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American Journal of Clinical Nutrition, Vol. 88, No. 4, 1180-1181, October 2008
© 2008 American Society for Nutrition

LETTER TO THE EDITOR

Reply to K Esposito and D Giugliano

Eric Brunner, Daniel Witte, Martin Shipley and Michael Marmot

Department of Epidemiology and Public Health
University College London
1-19 Torrington Place
London WC1E 6BT
United Kingdom
E-mail: e-brunner{at}ucl.ac.uk

Annhild Mosdøl

Section for Food Studies and Public Nutrition
Akershus University College
PO Box 423
2001 Lillestrom
Norway

Pekka Martikainen

Helsinki Collegium for Advanced Studies
University of Helsinki
Helsinki
Finland

Dear Sir:

We thank Esposito and Giugliano for their interest in our analysis of dietary patterns and the incidence of diabetes and coronary heart disease in British civil servants (1). They question the low estimates of daily carbohydrate intake as a proportion of total energy intake, and they note that the sum of mean energy intake from macronutrients and alcohol by dietary cluster is consistently <100%.

We have reviewed our computations, and we identified an error in the calculation of energy from carbohydrate. We wrongly used a conversion factor of 14 kJ/g, instead of 17 kJ/g. When the sum of estimated energy intakes derived from each macronutrient and alcohol for each participant is used as the estimate for total energy intake (Table 1Go), the corrected computation yields estimates of the proportion of energy from carbohydrate some 14% higher ({approx}6 percentage points) than those in our published article. Total energy intake in the published report was based on energy content data in McCance and Widdowson's food tables. This estimate was used to compute the ratio of energy intake to energy expenditure and to correct for energy misreporting in the regression models. Thus, our error with respect to energy derived from carbohydrate has no effect on the diet-disease analysis.


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  		TABLE 1 Estimated daily energy intake and energy distribution from macronutrients across empirically derived dietary clusters for Whitehall II participants in 1991–1993

 
We are also grateful to Esposito and Giugliano for the opportunity to clarify the method used to compute the Mediterranean diet score. We followed the approach of Trichopoulou et al (2) that uses a modified criterion for fat quality, grouping polyunsaturated and monounsaturated fatty acids together (on the basis that, over recent decades, one of the salutary changes in the Northern European food supply has been the greater availability of polyunsaturated seed oils). Values of 0 or 1 were assigned to each of 9 components. Participants reporting intakes of the 5 food groups vegetables, legumes, fruit and nuts, cereals, and fish above the sex-specific median intake per 10 MJ were assigned a value of 1 for each group. Participants with food group intakes of meat and dairy below the sex-specific median intake per 10 MJ were assigned values of 1. A score of 1 was given to moderate alcohol consumption (10 to <50 and 5 to <25 g/d in men and women, respectively). Participants with a ratio of unsaturated to saturated fat intake above the sex-specific median ratio were given a score of 1. The score based on crude food intake was positively correlated with total energy intake (r = 0.23, P < 0.001), and food intakes therefore were expressed as intakes per 10 MJ (3). The Mediterranean diet score (range: 0–9) was grouped (0–3, 4–5, and 6–9) for the analysis (4).

The "Mediterranean-like" diet was originally designated as "Continental" but was renamed in response to an American referee who suggested that non-European readers would not recognize that term. We have reservations about the term adopted, in parallel with those expressed by Esposito and Guigliano. However, because this cluster had the highest average Mediterranean diet score and a higher proportion of high scores (see Table 1), the change of designation seemed appropriate. With respect to the relation of the Mediterranean-like dietary pattern to health outcomes, it is interesting to compare our findings with those for the Healthy pattern. There is no significant difference in effects on coronary heart disease or diabetes incidence. The relative proportions of participants and events within each of these 2 clusters are important to an interpretation of the results obtained at this stage of follow-up.

ACKNOWLEDGMENTS

None of the authors had a personal or financial conflict of interest.

REFERENCES

  1. Brunner EJ, Mosdol A, Witte DR, et al. Dietary patterns and 15-y risks of major coronary events, diabetes, and mortality. Am J Clin Nutr 2008;87:1414–21.[Abstract/Free Full Text]
  2. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to Mediterranean diet and survival in a Greek population. N Engl J Med 2003;348:2599–608.[Abstract/Free Full Text]
  3. Knoops KTB, de Groot LCPM, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10 year mortality in elderly European men and women. JAMA 2004;292:1433–9.[Abstract/Free Full Text]
  4. Trichopoulou A, Orfanos P, Norat T, et al. Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. Br Med J 2005;330:991–5.[Abstract/Free Full Text]




This Article
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