European Journal of Epidemiology

, Volume 26, Issue 11, pp 877–886 | Cite as

Cereal fiber and coronary heart disease: a comparison of modeling approaches for repeated dietary measurements, intermediate outcomes, and long follow-up

  • Adam M. BernsteinEmail author
  • Bernard A. Rosner
  • Walter C. Willett


The appropriate manner of incorporating incident angina, coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), diabetes, hypertension, and hypercholesterolemia, which may be both intermediate events and time-dependent confounders, into analyses of diet and coronary heart disease (CHD) is not clear. Using data from 72,266 women in the Nurses’ Health Study between 1984 and 2006, the authors examined the relation between report of intermediate events and change in cereal fiber intake and used different proportional hazards models to evaluate the association between cereal fiber and CHD. Cereal fiber intake increased significantly among participants who reported hypercholesterolemia (0.42 g/day; 95% CI: 0.34, 0.51 g/day) and diabetes (0.07 g/day with each additional 2-year increment; 95% CI: 0.01, 0.13 g/day). However, angina, CABG/PCI, and hypertension were not associated with a change in cereal fiber intake and thus were not important time-dependent confounders. Cereal fiber intake was inversely associated with risk of CHD in all proportional hazards models, but results varied modestly depending on the approach used to incorporate multiple measures of diet. Because stopping the updating of dietary variables when an intermediate event is diagnosed may lead to misclassification, future analyses should consider updating diet even after these diagnoses to best represent long-term intake. To best evaluate associations with incidence of disease, considerations should include the temporal trends in diet, changes in intake following intermediate events, and latency patterns. Sensitivity analyses can also be useful.


Dietary fiber Coronary disease Confounding factors Cohort studies Diabetes mellitus Hypercholesterolemia 



This work was supported by National Institutes of Health grant T32 DK00703.

Conflict of interest

The authors declare they have no conflicts of interest.


  1. 1.
    Hu FB, Bronner L, Willett WC, Stampfer MJ, Rexrode KM, Albert CM, et al. Fish and omega-3 fatty acid intake and risk of coronary heart disease in women. JAMA. 2002;287(14):1815–21.PubMedCrossRefGoogle Scholar
  2. 2.
    Hu FB, Cho E, Rexrode KM, Albert CM, Manson JE. Fish and long-chain omega-3 fatty acid intake and risk of coronary heart disease and total mortality in diabetic women. Circulation. 2003;107(14):1852–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Hu FB, Rimm EB, Stampfer MJ, Ascherio A, Spiegelman D, Willett WC. Prospective study of major dietary patterns and risk of coronary heart disease in men. Am J Clin Nutr. 2000;72(4):912–21.PubMedGoogle Scholar
  4. 4.
    Hu FB, Stampfer MJ, Manson JE, Ascherio A, Colditz GA, Speizer FE, et al. Dietary saturated fats and their food sources in relation to the risk of coronary heart disease in women. Am J Clin Nutr. 1999;70(6):1001–8.PubMedGoogle Scholar
  5. 5.
    Hu FB, Stampfer MJ, Manson JE, Rimm E, Colditz GA, Rosner BA, et al. Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med. 1997;337(21):1491–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343(1):16–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Hu FB, Stampfer MJ, Rimm E, Ascherio A, Rosner BA, Spiegelman D, et al. Dietary fat and coronary heart disease: a comparison of approaches for adjusting for total energy intake and modeling repeated dietary measurements. Am J Epidemiol. 1999;149(6):531–40.PubMedGoogle Scholar
  8. 8.
    Liu S, Buring JE, Sesso HD, Rimm EB, Willett WC, Manson JE. A prospective study of dietary fiber intake and risk of cardiovascular disease among women. J Am Coll Cardiol. 2002;39(1):49–56.PubMedCrossRefGoogle Scholar
  9. 9.
    Pereira MA, O’Reilly E, Augustsson K, Fraser GE, Goldbourt U, Heitmann BL, et al. Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies. Arch Intern Med. 2004;164(4):370–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Wolk A, Manson JE, Stampfer MJ, Colditz GA, Hu FB, Speizer FE, et al. Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. JAMA. 1999;281(21):1998–2004.PubMedCrossRefGoogle Scholar
  11. 11.
    Feskanich D, Rimm EB, Giovannucci EL, Colditz GA, Stampfer MJ, Litin LB, et al. Reproducibility and validity of food intake measurements from a semiquantitative food frequency questionnaire. J Am Diet Assoc. 1993;93(7):790–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Giovannucci E, Colditz G, Stampfer MJ, Rimm EB, Litin L, Sampson L, et al. The assessment of alcohol consumption by a simple self-administered questionnaire. Am J Epidemiol. 1991;133(8):810–7.PubMedGoogle Scholar
  13. 13.
    Salvini S, Hunter DJ, Sampson L, Stampfer MJ, Colditz GA, Rosner B, et al. Food-based validation of a dietary questionnaire: the effects of week-to-week variation in food consumption. Int J Epidemiol. 1989;18(4):858–67.PubMedCrossRefGoogle Scholar
  14. 14.
    Willett WC, Sampson L, Browne ML, Stampfer MJ, Rosner B, Hennekens CH, et al. The use of a self-administered questionnaire to assess diet four years in the past. Am J Epidemiol. 1988;127(1):188–99.PubMedGoogle Scholar
  15. 15.
    Willett WC, Sampson L, Stampfer MJ, Rosner B, Bain C, Witschi J, et al. Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol. 1985;122(1):51–65.PubMedGoogle Scholar
  16. 16.
    USDA National Nutrient Database for Standard Reference. Release 21 [database on the Internet] 2008. Available from: Accessed: 22 December 2008.
  17. 17.
    Rose GA, Blackburn H. Cardiovascular survey methods. World Health Organization Monograph Series. Geneva; 1982. p. 58.Google Scholar
  18. 18.
    Willett WC. Nutritional epidemiology. 2nd ed. New York: Oxford University Press; 1998.CrossRefGoogle Scholar
  19. 19.
    Renaud S, Lanzmann-Petithory D. Coronary heart disease: dietary links and pathogenesis. Public Health Nutr. 2001;4(2B):459–74.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  • Adam M. Bernstein
    • 1
    • 2
    Email author
  • Bernard A. Rosner
    • 3
    • 5
  • Walter C. Willett
    • 2
    • 4
    • 5
  1. 1.Wellness InstituteCleveland ClinicLyndhurstUSA
  2. 2.Department of NutritionHarvard School of Public HealthBostonUSA
  3. 3.Department of BiostatisticsHarvard School of Public HealthBostonUSA
  4. 4.Department of EpidemiologyHarvard School of Public HealthBostonUSA
  5. 5.Channing Laboratory, Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonUSA

Personalised recommendations