intake. Associations were investigated between dairy intake (g/1000 kcal) and sociodemographic, lifestyle and anthropometric factors by multivariable linear regression. RESULTS: Dairy intake provided 16.3 g/day protein with cheese contributing highest amounts (9.9 g/day). Dairy protein intake was highest at dinner (6.3 g/day) followed by breakfast, lunch and snacks (4.3, 3.3 and 2.4 g/day, respectively). Per meal, total protein reached the amounts suggested for improving protein synthesis only at dinner and lunch (33.1 and 28.3 g/day, respectively). Energy-standardized dairy intake was 20.7 g/1000 kcal higher for women than men (95% CI 13.2; 28.1), 24.3 g/1000 kcal lower in the French than German-speaking region (95% CI - 32.4; - 16.1), and also significantly associated with nationality, household type and smoking status. CONCLUSION: This first description of dairy consumption is an important basis for developing meal-specific recommendations, aimed to optimize dairy and protein intake especially for older adults.

No-meat eaters are less likely to be overweight or obese, but take dietary supplements more often: results from the Swiss National Nutrition survey menuCH.

OBJECTIVE: To describe and analyse the sociodemographic, anthropometric, behavioural and dietary characteristics of different types of Swiss (no-)meat eaters. DESIGN: No-, low-, medium- and high-meat eaters were compared with respect to energy and total protein intake and sociodemographic, anthropometric and behavioural characteristics. SETTING: National Nutrition Survey menuCH, the first representative survey in Switzerland. PARTICIPANTS: 2057 participants, aged 18-75 years old, who completed two 24-h dietary recalls (24-HDR) and a questionnaire on dietary habits, sociodemographic and lifestyle factors. Body weight and height were measured by trained interviewers. No-meat eaters were participants who reported meat avoidance in the questionnaire and did not report any meat consumption in the 24-HDR. Remaining study participants were assigned to the group of low-, medium- or high-meat eaters based on energy contributions of total meat intake to total energy intake (meat:energy ratio). Fifteen percentage of the participants were assigned to the low- and high-meat eating groups, and the remaining to the medium-meat eating group. RESULTS: Overall, 4·4 % of the study participants did not consume meat. Compared with medium-meat eaters, no-meat eaters were more likely to be single and users of dietary supplements. Women and high-educated individuals were less likely to be high-meat eaters, whereas overweight and obese individuals were more likely to be high-meat eaters. Total energy intake was similar between the four different meat consumption groups, but no-meat eaters had lowest total protein intake. CONCLUSIONS: This study identified important differences in sociodemographic, anthropometric, behavioural and dietary factors between menuCH participants with different meat-eating habits.

Joints effects of BMI and smoking on mortality of all-causes, CVD, and cancer.

Obesity, underweight, and smoking are associated with an increased mortality. We investigated the joint effects of body mass index and smoking on all-cause and cause-specific mortality. Data of the Third National Health and Nutrition Examination Survey (1988-1994) including mortality follow-up until 2011 were used (n = 17,483). Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause, cardiovascular disease (CVD), and cancer mortality with BMI, smoking, and their combinations as exposure, stratified by sex. Normal weight never smokers were considered as reference group. Compared to normal weight never smokers, obese and underweight current smokers were the two combinations with the highest mortality from all-causes, CVD, and cancer. Among underweight current smokers, the HR of death from all-causes was 3.49 (95% CI 2.42-5.02) and for obese current smokers 2.76 (2.12-3.58). All-cause mortality was particularly high in women who were underweight and current smoker (3.88 [2.47-6.09]). CVD mortality risk was the highest among obese current smokers (3.33 [2.98-5.33]). Cancer mortality risk was the highest among underweight current smokers (5.28 [2.68-10.38]). Obese current smokers in the middle age group (between 40 and 59 years old) had the highest risk of all-cause mortality (4.48 [2.94-7.97]). No statistically significant interaction between BMI and smoking on all-cause and cause-specific mortality was found. The current study indicates that obesity and underweight in combination with smoking may emerge as a serious public health problem. Hence, public health messages should stress the increased mortality risk for smokers who are underweight or obese. Also, health messages regarding healthy lifestyle are aimed at maintaining a healthy body weight rather than just "losing weight" and at not starting smoking at all.

