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Associations of cereal grains intake with cardiovascular disease and mortality across 21 countries in Prospective Urban and Rural Epidemiology study: prospective cohort study

Swaminathan S 1 , Dehghan M 2 , Raj JM 3 , Thomas T 3 , Rangarajan S 4 , Jenkins D 5 Show all authors , Mony P 1 , Mohan V 6 , Lear SA 7 , Avezum A 8 , Lopez-Jaramillo P 9 , Rosengren A 10 , Lanas F 11 , AlHabib KF 12 , Dans A 13 , Keskinler MV 14 , Puoane T 15 , Soman B 16 , Wei L 17 , Zatonska K 18 , Diaz R 19 , Ismail N 20 , Chifamba J 21 , Kelishadi R 22 , Yusufali A 23 , Khatib R 24 , Xiaoyun L 17 , Bo H 17 , Iqbal R 25 , Yusuf R 26 , Yeates K 27 , Teo K 4 , Yusuf S 4

Affiliations 

  • 1 St John's Research Institute, Bangalore, India
  • 2 Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada Mahshid.dehghan@phri.ca
  • 3 St John's Medical College, Bangalore, India
  • 4 Population Health Research Institute (PHRI), McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
  • 5 Department of Nutritional Sciences and Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
  • 6 Madras Diabetes Research Foundation and Dr Mohan's Diabetes Specialities Centre, Chennai, India
  • 7 Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
  • 8 International Research Centre, Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil, Universidade Santo Amaro (UNISA), Sao Paulo, Brazil
  • 9 Masira Research Institute, Medical School, Santander University (UDES), Colombia
  • 10 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • 11 Universidad de La Frontera, Temuco, Chile
  • 12 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 13 University of Philippines, Section of Adult Medicine and Medical Research Unit, Manila, Philippines
  • 14 Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
  • 15 University of the Western Cape, Bellville, South Africa
  • 16 Health Action by People, Thiruvananthapuram, Kerala, India
  • 17 National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
  • 18 Wroclaw Medical University, Department of Social Medicine, Wroclaw, Poland
  • 19 Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
  • 20 Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
  • 21 Physiology Department, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
  • 22 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  • 23 Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  • 24 Institute for Community and Public Health, Birzeit University, Birzeit, Palestine
  • 25 Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 26 School of Life Sciences, Independent University, Bangladesh, Dhaka, Bangladesh
  • 27 Department of Medicine, Queen's University, Kingston, ON, Canada
BMJ, 2021 02 03;372:m4948.
PMID: 33536317 DOI: 10.1136/bmj.m4948

Abstract

OBJECTIVE: To evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study.

DESIGN: Prospective cohort study.

SETTING: PURE study in 21 countries.

PARTICIPANTS: 148 858 participants with median follow-up of 9.5 years.

EXPOSURES: Country specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice.

MAIN OUTCOME MEASURE: Composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre.

RESULTS: Analyses were based on 137 130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12 668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes.

CONCLUSION: High intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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