Association between substituting macronutrients and all-cause mortality: a network meta-analysis of prospective observational studies
Journal article, 2024

Background: Suboptimal diet quality is a key risk factor for premature death. Assuming relatively stable energy intake among individuals, changes in nutrient intakes occur by exchanging different nutrients. Therefore we aimed to examine the association of isocaloric substitution of dietary (macro)nutrients with all-cause mortality using network meta-analysis (NMA). Methods: For this systematic review and NMA of prospective observational studies MEDLINE, Embase, and Scopus were searched from inception to February 13th, 2024. Eligible studies reported substitution analyses for quantity and/or quality of macronutrients, including carbohydrates, proteins, and fatty acids on all-cause mortality. Random-effects NMA were used in order to evaluate the pooled hazard ratios (HR) and 95% confidence intervals (CI) of substituting each included nutrient with another. We assessed risk of bias with the ROBINS-E tool, and the certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach. This study is registered with PROSPERO (CRD42023450706). Findings: Thirty-nine studies with 1,737,644 participants, 395,491 deaths, 297 direct comparisons, and seven nutrient-specific networks were included. Moderate CoE was found for an association with lower mortality risk when replacing 5% of energy intake from carbohydrates with polyunsaturated fatty acids (PUFA; HR: 0.90; 95%CI: 0.84, 0.95), n-6 PUFA (0.85; 0.77, 0.94), n-3 PUFA (0.72; 0.59, 0.86), and plant monounsaturated fatty acids (MUFA; 0.90; 0.85, 0.95), and when replacing 5% of energy from saturated fatty acids (SFA) and trans-fatty acids (TFA), with PUFA, MUFA, and plant-MUFA (HRrange: 0.75 to 0.91). A lower mortality risk was additionally found when 5% of animal-MUFA was replaced with plant-MUFA, and when replacing animal protein, and SFA with plant protein (HRrange: 0.81 to 0.87, moderate CoE). Interpretation: Our results provide practical knowledge for public health professionals and can inform upcoming dietary guidelines. The beneficial association of increasing PUFA (both n-3 and n-6) and (plant-) MUFA intake while reducing carbohydrates, SFA and TFA, along with replacing animal protein and animal-MUFA with plant-based sources of protein and fat (MUFA) on the all-cause mortality risk, underscores the importance of plant-based dietary recommendations. Funding: None.

Replacement

Network meta-analysis

Macronutrients

Mortality

Substitution

Author

Sabina Wallerer

Universitats Klinikum Freiburg und Medizinische Fakultat

Theodoros Papakonstantinou

Universitats Klinikum Freiburg und Medizinische Fakultat

Jakub Morze

SGMK Copernicus University

Chalmers, Life Sciences, Food and Nutrition Science

Julia Stadelmaier

Universitats Klinikum Freiburg und Medizinische Fakultat

Eva Kiesswetter

Universitats Klinikum Freiburg und Medizinische Fakultat

Lea Gorenflo

Cochrane Germany Foundation

Universitats Klinikum Freiburg und Medizinische Fakultat

Janett Barbaresko

German Diabetes Center

Edyta Szczerba

Deutsches Zentrum für Diabetesforschung

German Diabetes Center

Manuela Neuenschwander

Deutsches Zentrum für Diabetesforschung

German Diabetes Center

William Bell

Queen's University Belfast

Tilman Kühn

University Hospital Heidelberg

Medizinische Universität Wien Zentrum für Public Health

Queen's University Belfast

University of Vienna

Szimonetta Lohner

University of Pécs Medical School

Marta Guasch-Ferré

University of Copenhagen

Harvard School of Public Health

Georg Hoffmann

University of Vienna

Joerg J. Meerpohl

Cochrane Germany Foundation

Universitats Klinikum Freiburg und Medizinische Fakultat

Sabrina Schlesinger

German Diabetes Center

Deutsches Zentrum für Diabetesforschung

Adriani Nikolakopoulou

Universitats Klinikum Freiburg und Medizinische Fakultat

Lukas Schwingshackl

Universitats Klinikum Freiburg und Medizinische Fakultat

eClinicalMedicine

25895370 (eISSN)

Vol. 75 102807

Subject Categories

Nutrition and Dietetics

DOI

10.1016/j.eclinm.2024.102807

PubMed

39296946

More information

Latest update

9/17/2024