Body height and mortality - mortality follow-up of four Swiss surveys.

BACKGROUND: Adult body height is largely determined by genetics, but also by dietary factors, which in turn depend on socioeconomic status and lifestyle. We examined the association between adult body height and mortality in Switzerland, a country with three main language regions with different cultural background. METHODS: We included 16,831 men and 18,654 women, who participated in Swiss population-based health surveys conducted 1977-1993 and who were followed up until end of 2008. Multivariable Cox proportional hazards models were computed to examine the association of body height with overall, cardiovascular, and cancer mortality. RESULTS: We observed a positive association between adult body height and all-cause mortality in women (HR=1.34, 95% CI 1.10-1.62, tallest vs. average women). In men, mortality risk decreased with increasing height, with shortest men tending to have higher (1.06, 0.94-1.19) and tallest men a lower (0.94, 0.77-1.14) risk compared with men of average height (p-trend 0.0001). Body height was associated with cancer mortality in women, such that tallest women had a higher risk of dying from cancer than women of average height (1.37, 1.02-1.84), but there was no such association in men (0.95, 0.69-1.30). In both sexes, height was not associated with cardiovascular mortality in a statistically significant manner. CONCLUSION: Our study does not support an inverse association of body height with all-cause mortality. On the contrary, our data suggests a higher overall risk in taller women, mainly driven by a positive association between body height and cancer mortality.

Diet and Other Lifestyle Factors Associated with Prostate Cancer Differ Between the German and Italian Region of Switzerland.

PURPOSE: In Switzerland, prostate cancer mortality is higher in the German than in the Italian-speaking region. We aimed at exploring the association of living in one of the two regions with lifestyle factors presumably lowering the risk of prostate cancer. METHODS: We pooled data from the Swiss Health Survey, conducted every 5 years 1992 - 2012. Information on diet (meat, fish, dairy, fruits and vegetables), alcohol, smoking, physical activity and body mass index were dichotomized into "risky" and "risk-reducing" lifestyle behaviour with respect to prostate cancer. Multivariable logistic regression analyses were performed to assess associations between the German and Italian region of Switzerland and each single lifestyle factor. RESULTS: Living in the Italian region was associated with "risk-reducing" diet, i.e. with a higher prevalence of low dairy products and meat consumption and high fish consumption (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.21 - 1.48; OR 3.31, 95% CI 2.94 - 3.72; OR 1.90, 95% CI 1.71 - 2.12, respectively). However, men in the Italian region were less likely to have low alcohol consumption and regular physical activity than men in the German region (OR 0.43, 95% CI 0.36 - 0.52 and OR 0.77, 95% CI 0.69 - 0.86, respectively). CONCLUSIONS: Prostate cancer risk-reducing dietary behaviour (i.e., less dairy products, less meat and more fish) was more common in the Italian region, whereas other risk-reducing lifestyle behaviours were more common in the German region.

Mediterranean diet and mortality in Switzerland: an alpine paradox?

