Associations of the glycaemic index and the glycaemic load with risk of type 2 diabetes in 127 594 people from 20 countries (PURE): a prospective cohort study.

BACKGROUND: The association between the glycaemic index and the glycaemic load with type 2 diabetes incidence is controversial. We aimed to evaluate this association in an international cohort with diverse glycaemic index and glycaemic load diets. METHODS: The PURE study is a prospective cohort study of 127 594 adults aged 35-70 years from 20 high-income, middle-income, and low-income countries. Diet was assessed at baseline using country-specific validated food frequency questionnaires. The glycaemic index and the glycaemic load were estimated on the basis of the intake of seven categories of carbohydrate-containing foods. Participants were categorised into quintiles of glycaemic index and glycaemic load. The primary outcome was incident type 2 diabetes. Multivariable Cox Frailty models with random intercepts for study centre were used to calculate hazard ratios (HRs). FINDINGS: During a median follow-up of 11·8 years (IQR 9·0-13·0), 7326 (5·7%) incident cases of type 2 diabetes occurred. In multivariable adjusted analyses, a diet with a higher glycaemic index was significantly associated with a higher risk of diabetes (quintile 5 vs quintile 1; HR 1·15 [95% CI 1·03-1·29]). Participants in the highest quintile of the glycaemic load had a higher risk of incident type 2 diabetes compared with those in the lowest quintile (HR 1·21, 95% CI 1·06-1·37). The glycaemic index was more strongly associated with diabetes among individuals with a higher BMI (quintile 5 vs quintile 1; HR 1·23 [95% CI 1·08-1·41]) than those with a lower BMI (quintile 5 vs quintile 1; 1·10 [0·87-1·39]; p interaction=0·030). INTERPRETATION: Diets with a high glycaemic index and a high glycaemic load were associated with a higher risk of incident type 2 diabetes in a multinational cohort spanning five continents. Our findings suggest that consuming low glycaemic index and low glycaemic load diets might prevent the development of type 2 diabetes. FUNDING: Full funding sources are listed at the end of the Article.

Assessing association of household diet diversity with mother's time use on productive and reproductive activities: a case for gender sensitive social safety nets.

OBJECTIVE: In South Asia, while women make substantial economic contributions through their participation in agricultural sector, these contributions are undercounted as most of their work is underpaid or unpaid. This paper examines how mothers allocate their time to productive and reproductive activities and its association with a household's ability to achieve high household diet diversity score. DESIGN: The analysis uses data on household consumption and expenditure including food during the kharif (June to October) season (seeds are sown) and a modular time-use survey. SETTING: Two districts of rural Bihar, India. PARTICIPANTS: Mothers with children less than 5 years of age and supported by the head of the household from 2026 households. RESULTS: The estimates indicate that the high household diet diversity (High HDDS ≥ 10) is associated with greater time spent in reproductive activities by all women (OR = 1·12, 95 % CI: 1·06, 1·18). However, with increasing time spent in productive activities by the women the odds of achieving 'High HDDS' reduced (OR = 0·83, 95 % CI: 0·77, 0·89) in adjusted logistic regression analysis. CONCLUSION: The findings highlight propensity to achieve 'High HDDS' in Bihar increased with mothers allocating time towards reproductive activities, while it had an opposing effect with mothers allocating time on productive activities. Our study highlights that the policies that encourage women's participation in agriculture or livestock should acknowledge the unpaid nature of some of the productive activities and design programs to improve economic agency of women to actuate the true potential of agriculture-nutrition pathways.

Predictors of anaemia in mothers and children in Uttar Pradesh, India.

OBJECTIVE: Anaemia affects more than half of Indian women and children, but the contribution of its causes remains unquantified. We examined interrelationships between Hb and nutritional, environmental, infectious and genetic determinants of anaemia in non-pregnant mothers and children in Uttar Pradesh (UP). DESIGN: We conducted a cross-sectional survey of households in twenty-five districts of UP between October and December 2016. We collected socio-demographic data, anthropometry and venous blood in 1238 non-pregnant mothers and their children. We analysed venous blood samples for malaria, Hb, ferritin, retinol, folate, Zn, vitamin B12, C-reactive protein, α1-acid glycoprotein (AGP) and ß-thalassaemia. We used path analysis to examine pathways through which predictors of anaemia were associated with Hb concentration. SETTING: Rural and urban households in twenty-five districts of UP. PARTICIPANTS: Mothers 18-49 years and children 6-59 months in UP. RESULTS: A total of 36·4 % of mothers and 56·0 % of children were anaemic, and 26·7 % of women and 44·6 % of children had Fe deficiency anaemia. Ferritin was the strongest predictor of Hb (ß (95 % CI) = 1·03 (0·80, 1·27) g/dL in women and 0·90 (0·68, 1·12) g/dL in children). In children only, red blood cell folate and AGP were negatively associated with Hb and retinol was positively associated with Hb. CONCLUSIONS: Over 70 % of mothers and children with anaemia had Fe deficiency, needing urgent attention. However, several simultaneous predictors of Hb exist, including nutrient deficiencies and inflammation. The potential of Fe interventions to address anaemia may be constrained unless coexisting determinants are jointly addressed.

