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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Obesity (Silver Spring). Author manuscript; available in PMC 2013 November 21.
Published in final edited form as:
PMCID: PMC3478414
NIHMSID: NIHMS383118

Dietary Patterns, Abdominal Visceral Adipose Tissue and Cardiometabolic Risk Factors in African Americans: the Jackson Heart Study

Jiankang Liu, Ph.D., M.D.,1 DeMarc A Hickson, PhD.,1 Solomon K Musani, PhD.,1 Sameera A. Talegawkar, PhD.,2 Teresa C. Carithers, PhD., RD., LD.,3 Katherine L. Tucker, PhD.,4 Caroline S. Fox, M.D. MPH.,5 and Herman A. Taylor, M.D., MPH.1

Abstract

Dietary behavior is an important lifestyle factor to impact an individual’s risk of developing cardiovascular disease (CVD). However, the influence of specific dietary factors on CVD risk for African Americans remains unclear. We conducted a cross-sectional study of 1775 participants from Jackson Heart Study (JHS) Exam 2 (between 2006 and 2009) who were free of hypertension, diabetes and CVD at the baseline (between 2001 and 2004). Dietary intakes were documented using a validated food-frequency questionnaire (FFQ) and dietary patterns were generated by factor analysis. Three major dietary patterns were identified: a “southern”, a “fast food” and a “prudent” pattern. After adjustment for age, sex, smoking and alcohol status, education level and physical activity, high “southern” pattern score was associated with an increased odds ratio (OR) for high abdominal visceral adipose tissue (VAT) (OR:1.80, 95%CI:1.1–3.0, p=0.02), hypertension (OR:1.42, 95%CI:1.1–1.9, p=0.02), diabetes (OR:2.03, 95%CI:1.1–3.9, p=0.03) and metabolic syndrome (OR:2.16, 95%CI:1.3–3.6, p=0.004). Similar associations were also observed in the “fast food” pattern (p ranges 0.03–0.0001). The “prudent” pattern was significantly associated, in a protective direction, with hypertension (OR 0.69, 95%CI 0.5–0.9, p=0.02). In conclusion, dietary patterns, especially the “southern” pattern, identified from a regional specific FFQ in this Deep South African Americans, are correlated with abdominal VAT and cardiometabolic risk factors.

Keywords: Jackson Heart Study, dietary patterns, cardiometabolic risk factors

Introduction

African Americans, compared to other ethnic groups, have been shown to have similar risk for cardiovascular disease (CVD) but greater cardiovascular mortality (1). Our recent studies demonstrated higher CVD risk in African Americans from the Jackson Heart Study (JHS), with higher prevalence of obesity, diabetes and hypertension than that in European Americans from the Framingham Heart Study (FHS) (2,3). Although the underlying explanations for ethnic disparities remains poorly understood, they may be associated with a greater clustering of risk factors in African Americans, including lower socioeconomic status (4,5), lower physical activity (6) and genetic factors (7). These variations may also implicate environmental factors and/or modifiable lifestyle habits as important determinants of CVD risk. Numerous studies have shown that dietary behavior is an important lifestyle factor impacting risk of developing CVD (810). However, the influence of specific dietary factors on CVD risk for African Americans remains unsolved, particularly because the dietary behaviors and patterns differ across geographical areas and ethnic groups (11). Furthermore, associations of diet with CVD risk have been rarely examined in population-based studies with an adequate sample size of African Americans. Thus, the objective of this report is to describe dietary patterns, derived from principal component analysis (PCA), and to determine whether these dietary patterns can impact cardiometabolic abnormalities in African Americans of the JHS cohort from the Deep South metropolitan area of Jackson, Mississippi.