PURPOSE: Reports on the protective effect of a Mediterranean diet on mortality usually refer to populations from Mediterranean countries, leaving uncertain whether really diet is the fundamental cause. Our aim was to examine the effect of a Mediterranean diet on mortality in Switzerland, a country combining cultural influences from Mediterranean and Central European countries within a common national health and statistical registry. METHODS: In this prospective investigation, we included 17,861 men and women aged ≥16 years who participated 1977-1993 in health studies and were followed up for survival until 2008 by anonymous record linkage with the Swiss National Cohort. A 9-point score Mediterranean Diet Score (MDS) was used to assess adherence to a Mediterranean diet. Mortality hazard ratios (HR) and 95% confidence intervals (CIs) were calculated by using Cox regression models adjusted for age, sex, survey wave, marital status, smoking, body mass index, language region and nationality. RESULTS: In all language regions, MDS was inversely associated with mortality. Consumption of dairy products was also consistently associated with lower mortality. When categorizing dairy food consumption as beneficial instead of harmful, this association between MDS and mortality increased in strength and was partly statistically significant. For all causes of death combined (HR for a one-point increase in MDS 0.96, 95% CI 0.94-0.98), in men (0.94, 0.92-0.97), in women (0.98, 0.95-1.02) for cardiovascular diseases (CVD, 0.96, 0.92-0.99; 0.95, 0.90-1.00; 0.98, 0.92-1.04) and for cancer (0.95, 0.92-0.99; 0.92, 0.88-0.97; 0.98, 0.93-1.04). CONCLUSIONS: Stronger adherence to a Mediterranean diet was associated with lower all-cause, CVD and cancer mortality, largely independently of cultural background. These associations were primary due to the effect in men. Our finding of a beneficial rather than a deleterious impact of dairy products consumption prompts at considering culturally adapted Mediterranean diet recommendations. However, results should be interpreted with caution since only a crude 1-day dietary estimate was available to assess individuals' habitual dietary intake.

Diabetes risk scores and death: predictability and practicability in two different populations.

The aim was to examine the capacity of commonly used type 2 diabetes mellitus (T2DM) risk scores to predict overall mortality. The US-based NHANES III (n = 3138; 982 deaths) and the Swiss-based CoLaus study (n = 3946; 191 deaths) were used. The predictive value of eight T2DM risk scores regarding overall mortality was tested. The Griffin score, based on few self-reported parameters, presented the best (NHANES III) and second best (CoLaus) predictive capacity. Generally, the predictive capacity of scores based on clinical (anthropometrics, lifestyle, history) and biological (blood parameters) data was not better than of scores based solely on clinical self-reported data. T2DM scores can be validly used to predict mortality risk in general populations without diabetes. Comparison with other scores could further show whether such scores also suit as a screening tool for quick overall health risk assessment.

Variation in mortality patterns among the general population, study participants, and different types of nonparticipants: evidence from 25 years of follow-up.

The general willingness to participate in health surveys is decreasing, resulting in increasingly selected study populations. We aimed to examine relative mortality rates by different categories of nonparticipation. We included 14,223 men and women aged 25-74 years who were sampled in the Swiss centers of the international Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Study (1983-1992) and followed-up until 2008. Logistic regression was used to describe factors associated with nonparticipation. We compared persons who refused to participate (n = 2,911), persons who did not go to their examination (n = 470), and persons that could not be contacted for inclusion in the MONICA Study (n = 989) with participants (n = 9,853). We used Cox regression to determine mortality hazard ratios for the various categories of nonparticipants versus participants or versus the 1990 Census population average. Persons who refused were more likely to be older and female. Compared with participants, those who refused had a higher risk of death (for men, hazard ratio = 1.34, 95% confidence interval: 1.17, 1.54; for women, hazard ratio = 1.31, 95% confidence interval: 1.12, 1.52), whereas persons who did not go to their examination and those who could not be contacted did not differ. Compared with the general (census) population, participants had a lower risk of all-cause mortality and those who refused had a higher risk of all-cause mortality. These variations were mainly due to cardiovascular disease and not cancer. Variations in relative mortality risks between study participants and the general population could depend on the proportion of subjects who actively refused to participate in the study. Considering the increasing participation reluctance, our findings underline the importance of carefully assessing the reasons for nonparticipation.

Italianity is associated with lower risk of prostate cancer mortality in Switzerland.

