Correction: Impact of diets high in trans-fatty acids on cardiovascular diseases in adults aged 55 and older: insights from the Global Burden of Disease 2021 data

Cardiovascular diseases (CVD), primarily including ischemic heart disease (IHD) and stroke, are the leading causes of death and disability worldwide, posing a significant burden on public health and healthcare systems (1,2). The pathogenesis of CVD is characterized by endothelial dysfunction and chronic vascular wall inflammation, which gradually progress to atherosclerotic lesions and ultimately result in myocardial infarction and stroke (3,4). With the global increase in major risk factors such as population aging, obesity, and diabetes, the burden of CVD has been rising markedly in both industrialized and developing countries (5)(6)(7). It is estimated that between 1990 and 2019, the global prevalence of CVD nearly doubled, and this trend is likely to continue in the coming years (6). Among these, adults aged 55 years and older-due to cumulative exposure to risk factors and age-related physiological decline-are at particularly high risk for CVD incidence and mortality (8).Diet is a key modifiable risk factor for CVD, and high intake of trans-fatty acids (TFA) has drawn increasing attention due to its role in dyslipidemia, inflammatory responses, and promotion of atherosclerosis (9,10). TFA are mainly found in partially hydrogenated vegetable oils, margarine, processed baked goods, and fried foods. Although some high-income countries have implemented strict regulations to limit TFA content, intake levels remain elevated in many parts of the world, particularly in low-and middle-income countries (11,12). Numerous epidemiological studies have confirmed that TFA intake is significantly associated with coronary heart disease, stroke, and other CVDs (13). Older adults are particularly vulnerable to the long-term harmful effects of TFA, with higher incidence, mortality, and long-term disability risks observed in this population (14,15). Therefore, evaluating the CVD burden attributable to high TFA intake among individuals aged 55 years and older is essential for formulating targeted dietary interventions, optimizing resource allocation, and reducing healthcare burdens.The Global Burden of Disease (GBD) study provides valuable data and methodologies for quantifying disease burdens attributable to various risk factors. The GBD database systematically assesses the health burden of 369 diseases and injuries and 87 risk factors across 204 countries and territories from 1990 to 2021 (16). However, a comprehensive analysis focusing on the CVD mortality and disabilityadjusted life years (DALYs) burden attributable to high TFA intake among adults aged 55 and above is still lacking. Based on GBD 2021 data, this study employs an age-period-cohort (APC) model to comprehensively analyze the trends in CVD burden attributable to TFA intake at global, regional, and national levels from 1990 to 2021. It also examines differences by sociodemographic index (SDI), sex, and geographic region, aiming to provide data support and policy implications for CVD prevention and control in older populations worldwide.The Global Burden of Disease Study 2021 (GBD 2021), led by the Institute for Health Metrics and Evaluation (IHME), is a large-scale international collaborative project. Based on sustained cooperation across countries, the study systematically evaluated the global burden of 369 diseases and injuries and 87 risk factors, stratified by age and sex, across 204 countries and territories from 1990 to 2021.The data used in this study were obtained from the official GBD 2021 data platform. 1 We accessed the "GBD Results Tool" to retrieve relevant data. Under the "GBD Estimate" section, we selected "risk factor" to identify specific exposures contributing to disease burden. In the "Measure" section, we chose both "Death" and "DALYs" to quantify the overall health impact. For the "Risk" category, we selected "diet high in trans-fatty acid" as the exposure of interest, and in the "Cause" section, we selected "cardiovascular disease" as the specific health outcome. In the "Age" section, we selected "55+" and additional age group categories above 55 years to focus on older populations.By clicking the "Search" button, we were able to filter and extract the raw data relevant to our study; alternatively, the data could be downloaded using the "Download" option. This systematic data extraction process ensured that we obtained accurate and detailed data on the impact of a diet high in trans-fatty acids on cardiovascular disease outcomes, as measured by deaths and DALYs, thereby providing a solid foundation for subsequent burden of disease analysis.The primary objective of this study was to analyze the temporal trends in mortality and disability-adjusted life years (DALY) rates of cardiovascular disease (CVD) attributable to diets high in trans-fatty acids from 1990 to 2019. To eliminate the impact of differences in population structure, we used age-standardized mortality rates (ASMR) and age-standardized DALY rates (ASDR) as