Methods

Study Sample

The JHS recruited 5301 African Americans from the Jackson, MS metropolitan area between September 2000 and March 2004 and comprises 5301 participants between the ages of 21–94 years (12). The cohort composed of four components: 1) approximately 31% of the cohort members were participants from the Atherosclerosis Risk in Communities (ARIC) study recruited to the JHS; 2) 30% were representative community volunteers who met census-derived age, sex and socioeconomic status eligibility criteria from the Jackson, MS metropolitan area; 3) 17% were randomly ascertained from the Jackson, Mississippi; 4) 22% were in the JHS family study. The sampling frame for the family study was participants in any one of the ARIC, random or volunteer samples whose family size met eligibility requirements as detailed previously (12). For the present study, study sample consisted of JHS participants, who underwent extensive dietary assessment interviews and multi-detector computed tomography scan. The study excluded participants with the presence of CVD, hypertension or diabetes (n=3361) and those without dietary assessments (n=165). Thus, the final sample size for this analysis is 1775.

Dietary Assessment and dietary Patterns

As part of the standard dietary data collection, usual dietary intake was assessed for all participants with a short food frequency questionnaire (FFQ) developed from a long questionnaire previously designed for the USDA Delta Nutrition Intervention Research Initiative (Delta-NIRI) (13). This Delta NIRI FFQ was specifically designed for a southern United States population to capture the regional eating patterns and the regional foods such as ham hocks, chitterling, grits, etc, with specified serving sizes that were described using natural portions or standard weight and volume measures of servings commonly consumed, based on 24 hour recall data in the Delta region. Due to limitations in time for the questionnaire, a shorter version of the Delta NIRI questionnaire was created for the JHS, reducing the number of food items from 283 to 158 by collapsing similar food items into categories (14). Average daily energy intakes of food items and total energy intake were calculated with software at Nutrition coordinating Center (University of Minnesota, Minneapolis, MN) and developed for the survey instrument (15). In order to minimize within-person variation in consumption of individual foods, the 158 food items were aggregated into 31 predefined food groups based on their energy contributions. Individual food items were preserved if they constituted distinct items on their own (i.e., chicken, corn products, butter, soup, coffee and tea) or if they were thought to represent particular dietary habits (Table 1).

Table 1
Food Grouping Used in Dietary Pattern Analysis in the Jackson Heart Study

For the reproducibility and validity of the short Delta NIRI JHS FFQ used for the entire cohort, a subset of participants (n=499) was selected from the whole JHS cohort (n=5301) for the Diet and Physical Activity sub-Study (DPASS) (15,16). Participants included for DPASS were matched on age, sex, socioeconomic status and physical activities (15). The original, long FFQ and 24-hour diet recalls were administrated for participants during their initial clinic visit, followed by four 24-hour dietary recalls scheduled a month apart from a month after the initial clinic visit, and the quality control checks were performed on both the short and the long FFQ (16). For most nutrients analyzed, both short and the long FFQ are reasonably valid for assessment of dietary intake of adult African Americans in the South (16).

Risk Factors and Covariate Assessment

Risk factors and covariates were measured at Exam 2 (2005 – 2008) (17). Body mass index (BMI) was defined as weight (in kilograms) divided by the square of height (in meters). Two measures of waist circumference (WC) (at the level of the umbilicus, in the upright position) were averaged to determine WC for each participant. Fasting blood samples were collected according to standardized procedures and the assessment of plasma glucose and lipids were processed at the Central Laboratory (University of Minnesota) as previously described. Sitting blood pressure was measured twice at 5-minutes intervals and the average of two measurements was used for analysis.

Participants were considered to have hypertension if they were taking antihypertensive medications and/or if their systolic pressure was ≥ 140 mm Hg or diastolic pressure ≥ 90 mm Hg. Impaired fasting glucose was defined as fasting plasma glucose of 100–125 mg/dl among those not treated for diabetes. Diabetes was defined as a fasting plasma glucose level ≥ 126 mg/dl or treatment with insulin or hypoglycemic agents. High triglycerides level were defined as fasting plasma triglyceride level ≥ 150 mg/dl and low HDL-C level was defined as fasting plasma HDL-C level < 40 mg/dl in men and < 50 in women. Participants were considered current smokers if they had smoked, used chewing tobacco or nicotine gum, or were wearing a nicotine patch at the time of interview. Daily alcohol consumption were assessed by the validated food frequency questionnaires and collected during the face-to-face encounters by trained interviewers (16). Physical activity was assessed using the JHS Physical Activity Cohort survey (JPAC) (18). Obesity was defined by BMI of at least 30 kg/m2 and modified National cholesterol Education Program Adult Treatment Panel III criteria were used to define the metabolic syndrome (19).

