• Sumathi Swaminathan, Mahshid Dehghan, John Michael Raj, Tinku Thomas, Sumathy Rangarajan, David Jenkins, Prem Mony, Viswanathan Mohan, Scott A Lear, Alvaro Avezum, Patricio Lopez-Jaramillo, Annika Rosengren, Fernando Lanas, Khalid F AlHabib, Antonio Dans, Mirac Vural Keskinler, Thandi Puoane, Biju Soman, Li Wei, Katarzyna Zatonska, Rafael Diaz, Noorhassim Ismail, Jephat Chifamba, Roya Kelishadi, Afzalhussein Yusufali, Rasha Khatib, Liu Xiaoyun, Hu Bo, Romaina Iqbal, Rita Yusuf, Karen Yeates, Koon Teo, and Salim Yusuf.
• St John's Research Institute, Bangalore, India.
• BMJ. 2021 Feb 3; 372: m4948.

ObjectiveTo 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.DesignProspective cohort study.SettingPURE study in 21 countries.Participants148 858 participants with median follow-up of 9.5 years.ExposuresCountry specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice.Main Outcome MeasureComposite 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.ResultsAnalyses 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.ConclusionHigh 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.© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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