key indicators. Trends in ASMR and ASDR were evaluated using the estimated annual percentage change (EAPC), a widely used metric for assessing changes in age-standardized rates (ASR). The ASR per 100,000 population was calculated using the following formula:∑ = = × ∑ = i i i A a w i 1 ASR 100000 A w i 1 (1)In this formula (1), aᵢ denotes the age-specific rate for the ith age group, wᵢ is the number of individuals in the corresponding ith age group of the standard population, and A is the total number of age groups. To assess temporal trends in incidence, mortality, and DALYs, we calculated the Estimated Annual Percentage Change (EAPC), a α β ε = + + y x (2) ( ) ( ) β = × - 100 1 EAPC exp (3)The direction of ASR trends was assessed by examining the Estimated Annual Percentage Change (EAPC) alongside its 95% confidence interval (CI) formula ( 3). An increasing trend was identified when both the EAPC and the lower bound of its 95% CI were greater than zero, whereas a decreasing trend was indicated when both the EAPC and the upper bound of the 95% CI were less than zero. To forecast the future burden of disease from 1990 to 2035, we applied a log-linear age-period-cohort (APC) model.We analyzed sex-specific and age-specific burden across SDI quintiles. Age groups were categorized in 5-year intervals (55-59, 60-64, …, 95+). Comparisons were made between males and females and across SDI levels.We applied the Age-Period-Cohort (APC) model using the Intrinsic Estimator method to disentangle age, period, and cohort effects on CVD mortality and DALY burden attributable to high TFA intake.• Age effect reflects the variation in risk associated with biological and behavioral factors at different ages. • Period effect represents temporal influences such as medical advancements, public health interventions, or policy changes (e.g., TFA bans). • Cohort effect captures generational differences in exposure and risk accumulation.We also conducted local drift analysis to estimate the annual percentage change in mortality and DALY rates across age groups.We fitted a log-linear Poisson APC model with polynomial parameterization (quadratic age, period, and cohort effects plus higher-order categorical deviations). The model addresses identifiability through mean-centering, where linear age trend (LAT), net drift, and cohort age trend (CAT) satisfy LAT = Net Drift + CAT. We estimated net drift (overall annual percentage change), local drifts (age-specific trends), and age-period-cohort deviations. Statistical significance was assessed using Wald tests. Analysis used R 4.5.1 with custom functions following Holford (17) and Clayton and Schifflers (18).We quantified cross-country health inequalities using the Slope Index of Inequality (SII) and Concentration Index (CI).• SII measures absolute inequality by regressing health outcomes on the relative socioeconomic rank of countries. • CI assesses relative inequality, with positive values indicating concentration in higher-SDI countries and negative values indicating concentration in lower-SDI countries.To predict future trends, we employed a Bayesian Age-Period-Cohort (BAPC) model, incorporating historical ASMR and ASDR data from 1990-2021 to project CVD burden trends up to 2035. The BAPC analysis was implemented using the BAPC R package, which employs Bayesian Age-Period-Cohort modeling via Integrated Nested Laplace Approximation (INLA) (19). All analyses were conducted using R software (version 4.2.2) with packages Epi, BAPC, and ggplot2. A p-value <0.05 was considered statistically significant.Frontiers in Nutrition 04 frontiersin.orgTrends in CVD burden attributable to diet high in TFABetween 1990 and 2021, the number of CVD deaths attributable to high TFA intake among individuals aged 55 and older decreased from 104 million in 1990 to 71.32 million in 2021, marking a 32% reduction (95% CI: -0.33 to -0.31). The ASMR declined from 15.5 per 100,000 to 4.8 per 100,000, representing a 69% decrease (EAPC: -3.7, 95% CI: -4.1 to -3.3), reflecting the positive impact of dietary changes, policy interventions (such as TFA bans), and medical improvements.The most notable improvements were observed in high-SDI regions, where the number of deaths decreased by 91%, the ASMR dropped from 33.10 to 1.60, and the EAPC was -7.1%. In contrast, low-SDI regions saw an increase in the number of deaths, although mortality rates showed a slight decline (EAPC: -1.6%). Geographically, the fastest declines in mortality rates were recorded in high-income North America (EAPC: -17.3%), Central Europe (-8.4%), and the Caribbean (-7.5%), while more modest declines were seen in North Africa and the Middle East (-0.9%), East Africa (-3.4%), and low-income Asia (-1.5%). Overall, significant global progress has been made in CVD prevention and control; however, regional disparities persist, particularly in areas with limited medical resources, which continue to face considerable challenges (Table 1; Figure 1A).At the national level, the number of deaths in China increased by 76.3%, and in India by 64.3%; however, their ASMR declined from 1.9 to 1.3 and from 