Multi-Detector CT Scan Protocol for Measuring Abdominal Adipose tissue (VAT) and Liver Fat

Abdominal adipose tissues (VAT) was measured at Exam 2 (2005 – 2008) and the research CT protocol has been reported previously (17). Briefly, the CT images included scout images, one ECG gated series of the entire heart, and a series through the lower abdomen detected by computed tomography system equipped with cardiac gating (GE Healthcare Lightspeed 16 Pro, Milwaukee, Wisconsin). The abdominal muscular wall was first manually traced and 24 contiguous 2-mm thick imaging slices covering the lower abdomen from L3 to S1 were used to measure VAT by semiautomatic segmentation technique. The abdominal fat volumes were the sum of VAT voxels over 24 slices. Volume Analysis software (Advantage Windows, GE Healthcare, Waukesha, WI) was used to segment and characterize each individual voxel as a tissue attenuation of fat using a threshold range −190 to −30 Hounsfield units. Participants were excluded from the CT scan Exam if: 1) body weight was greater than 350 lbs (~160 kg); 2) pregnant or unknown pregnancy status; 3) female participant < 40 years of age; 4) Male participant < 35 years of age.

The CT diagnosis of fatty liver can be made by measuring CT attenuation in Hounsfield Units (HU), which have been shown to be inversely correlated with the fatty filtration of the liver seen on liver biopsy (20). A more recent study demonstrates that a simple measurement of liver attenuation on unenhanced CT scans is the best method of predicting pathologic fat content in the liver (21). Thus, measurement of liver attenuation in HU (LA) was performed in multi-detector CT scans of the abdomen at the level of the T12 – L1 intervertebral space and was used to estimate liver fat. The LA was determined by calculating the mean HU of three regions of interest (ROI) in the parenchyma of the right lobe of the liver (20). In this study, high VAT or high liver fat were defined by 90th percentile of VAT or 10th percentile of LA (low LA = high liver fat) generated from the healthy participants. These participants were free of abnormal conditions including CVD, diabetes, hypertension and dyslipidemia at the time when CT Exam were conducted.

The study protocol was approved by the institutional review board of the participating institutions: the University of Mississippi Medical Center, Jackson State University and Tugaloo College. All participants provided informed consent.

Statistical Analysis

To identify major dietary patterns based on the 31 food groups, principal component analysis (PCA) was performed (22). Selected factors were rotated by an orthogonal transformation, which maintains uncorrelated factors and achieves a simple structure with greater interpretability. To determine the number of factors to be retained, the criteria of an eigenvalue > 1, the scree plot and interpretability of the factors were considered (22). The factor score for each pattern was constructed by summing observed energy intakes of the component food groups weighted by their factor loadings (23), and each participants received a factor score for each identified dietary pattern. The dietary patterns were interpreted and named based on high or low factor loadings of the food group relative to the population mean intake and to relative ranking of all food groups included in the PCA (Table 2).

Table 2
Factor Loadings* for Food Groups to the Dietary Patterns (Southern, Fast Food and Prudent)

LA and triglycerides were normalized by logarithmic transformation. Dietary factor scores were divided into tertiles. Descriptive statistics (means, SE and percentage) by tertiles of each dietary pattern were calculated for demographic/lifestyle/nutrient intakes of study participants. The generalized linear or logistic regression models were constructed with cardiometabolic risk factors as the independent variable and measures of dietary pattern as the dependent variable. Odds ratios and 95% confidence intervals from logistic regression models were calculated to ascertain the associations of dietary patterns with cardiometabolic risk factors after adjustment for age, sex, smoking and alcohol status, education and physical activities. All computations were performed by SAS software version 9.2 (SAS Institute Inc., Cary, North Carolina).

