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Participants in NHS and HPFS have been followed via biennial self administered questionnaires on health and lifestyle habits, anthropometrics, environmental exposures, and medical conditions.
However, the avoidance of gluten may result in reduced consumption of beneficial whole grains, which may affect cardiovascular risk.We calculated the quantity of gluten on the basis of the protein content of wheat, rye, and barley based on recipe ingredient lists from product labels provided by manufacturers or cookbooks in the case of home prepared items.Previous studies have used conversion factors of 75% or 80% when calculating the proportion of protein content that comprises gluten; we used the more conservative estimate of 75%.222324 Although gluten’s proportion of total protein may be more variable for rye and barley than for wheat,25 we used the same conversion factor for all three grains, consistent with previous studies.2223 Although trace amounts of gluten can be present in oats and in condiments (for example, soy sauce), we did not calculate gluten on the basis of these items as the quantity of gluten is much lower than that in cereals and grains and the contribution to total gluten intake would be negligible.26In 1986 the five largest contributors to gluten in both cohorts were dark bread, pasta, cold cereal, white bread, and pizza (supplementary table A).Compared with participants in the lowest fifth of gluten intake, who had a coronary heart disease incidence rate of 352 per 100 000 person years, those in the highest fifth had a rate of 277 events per 100 000 person years, leading to an unadjusted rate difference of 75 (95% confidence interval 51 to 98) fewer cases of coronary heart disease per 100 000 person years.After adjustment for known risk factors, participants in the highest fifth of estimated gluten intake had a multivariable hazard ratio for coronary heart disease of 0.95 (95% confidence interval 0.88 to 1.02; P for trend=0.29).Previous validation studies within these cohorts found that the Pearson correlation coefficients between the number of servings of these items reported on food frequency questionnaires and that reported on seven day dietary records ranged from 0.35 (pasta) to 0.79 (cold cereal) for women and from 0.37 (dark bread) to 0.86 (cold cereal) for men.2728 A separate validation study of this food frequency questionnaire found that this method of measuring vegetable (that is, plant based) protein intake, of which gluten is the major contributor, correlated highly with that measured in seven day dietary records (Spearman correlation coefficient 0.66).29We divided cohort participants into fifths of estimated gluten consumption, according to energy adjusted grams of gluten per day.
We obtained energy adjusted values by regression using the residual method, as described previously.30 To quantify long term dietary habits, we used cumulative averages through the questionnaires preceding the diagnosis of coronary heart disease, death, or the end of follow-up.31 For example, we calculated cumulative average estimated gluten intake in 1994 by averaging the daily consumption of gluten reported in 1986, 1990, and 1994.
Main outcome measure Development of coronary heart disease (fatal or non-fatal myocardial infarction).
Results During 26 years of follow-up encompassing 2 273 931 person years, 2431 women and 4098 men developed coronary heart disease.
One national survey showed a steep rise in interest in this diet in recent years, and by 2013 nearly 30% of adults in the US reported that they were trying to minimize or avoid gluten.15 Concerns exist that a gluten-free or gluten restricted diet may be nutritionally suboptimal,16 and gluten-free substitute foods cost considerably more than their counterparts that contain gluten.1718 Despite the rising trend in gluten restriction, no long term, prospective studies have assessed the relation of dietary gluten with the risk of chronic conditions such as coronary heart disease in people without celiac disease.
Thus, using prospective, validated data on dietary intake collected over 20-30 years, we examined the association of estimated long term intake of gluten with the development of incident coronary heart disease (fatal or non-fatal myocardial infarction).
After these exclusions, 64 714 women and 45 303 men were available for analysis.