24.7 to 15.5, respectively. In contrast, Germany saw a 71.5% decrease in deaths, and the UK a 75.4% decrease, both accompanied by substantial reductions in ASMR, reflecting effective disease prevention and treatment strategies. Regionally, South Asia-particularly Pakistan (ASMR: 18.5)-bears a heavy burden of CVD; similarly, Egypt (ASMR: 95.9) and Iran (ASMR: 36.1) in North Africa and the Middle East also report high levels. The most significant improvements were seen in Eastern Europe's Georgia, where ASMR dropped from 25.2 to 1.8; Western Europe's Ireland, with an EAPC of -11.1%; and Central Asia's Kazakhstan, with an EAPC as high as -14.4% (Supplementary Table S1; Figure 2).In terms of DALYs, from 1990 to 2021, the global burden of CVD attributable to TFA intake showed a declining trend both globally and across different SDI regions. The global ASDR dropped from 309.6 per 100,000 in 1990 (95% UI: 31.1-581.3) to 100.1 in 2021 (95% UI: 9.4-193.2). In low SDI regions, the ASDR decreased from 192.1 (95% UI: 22.0-384.5) to 118.2 (95% UI: 11.2-235.1); in low-middle SDI regions, from 450.9 (95% UI: 45.9-856.9) to 306.4 (95% UI: 28.3-578.0); in middle SDI regions, from 196.9 (95% UI: 21.4-378.4) to 106.8 (95% UI: 10.2-208.8); and in high-middle SDI regions, from 61.0 (95% UI: 6.4-124.6) to 18.8 (95% UI: 1.8-38.7). These figures indicate a general reduction in the burden of CVD due to high TFA intake across all regions, with the most significant decline observed in high-middle SDI areas (Table 2; Figure 1B).At the national level, taking China as an example, the total DALYs increased from 57,176.1 to 79,733.1, representing a 39.5% rise. However, ASDR declined from 39.8 to 21.0, marking a 47.2% decrease. Globally, EAPC in ASDR was -4.6%. Kazakhstan showed the best performance, with an EAPC of -14.9%, while Georgia's ASDR dropped significantly from 478.6 to 31.2, with an EAPC of -11.5%.The countries with the heaviest burden in 2021 included Egypt (ASDR as high as 2208.4), India (342.9), and Pakistan (417.8). Notably, Libya exhibited an abnormal upward trend, with its ASDR increasing from 52.1 to 76.5 and an EAPC of +2.1% (Supplementary Table S2; Figure 2).Figures 1C,D show a significant positive correlation between ASMR and ASDR and the SDI (p < 0.01). Although the data indicate that higher SDI levels are associated with higher ASMR and ASDR values, overall, both ASMR and ASDR of CVD attributable to high TFA intake have declined globally and across all SDI regions. Moreover, the degree of reduction in disease burden is positively associated with SDI level, suggesting that higher-income countries have achieved more notable progress through effective interventions and improvements.From 1990 to 2021, the burden of CVD attributable to high TFA intake among adults aged 55 and older exhibited notable sex differences across different SDI regions. Overall, males consistently bore a higher burden than females in nearly all SDI levels, in terms of both DALYs and mortality. This disparity was most pronounced in low and low-middle SDI regions, where the gaps between sexes were particularly large. In contrast, high SDI regions showed relatively minor differences between males and females, with their DALYs and mortality rates converging, reflecting more equitable health interventions and access to resources. Thus, while sex disparities in CVD burden are globally prevalent, they are especially significant in regions with lower SDI levels (Figures 3A,B).We conducted a global analysis of sex-and age-specific differences in CVD attributable to high TFA intake among adults aged 55 and older. As shown in Figures 4A,B, in terms of sex differences, the CVD mortality and DALYs rate attributable to high TFA intake in 2021 was significantly higher in males than in females across the 55 + age group, reflecting the global epidemiological pattern of CVD. Regarding age differences, we found that the absolute numbers of deaths and DALYs were highest in the 55-59, 60-64, and 65-69 age groups. However, both mortality rate and DALY rate increased markedly with age, with a sharp rise observed among individuals aged 80 and above. The highest rates were recorded in the 95 + age group, while the lowest were in the 55-59 age group. As shown in Figures 4C,D, the burden of deaths and DALYs across different age groups also varies by SDI level. In high SDI regions, due to a higher degree of population aging, the disease burden is more heavily concentrated in the 85 + age group. In contrast, in low SDI regions, the burden is more prominent in younger age groups, particularly among those aged 55-64. Over time, from 1990 to 2021, the age distribution of CVD burden has shifted. The proportion of the burden among the middle-aged and elderly groups (55-79 years) has steadily increased, while the proportion in the 95 + age group has declined. This indicates a gradual shift in CVD burden from the oldest old to the younger elderly population. the burden for the and age groups have also increased, that middle-aged age groups are the focus of disease burden. 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