Amount, type, and sources of carbohydrates in relation to ischemic heart disease mortality in a Chinese population: a prospective cohort study.
BACKGROUND
The relation between carbohydrate intake and risk of ischemic heart disease (IHD) has not been fully explored in Asian populations known to have high-carbohydrate diets.


OBJECTIVE
We assessed whether intakes of total carbohydrates, different types of carbohydrates, and their food sources were associated with IHD mortality in a Chinese population.


METHODS
We prospectively examined the association of carbohydrate intake and IHD mortality in 53,469 participants in the Singapore Chinese Health Study with an average follow-up of 15 y. Diet was assessed by using a semiquantitative food-frequency questionnaire. HRs and 95% CIs were calculated by using a Cox proportional hazards analysis.


RESULTS
We documented 1660 IHD deaths during 804,433 person-years of follow-up. Total carbohydrate intake was not associated with IHD mortality risk [men: HR per 5% of energy, 0.97 (95% CI: 0.92, 1.03); women: 1.06 (95% CI: 0.99, 1.14)]. When types of carbohydrates were analyzed individually, starch intake was associated with higher risk [men: 1.03 (95% CI: 0.99, 1.08); women: 1.08, (95% CI: 1.02, 1.14)] and fiber intake with lower risk of IHD mortality [men: 0.94 (95% CI: 0.82, 1.08); women: 0.71 (95% CI: 0.60, 0.84)], with stronger associations in women than men (both P-interaction < 0.01). In substitution analyses, the replacement of one daily serving of rice with one daily serving of noodles was associated with higher risk (difference in HR: 26.11%; 95% CI: 10.98%, 43.30%). In contrast, replacing one daily serving of rice with one of vegetables (-23.81%; 95% CI: -33.12%, -13.20%), fruit (-11.94%; 95% CI: -17.49%, -6.00%), or whole-wheat bread (-19.46%; 95% CI: -34.28%, -1.29%) was associated with lower risk of IHD death.


CONCLUSIONS
In this Asian population with high carbohydrate intake, the total amount of carbohydrates consumed was not substantially associated with IHD mortality. In contrast, the shifting of food sources of carbohydrates toward a higher consumption of fruit, vegetables, and whole grains was associated with lower risk of IHD death.
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Salome A
SA
Rebello
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Hiromi
H
Koh
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Cynthia
C
Chen
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Nasheen
N
Naidoo
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Andrew O
AO
Odegaard
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Woon-Puay
WP
Koh
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Lesley M
LM
Butler
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Jian-Min
JM
Yuan
From the Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore (SAR, HK, CC, NN, W-PK, and RMvD); the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN (AOO), the Duke-National University of Singapore Graduate Medical School, Singapore (W-PK); the Division of Cancer Control and Population Sciences, University of Pittsburgh Cancer Institute and Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (J-MY and LMB); the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (RMvD); and the Department of Nutrition, Harvard School of Public Health, Boston, MA (RMvD).
Rob M
RM
van Dam
D000368:Aged; D044466:Asian People; D015992:Body Mass Index; D004032:Diet; D004040:Dietary Carbohydrates / Q000008:administration & dosage* / Q000009:adverse effects; D002523:Edible Grain; D005247:Feeding Behavior; D005260:Female; D005500:Follow-Up Studies; D005638:Fruit; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000401:mortality*; D015596:Nutrition Assessment; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D012846:Singapore / Q000453:epidemiology; D011795:Surveys and Questionnaires; D014675:Vegetables
D004040:Dietary Carbohydrates