PURPOSE: Different prostate cancer mortality rates observed in European countries may depend on cultural background. We aimed at exploring variation in prostate cancer mortality in the language regions of Switzerland as a function of "Italianity", a proxy for adherence to an Italian lifestyle. METHODS: We used data of the Swiss National Cohort, a census-based record linkage study, consisting of census (1990 and 2000) and mortality (until 2008) data. 1,163,271 Swiss and Italian nationals 40+-year old were included. Multivariate age-standardized prostate cancer mortality rates and hazard ratios (HR) from Cox proportional hazards regression analysis were performed. Italianity was defined by an individual's nationality, place of birth and principal language, resulting in a score of 0-3 points. RESULTS: Age-standardized prostate cancer mortality rates (per 100,000 person-years) were lowest in the Italian-speaking region of Switzerland (66.7 vs. 87.3 in the German-speaking region). Both Italian nationality and/or place of birth were significantly associated with lower mortality. There was a graded inverse association between mortality rates and increasing Italianity score. Individuals with the highest level of Italianity had a HR of 0.67 (95 % CI 0.59-0.76) compared to those with an Italianity score of zero. Results were similar when looking at language regions separately. CONCLUSIONS: The strong and consistent association between Italianity and prostate cancer mortality suggests protective properties of an Italian lifestyle. Further research is required in order to determine which factors specific for Italian culture are responsible for the lower prostate cancer mortality.

Impact of different domains of physical activity on cause-specific mortality: a longitudinal study.

OBJECTIVE: The aim of this paper is to examine the associations between different domains of physical activity and all-cause, cardiovascular disease (CVD) and cancer mortality. METHODS: Participants (n=17,663, aged 16-92 years) of two general population health studies conducted between 1977 and 1993 in Switzerland were included. Physical activity was assessed at baseline in the domains of commuting to work, work-related physical activity, and leisure-time physical activity (including leisure-time activity level and sport activity). A median follow-up time of 20.2 years was obtained with anonymous record linkage providing 3878 deaths (CVD: 1357; cancer: 1351). Adjusted Cox proportional hazard models were calculated. RESULTS: There were no significant associations between commuting and work-related physical activities, respectively, and mortality. Leisure-time activity level was associated with all-cause mortality in men [adjusted hazard ratio (HR) 0.75, 95% confidence intervals (CI) 0.63-0.89] and women [HR 0.82 (0.74-0.91)], with CVD mortality in women only [HR 0.79 (0.67-0.94)] and with cancer mortality in men only [HR 0.63 (0.47-0.86)]. Sport activity was associated with all-cause, CVD and cancer mortality in men [HR ranged between 0.76 (0.63-0.92) and 0.85 (0.76-0.95)], but not in women. CONCLUSIONS: These results underline the public health relevance of physical activity for the prevention of CVD and cancer, especially regarding leisure-time physical activity.

The combined effect on survival of four main behavioural risk factors for non-communicable diseases.

OBJECTIVE: To quantify and illustrate the combined effects of WHO's four behavioural risk factors for non-communicable diseases (NCDs) on mortality. METHODS: Participants (n=16,721) were part of two Swiss population studies conducted between 1977 and 1993. Smoking status, alcohol consumption, physical activity and diet were assessed at baseline. With record linkage in 2008, up to 31years of follow-up with 3,533 deaths could be recorded. Mortality was assessed with Cox proportional hazard models for each risk factor and their combinations. Ten-year survival probabilities for 65- and 75-year-olds were estimated with Weibull regression models. RESULTS: Hazard ratios for the combination of all four risk factors compared to none were 2.41 (1.99-2.93) in men and 2.46 (1.88-3.22) in women. For 65-year-olds, the probability of surviving the next 10years was 86% for men with no risk factors and 67% for men with four. In women, the respective numbers were 90% and 77%. In 75-year-olds, probabilities were 67% and 35% in men, and 74% and 47% in women. CONCLUSIONS: The combined impact of four behavioural NCD risk factors on survival probability was comparable in size to a 10-year age difference and bigger than the gender effect.

Mortality risk associated with underweight: a census-linked cohort of 31,578 individuals with up to 32 years of follow-up.