Results

Study Sample Characteristics by Dietary Patterns

Three major dietary patterns were identified in this study: the “southern”, the “fast food” and the “prudent” dietary pattern (Table 1). The “Southern” dietary pattern was principally characterized by high consumption of traditional rural southern US foods, such as beans & legumes, corn products, fried fish & chicken, margarine & butter, rice & pasta, and low consumption of wine, liquor and salty snacks. The “Fast Food” pattern was characterized by high consumption of sugar & candy juice, fast food and salty snacks, and the “Prudent” pattern was characterized by high intakes of fruits & vegetables, cold & hot cereals, nuts & seeds and low intakes of white bread and sweets. Compared with participants with lower “southern” dietary pattern scores, those with higher scores had significantly higher intakes of total energy, fat, total cholesterol and protein, but lower intake of dietary fibers (All p < 0.0001 for trend) (Table 3). Participants with higher “southern” pattern scores had adverse risk factor profiles, including larger WC, more VAT, elevated diastolic blood pressure, lower HDL-C and greater likelihood of metabolic syndrome (p range 0.007–0.0001 for trend). Similar trends were observed for the “fast food” pattern, with the exception of VAT. However, no significance was found between “prudent” pattern scores and any cardiometabolic risk factor (Table 4).

Table 3
Baseline Characteristics of Jackson Heart Study Participants without Medical Conditions by Dietary Pattern
Table 4
Cardiometabolic Risk Factor Profiles (Mean ± SE or Prevalence %) in Jackson Heart Study Participants without Medical Conditions by Dietary Pattern

Multivariate-Adjusted Association of Dietary Patterns with Cardiometabolic Risk Factors

Odds ratio (OR) for associations of dietary patterns with cardiometabolic risk factors were computed in multivariable models (Table 5). After adjustment for age, sex, energy intake, smoking and alcohol status, education level and physical activity, higher “southern” pattern scores were significantly associated with increased OR for high VAT, hypertension, diabetes and metabolic syndrome (p ranges 0.02–0.0005). Similar significant associations were observed with higher “fast food” pattern scores for hypertension, diabetes, metabolic syndrome, and low HDL-C (p ranges 0.03–0.0001). However, no significant associations were found between the “prudent” pattern scores and most cardiometabolic risk factors; with the exception of hypertension and high liver fat, which was inversely associated with the “prudent” pattern (OR 0.75, 95%CI 0.6–0.9 in Tertile 2, p=0.049 and OR 0.69, 95%CI 0.5–0.9 in Tertile 3, p=0.02).

Table 5
Association* between Dietary Patterns and Cardiometabolic Risk Factors across Score Tertiles

Discussion

Principal Findings

Using the Delta NIRI JHS FFQ that was specifically designed for the southern United States population to capture the regional food behaviors and eating habits, three dietary patterns, the “southern”, the “fast food” and the “prudent”, were identified in this cohort of African American adults. Both the “southern” and “fast food” dietary patterns were correlated with abdominal VAT and most of cardiometabolic risk factors. In contrast, the “prudent” pattern was significantly associated, in a protective direction, with liver fat and hypertension.

In the Context of the Current Literature

Identification of the “southern”, the “fast food” and the “prudent” patterns in this study sample is consistent with findings of our previous study (24) and others (8,10,11,15,2527), and with anthropological and historical accounts of traditional African American eating habits in the southern United States (11). The “fast food” and the “prudent” patterns identified in our study are characterized by high-fat, high-cholesterol, high-refined carbohydrate foods or with high-fruits, high-vegetables and high-fibers foods, respectively. These two dietary patterns resemble the “western” and the “healthy” patterns observed in other studies (8,10,23,25,26,28). The “southern” pattern is less commonly reported but is highlighted as a major recognizable dietary pattern in our study sample. Using the Delta NIRI JHS FFQ that was specifically designed for the southern United States populations to capture the regional eating habits and the regional foods, this pattern may reflect the southern roots and African American ancestral experiences of living in the South (11). Moreover, the observed associations between the “southern” dietary pattern, cardiometabolic risk factors and abdominal adiposity are especially intriguing because African Americans are more likely to consume this pattern (11), and this may contribute to higher risk for cardiovascular disease and obesity (1).

