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 102807Subject Categories (SSIF 2011)
Nutrition and Dietetics
DOI
10.1016/j.eclinm.2024.102807
PubMed
39296946