BACKGROUND: In contrast to obesity, information on the health risks of underweight is sparse. We examined the long-term association between underweight and mortality by considering factors possibly influencing this relationship. METHODS: We included 31,578 individuals aged 25-74 years, who participated in population based health studies between 1977 and 1993 and were followed-up for survival until 2008 by record linkage with the Swiss National Cohort (SNC). Body Mass Index (BMI) was calculated from measured (53% of study population) or self-reported height and weight. Underweight was defined as BMI < 18.5 kg/m2. Cox regression models were used to determine mortality Hazard Ratios (HR) of underweight vs. normal weight (BMI 18.5- < 25.0 kg/m2). Covariates were study, sex, smoking, healthy eating proxy, sports frequency, and educational level. RESULTS: Underweight individuals represented 3.0% of the total study population (n = 945), and were mostly women (89.9%). Compared to normal weight, underweight was associated with increased all-cause mortality (HR: 1.37; 95% CI: 1.14-1.65). Increased risk was apparent in both sexes, regardless of smoking status, and mainly driven by excess death from external causes (HR: 3.18; 1.96-5.17), but not cancer, cardiovascular or respiratory diseases. The HR were 1.16 (0.88-1.53) in studies with measured BMI and 1.59 (1.24-2.05) with self-reported BMI. CONCLUSIONS: The increased risk of dying of underweight people was mainly due to an increased mortality risk from external causes. Using self-reported BMI may lead to an overestimation of mortality risk associated with underweight.

Dietary fibre intake and its association with ultraprocessed food consumption in the general population of Switzerland: analysis of a population-based, cross-sectional national nutrition survey.

Objectives: The objective of this study was to describe the compliance to dietary fibre recommendations of the Swiss population and to investigate the association between dietary fibre intake and ultraprocessed food (UPF) consumption. Methods: Data were obtained from the cross-sectional Swiss National Nutrition Survey menuCH. We summarised the sociodemographic, lifestyle and anthropometric parameters as well as dietary data collected with two 24-hour dietary recalls for the whole population and subgroups according to absolute and relative dietary fibre intake. We analysed the associations between dietary fibre intake and UPF consumption by fitting multinomial logistic regression models. Data were weighted according to the menuCH weighting strategy to achieve a representation of the Swiss population. Results: Data obtained from 2057 adults were included in the analysis, of which 87% had a dietary fibre intake of <30 g/day. Participants with high UPF consumption had lower odds of being in the medium or high dietary fibre intake groups than participants with low UPF consumption. The odds of being in the medium or high dietary fibre intake groups decreased linearly across quartiles of UPF consumption (p for trend ≤0.004). Conclusions: Dietary fibre intake is insufficient in all population groups in Switzerland. UPF consumption is inversely and dose dependently associated with dietary fibre intake. To increase dietary fibre intake, public health measures should discourage UPF consumption and increase dietary fibre intake via unprocessed or minimally processed foods.

Should we go nuts about nuts?

Since the beginning of the 1990s, increasing evidence supports beneficial effects of nut consumption on health. A new analysis of the Spanish PREDIMED trial, published in BMC Medicine, has expanded our knowledge. The study showed that individuals eating nuts more than three times per week died less often from cardiovascular disease and cancer than non-consumers. The study also adds an important finding that previous epidemiological studies could not provide: a protective effect on premature mortality was only seen in the intervention group in which nut consumption increased during the 4.8 years of follow-up, not in the intervention group with additional olive oil consumption or in the control group. Nut consumption actually decreased during follow-up in the latter two groups. Questions remain to be answered on the quantity of nuts to be consumed for health benefits, on possible mechanisms of action, and on whether some types of nuts should be favored.Please see related research: http://www.biomedcentral.com/1741-7015/11/164.

Blood glucose may be an alternative to cholesterol in CVD risk prediction charts.

BACKGROUND: Established risk models for the prediction of cardiovascular disease (CVD) include blood pressure, smoking and cholesterol parameters. The use of total cholesterol for CVD risk prediction has been questioned, particularly for primary prevention. We evaluated whether glucose could be used instead of total cholesterol for prediction of fatal CVD using data with long follow-up. METHODS: We followed-up 6,095 men and women aged ≥16 years who participated 1977-79 in a community based health study and were anonymously linked with the Swiss National Cohort until the end of 2008. During follow-up, 727 participants died of CVD. Based on the ESC SCORE methodology (Weibull regression), we used age, sex, blood pressure, smoking, and fasting glucose or total cholesterol. The mean Brier score (BS), area under the receiver-operating characteristic curve (AUC) and integrated discrimination improvement (IDI) were used for model comparison. We validated our models internally using cross-validation and externally using another data set. RESULTS: In our models, the p-value of total cholesterol was 0.046, that of glucose was p < 0.001. The model with glucose had a slightly better predictive capacity (BS: 2216x10-5 vs. 2232x10-5; AUC: 0.9181 vs. 0.9169, IDI: 0.009 with p-value 0.026) and could well discriminate the overall risk of persons with high and low concentrations. The external validation confirmed these findings. CONCLUSIONS: Our study suggests that instead of total cholesterol glucose can be used in models predicting overall CVD mortality risk.