Characterized by high intakes of energy, fat, saturated fat and trans fatty acids from typical southern food items including grits, corn products, processed meats and poultry, margarine and butter, and miscellaneous fat (24), our results support the hypothesis that the “southern” dietary pattern, similar to the “fast food” pattern, is associated with increased risk for cardiometabolic abnormalities and abdominal fat accumulation. The detrimental association between the “southern” dietary pattern and cardiometabolic risk factors could be attributed to high-energy or high-fat but low-fiber constituents, which have been reported to be associated with visceral fat accumulation (29) or with lower insulin sensitivity (28) but higher plasma lipids (26), inflammatory cytokines (25) and metabolic syndrome (9,26). Therefore, it is possible that the “southern” dietary pattern clustering with other risk factors, such as socioeconomic status (4,5), physical activity (6) and genetic factors (7), represents one of the possible mechanisms leading to the high prevalence of hypertension, diabetes and obesity in this cohort (2,17).

Implications

Identifying and recognizing existing dietary patterns and their relationships with unhealthy outcomes in African American cohort from Jackson, MS are critically important to understand the pathological mechanisms linking obesity and CVD, two of most pressing diseases in the African American community. Our findings highlight an important role of the “southern” dietary pattern in the development of cardiometabolic abnormalities for the African American populations living in the south United States.

Limitations

The dietary pattern approach is complementary to analyses using individual food or nutrients, which are limited by biological explanations because of numerous dietary factors that can act individually, in combination and/or in interaction with each other. Thus, the logic behind the dietary pattern approach is that foods and nutrients are not eaten separately but are eaten in the form of specified dietary patterns. Although the statistical methods that have been used for data reduction have their own limitations, similar dietary patterns derived by factor analysis have been observed in different populations (810,2328). In addition, limitations of the FFQ also apply to dietary pattern analyses that are based on dietary information collected by this method. The other limitation of this study is its cross-sectional nature, thus, the associations between these dietary patterns and cardiometabolic risk factors remain to be confirmed in prospective analyses. We cannot generalize our findings to other ethnic groups because of geographical locations and cultural differences in eating behaviors and eating habits.

Conclusions

Dietary patterns, especially the “southern” pattern, identified from a regionally specific FFQ in this population of Deep South African Americans, are correlated with abdominal VAT and cardiometabolic risk factors.

Acknowledgments

The authors thank the staff, interns and participants in Jackson Heart Study for their long-term commitment and important contributions to the study.

Funding/Support:

The Jackson Heart Study is supported by the National Heart, Lung, and Blood Institute and the National Center on Minority Health and Health Disparities. Funding for Dr. Herman A. Taylor was provided under contracts N01-HC-95170, N01-HC-95171 and N01-C-95172 from the National Heart, Lung and Blood Institute and the National Center on Minority Health and Health Disparities.

Footnotes

Disclosure:

The authors declared no conflict of interest.

Author Contributions:

Dr. Liu had full access to all of the data in the study and takes responsibility for integrity of the data and accuracy of data analysis.

Study Concept and Design: Drs. Liu, Fox, Talegawkar, Tucker and Taylor.

Acquisition of data: Dr. Liu.

Analysis and Interpretation of data: Drs. Liu, Fox, Hickson, Talegawkar and Taylor.

Manuscript drafting: Drs. Liu, Fox and Taylor.

Critical revisions of the manuscript for important intellectual content: Drs. Fox, Taylor, Liu, Hickson, Musani, Talegawkar and Tucker.

Statistical analysis: Dr. Liu.