A longitudinal survey on changes in employment and food consumption during the COVID-19 pandemic in rural Bihar, India.

BACKGROUND: There is a need for empirical evidence on changes in employment and food consumption during pandemic situations in households belonging to the informal economy. OBJECTIVE: To examine changes in food insecurity, household diet diversity, and employment in agriculture during the pre-COVID-19 (2019-early 2020) and COVID-19 pandemic (September 2021) periods. METHODS: A total of 1632 households from a face-to-face pre-COVID-19 survey and 621 of those followed up by a telephonic survey during COVID-19 in Bihar, India, were included in the analyses. Household food insecurity, household diet diversity score (HDDS), and employment change (agriculture or nonagriculture) were assessed during both periods. Food insecurity and diet diversity in the 2 periods were examined by logistic regression. A change in the odds of being food insecure or having low HDDS was examined as an interaction between time and employment status. RESULTS: Prevalence of food insecurity increased from 21% to 55%, and low diet diversity increased from 47% to 69% in households assessed in both surveys. Employment status was not associated with food insecurity or low HDDS during the baseline survey. However, during the pandemic, ∼30% of households changed their employment from agriculture to nonagriculture and were more likely to be food insecure (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI] 1. 78-4.32) and have low HDDS (aOR: 1.66; 95%CI: 1.05-2.61), than those who remained in agriculture. Similarly, those who retained nonagricultural employment during the pandemic were more likely to be food insecure (aOR: 2.23; 95%CI: 1.45-3.43) and have low HDDS (aOR: 1.73; 95%CI: 1.11-2.70), compared to those who remained in agriculture. In propensity score-adjusted interaction analysis of time and employment, food insecurity and low HDDS remained significantly associated with nonagricultural employment during the pandemic. CONCLUSIONS: Enhanced support to rural households in agricultural occupations could buffer them from unexpected crises, which may also protect their nutritional intake.

Diet, cardiovascular disease, and mortality in 80 countries.

AIMS: To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. METHODS AND RESULTS: A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). CONCLUSION: A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.

Contextual Factors Influencing Production, Distribution, and Consumption of Nutrient-Rich Foods in Bihar, India: A Qualitative Study of Constraints and Facilitators.

BACKGROUND: Production-to-consumption linkages are important to improve consumption of nutrient-rich foods to tackle malnutrition. However, understanding specific contextual factors influencing production, distribution, and consumption in rural communities is necessary. OBJECTIVE: To explore household-, farm-, and market-level factors affecting consumption of nutrient-rich foods among producer and nonproducer households in Bihar, India. METHODS: We conducted focus group discussions (FGDs) and key informant interviews (KIIs) in producer and nonproducer households of Gaya and Nalanda districts in Bihar to examine factors affecting production and consumption of red lentils, green leafy vegetables (GLVs), milk, eggs, and chicken. Through the KIIs, we identified distribution chains and elicited market-level challenges faced by producers, sellers, and consumers. Data were translated, transcribed, and analyzed thematically using NVivo version 9. RESULTS: Findings from 27 FGDs indicate that consumers and producers were aware of the importance of nutrient-rich foods to health and the necessity of prioritizing their consumption in children. Food preferences, social factors, seasons, religions, and livestock epidemics influenced consumption. Among producers, consumption was mainly dependent on own production. Nonproducers perceived that production could help overcome the barrier of affordability and improve consumption. Data from 69 KIIs indicated that markets were unfavorable in terms of profitability for producers, spoilage and losses for market players, issues of accessibility, and availability for consumers. CONCLUSIONS: A local context-specific multipronged approach such as understanding sociocultural factors, own production, and local markets influencing consumption needs to be examined further to improve consumption of nutrient-rich foods among agricultural communities in India.

Perceptions of healthcare providers and mothers on management and care of severely wasted children: a qualitative study in Karnataka, India.