J-shaped association between plasma glucose concentration and cardiovascular disease mortality over a follow-up of 32years.

OBJECTIVE: We aimed at examining the association between plasma glucose (PG) concentration and cardiovascular mortality in a population sample from Switzerland over a follow-up time of 32 years. METHODS: We analyzed 7984 men and women enrolled in the first National Research Program (NRP1A, 1977-1979) and followed up for survival until 2008. Mortality hazard ratios (HR) were calculated using adjusted Cox regression models. PG was measured in fasting state or randomly with known fasting time. Models were adjusted for age, sex, socio-demographic, lifestyle and cardiovascular risk factors. RESULTS: PG concentrations ≥ 6.1 mmol/L were associated with increased risk of cardiovascular disease (CVD) and all-cause mortality. Compared to normal PG (3.8-4.9 mmol/L) the adjusted HR (95% CI) for CVD mortality was 1.26 (1.01-1.58) for PG ≥ 6.1-6.9 mmol/L, 1.56 (1.18-2.06) for PG ≥ 7 mmol/L, 1.67 (1.22-2.30) for known diabetes. All-cause mortality essentially showed the same patterns. All-cause mortality was increased [1.35 (1.01-1.80)] also for PG <3.8 mmol/L. CONCLUSION: Plasma glucose remained significantly and independently associated with CVD mortality even after full follow-up. The relationship was J-shaped. In order to prevent premature death, persons with abnormal PG concentrations on both extremes should be screened and counseled for other CVD risk factors.

Direct estimation of death attributable to smoking in Switzerland based on record linkage of routine and observational data.

INTRODUCTION: In Switzerland, estimations of smoking-attributable deaths were based on age- and sex-adjusted hazard ratios (HRs) from foreign cohorts, precluding consideration of country-specific properties and adjustment for confounding. In order to overcome this, we analyzed recently available individual data from Switzerland. METHODS: We included 17,861 individuals aged ≥16 years who participated between 1977-1993 in health studies and were anonymously linked with the Swiss National Cohort. Adjusted Cox regression was used to calculate mortality HRs. Smoking status at baseline was categorized into never-smokers, former smokers, and current light or heavy smokers (<20 or ≥20 cigarettes/day). As covariates, we selected education, marital status, lifestyle, alcohol consumption, and body mass index. We differentiated between cardiovascular disease (CVD), cancer, and noncancer-non-CVD deaths. Smoking-attributable deaths were estimated with a HR-based approach and with age-specific prevalence rates and mortality estimates from 2007. RESULTS: Smoking men and women not only had an increased risk for all-cause (HR and 95% confidence interval vs. never-smokers: 1.71 [1.53-1.90]; 1.54 [1.36-1.75]), CVD (1.72 [1.43-2.06]; 1.50 [1.19-1.90]) and cancer (1.87 [1.56-2.25]; 1.58 [1.30-1.93]), but also for noncancer-non-CVD death (1.57 [1.29-1.89]; 1.58 [1.30-1.93]). Former smoking men had an increased risk for all-cause (1.16 [1.03-1.31]) and cancer death (1.35 [1.10-1.65]). Multivariate adjustment only slightly modified the association between smoking and mortality. Overall, 7,153 deaths per year could be attributed to smoking. CONCLUSIONS: Smoking is an important avoidable health burden in Switzerland, and its consequences may persist for decades after quitting. This stresses the need for putting more efforts in strategies aimed at preventing the onset of smoking.