Obtained funding: Dr. Herman A. Taylor

Reference List

1. Ferdinand KC. Coronary artery disease in minority racial and ethnic groups in the United States. Am J Cardiol. 2006;97:12A–19A. [PubMed]
2. Taylor HA, Jr, Coady SA, Levy D, Walker ER, Vasan RS, Liu J, Akylbekova EL, Garrison RJ, Fox C. Relationships of BMI to cardiovascular risk factors differ by ethncity. Obesity (Silver Spring) 2010;18:1638–1645. [PMC free article] [PubMed]
3. Taylor HA, Liu J, Wilson G, Golden SH, Crook E, Brunson CD, Steffes M, Johnson WD, Sung JH. Distinct component profiles and high risk among African Americans with metabolic syndrome: the Jackson Heart Study. Diabetes Care. 2008;31:1248–1253. [PMC free article] [PubMed]
4. Bruce MA, Beech BM, Sims M, Brown TN, Wyatt SB, Taylor HA, Williams DR, Crook E. Social environmental stressors, psychological factors, and kidney disease. J Investig Med. 2009;57:583–589. [PMC free article] [PubMed]
5. Loustalot F, Wyatt SB, Sims M, Ellison CG, Taylor HA, Underwood L. Psychometric Testing of the Daily Spritual Experiences Scale Among African Americans in the Jackson Heart Study. J Relig Health. 2009 [PMC free article] [PubMed]
6. Dubbert PM, Robinson JC, Sung JH, Ainsworth BE, Wyatt SB, Carithers T, Newton R, Jr, Rhudy JL, Barbour K, Sternfeld B, Taylor H., Jr Physical activity and obesity in African Americans: the Jackson Hear Study. Ethn Dis. 2010;20:388–389. [PubMed]
7. Deo RC, Reich D, Tandon A, Akylbekova E, Patterson N, Waliszewska A, Kathiresan S, Sarpong D, Taylor HA, Jr, Wilson JG. Genetic differences between the determinants of lipid profile phenotypes in African and European Americans: the Jackson Heart Study. PLoS Genet. 2009;5:e1000342. [PMC free article] [PubMed]
8. Berg CM, Lappas G, Strandhagen E, Wolk A, Toren K, Rosengren A, Aires N, Thelle DS, Lissner L. Food patterns and cardiovascular disease risk factors: the Swedish INTERGENE research program. Am J Clin Nutr. 2008;88:289–297. [PubMed]
9. Liu L, Nettleton JA, Bertoni AG, Bluemke DA, Lima JA, Szklo M. Dietary pattern, the metabolic syndrome, and left ventricular mass and systolic function: the Multi-Ethnic Study of Atherosclerois. Am J Clin Nutr. 2009;90:362–368. [PubMed]
10. Panagiotakos D, Pitsavos C, Chrysohoou C, Palliou K, Lentzas I, Skoumas I, Stefanadis C. Dietary patterns and 5-year incidence of cardiovascular disease: a multivariate analysis of the ATTICA study. Nutr Metab Cardiovasc Dis. 2009;19:253–263. [PubMed]
11. Dirks RT, Duran N. African American dietary patterns at the beginning of the 20th century. J Nutr. 2001;3:1881–1889. [PubMed]
12. Fuqua SR, Wyatt SB, Andrew ME, Sarpong DF, Henderson FR, Cunningham MF, Taylor HA., Jr Recruiting African-American research participation in the Jackson Heart Study: methods, response rates, and sample description. Ethn Dis. 2005;15:S6–29. [PubMed]
13. Tucker KL, Maras J, Champagne C, Connell C, Goolsby S, Weber J, Zaghloul S, Carithers T, Bogle ML. A regional food-frequency questionnaire for the US Mississippi Delta. Public Health Nutr. 2005:87–96. [PubMed]
14. Carithers T, Dubbert PM, Crook E, Davy B, Wyatt SB, Bogle ML, Taylor HA, Jr, Tucker KL. Dietary assessment in African Americans: methods used in the Jackson Heart Study. Ethn Dis. 2005;15:S6–55. [PubMed]
15. Carithers TC, Talegawkar SA, Rowser ML, Henry OR, Dubbert PM, Bogle ML, Taylor HA, Jr, Tucker KL. Validity and calibration of food frequency questionnaires used with African-American adults in the Jackson Heart Study. J Am Diet Assoc. 2009;109:1184–1193. [PMC free article] [PubMed]
16. Carithers T, Dubbert PM, Crook E, Davy B, Wyatt SB, Bogle ML, Taylor HA, Jr, Tucker KL. Dietary assessment in African Americans: methods used in the Jackson Heart Study. Ethn Dis. 2005;15:S6–55. [PubMed]
17. Liu J, Fox CS, Hickson DA, May WD, Hairston KG, Carr JJ, Taylor HA. Impact of abdominal visceral and subcutaneous adipose tissue on cardiometabolic risk factors: the Jackson Heart Study. J Clin Endocrinol Metab. 2010;95:5419–5426. [PubMed]
18. Smitherman TA, Dubbert PM, Grothe KB, Sung JH, Kendzor DE, Reis JP, Ainsworth BE, Newton RL, Jr, Lesniak KT, Taylor HA., Jr Validation of the Jackson Heart Study Physical Activity Survey in African Americans. J Phys Act Health. 2009;6 (Suppl 1):S124–S132. [PubMed]
19. Grundy SM, Brewer HB, Jr, Cleeman JI, Smith SC, Jr, Lenfant C. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Arterioscler Thromb Vasc Biol. 2004;24:e13–e18. [PubMed]
20. Liu J, Fox CS, Hickson D, Bidulescu A, Carr JJ, Taylor HA. Fatty Liver, Abdominal Visceral Fat, and Cardiometabolic Risk Factors: The Jackson Heart Study. Arterioscler Thromb Vasc Biol. 2011 [PMC free article] [PubMed]
21. Kodama Y, Ng CS, Wu TT, Ayers GD, Curley SA, Abdalla EK, Vauthey JN, Charnsangavej Comparison of CT methods for determining the fat content of the liver. AJR Am J Roentgenol. 2007;188:1307–1312. [PubMed]
22. Newby PK, Tucker KL. Empirically derived eating patterns using factor cluster analysis: a review. Nutr Rev. 2004;62:177–203. [PubMed]
23. Esmaillzadeh A, Kimiagar M, Mehrabi Y, Azadbakht L, Hu FB, Willett WC. Dietary patterns, insulin resistance, and prevalence of the metabolic syndrome in women. Am J Clin Nutr. 2007;85:910–918. [PubMed]
24. Talegawkar SA, Johnson EJ, Carithers TC, Taylor HA, Jr, Bogle ML, Tucker KL. Serum carotenoid and tocopherol concentrations vary by dietary pattern among African Americans. J Am Diet Assoc. 2008;108:2013–2020. [PMC free article] [PubMed]
25. Lopez-Garcia E, Schulze MB, Fung TT, Meigs JB, Rifai N, Manson JE, Hu FB. Major dietary patterns are related to plasma concentrations of markers of inflammation and endothelial dysfunction. Am J Clin Nutr. 80:1029–1035. 204. [PubMed]
26. shmukh-Taskar PR, O’Neil CE, Nicklas TA, Yang SJ, Liu Y, Gustat J, Berenson GS. Dietary patterns associated with metabolic syndrome, sciodemographic and lifestyle factors in young adults: the Bogalusa Heart Study. Public Health Nutr. 2009;12:2493–2503. [PMC free article] [PubMed]
27. Velie EM, Schairer C, Flood A, He JP, Khattree R, Schatzkin A. Empirically derived dietary patterns and risk of postmenopausal breast cancer in large prospective cohort study. Am J Clin Nutr. 2005;82:1308–1319. [PubMed]
28. McNaughton SA, Mishra GD, Bruner EJ. Dietary patterns, insulin resistance, and incidence of type 2 diabetes in the Whitehall Study. Diabetes Care. 2008;31:1343–1348. [PMC free article] [PubMed]
29. Votruba SB, Mattison RS, Dumesic DA, Koutsari C, Jensen MD. Meal fatty acid uptake in visceral fat in women. Diabetes. 2007;56:2589–2597. [PubMed]