OBJECTIVES: To explore perceptions of healthcare providers and mothers of children with severe wasting on the perceived reasons for severe wasting, constraints on the management and barriers to caregiving and care-seeking practices. DESIGN: In-depth qualitative interviews conducted with healthcare providers and mothers of children with severe wasting. SETTING: Urban and rural locations in Karnataka state, India. PARTICIPANTS: Healthcare providers (anganwadi workers, accredited social health activists, auxiliary nurse midwives, junior health assistant, medical officers, nutrition counsellors) from public healthcare centres and mothers of children with severe wasting. RESULTS: Forty-seven participants (27 healthcare providers, 20 mothers) were interviewed. Poverty of households emerged as the underlying systemic factor across all themes that interfered with sustained uptake of any intervention to address severe wasting. Confusion of 'thinness' and shortness of stature as hereditary factors appeared to normalise the condition of wasting. Management of this severe condition emerged as an interdependent phenomenon starting at the home level coupled with sociocultural factors to community intervention services with its supplemental nutrition programme and clinical monitoring with therapeutic interventions through an institutional stay at specialist referral centres. A single-pronged malnutrition alleviation strategy fails due to the complexity of the ground-level problems, as made apparent through respondents' lived experiences. Social stigma, trust issues between caregivers and care-seekers and varying needs and priorities as well as overburdened frontline workers create challenges in communication and effectiveness of services resulting in perpetuation of severe wasting. CONCLUSIONS: To ensure a continuum of care in children with severe wasting, economic and household constraints, coordinated policies across the multidimensional determinants of severe wasting need to be addressed. Context-specific interventions are necessary to bridge communication gaps between healthcare providers and caregivers.

Impact of the COVID-19 lockdown on household diet diversity in rural Bihar, India: a longitudinal survey.

BACKGROUND: The COVID-19 pandemic disrupted livelihoods and diets across the world. This study aimed to assess changes in household diet diversity and food consumption between the pre-COVID-19 period (December 2019-January 2020) and during the lockdown (March-May 2020), and to identify the socio-economic characteristics that determine these changes in rural Bihar, India. METHODS: Households that had provided their phone numbers in the pre-COVID-19 household survey (n = 1797) were contacted for interviews during the lockdown telephonic survey in a longitudinal survey in two districts (Gaya and Nalanda) in Bihar. In total, 939 households were interviewed. Using data on food consumption from both surveys, 876 households were included in the analysis. Food and Agriculture Organization's household diet diversity score (HDDS) was used to compare diet diversity between the pre-COVID-19 period and during the lockdown. Logistic regression was used to identify factors affecting household diet diversity and food consumption in the study households. RESULTS: Low diet diversity increased from 51.6% (95% CI 48.3-54.9) to 75.8% (95% CI 73.0-78.6) from the pre-COVID-19 to the lockdown period. Reduced food consumption was reported across all foods with nearly a quarter of the households reporting reduced consumption of fruits (27%), pulses (25%) and cereals (21%). Nearly 60% and above reported stopping consumption of nutrient-rich foods such as chicken, fish and eggs although the population was predominantly non-vegetarian. Logistic regression analysis revealed that taking a loan from neighbours/relatives (OR = 1.8; 95% CI 1.3-2.5) and belonging to lower social groups (OR = 1.8; 95% CI 1.1-2.9) increased odds of low HDDS. While those possessing ration cards had lower odds of reduced consumption of all food items, it was not associated with stopping consumption of any food item. In an unadjusted analysis, receipt of cash transfer during lockdown was also not associated with diet diversity (OR = 1.2; 95% CI 0.9-1.7). CONCLUSIONS: COVID-19 has impacted the consumption of nutrient-rich foods among already low-income rural households in India. Maintaining diet diversity among socio-economically vulnerable households during periods when food consumption is most threatened by shocks such as COVID-19 would need sustained government support in terms of social protection coverage and benefit transfers in rural communities.

Ultra-processed foods and mortality: analysis from the Prospective Urban and Rural Epidemiology study.

BACKGROUND: Higher intake of ultra-processed foods (UPFs) has been associated with increased risk of CVD and mortality in observational studies from Western countries but data from non-Western countries are limited. OBJECTIVES: We aimed to assess the association between consumption of UPFs and risk of mortality and major CVD in a cohort from multiple world regions. DESIGN: This analysis includes 138,076 participants without a history of CVD between the ages of 35 and 70 y living on 5 continents, with a median follow-up of 10.2 y. We used country-specific validated food-frequency questionnaires to determine individuals' food intake. We classified foods and beverages based on the NOVA classification into UPFs. The primary outcome was total mortality (CV and non-CV mortality) and secondary outcomes were incident major cardiovascular events. We calculated hazard ratios using multivariable Cox frailty models and evaluated the association of UPFs with total mortality, CV mortality, non-CV mortality, and major CVD events. RESULTS: In this study, 9227 deaths and 7934 major cardiovascular events were recorded during the follow-up period. We found a diet high in UPFs (≥2 servings/d compared with 0 intake) was associated with higher risk of mortality (HR: 1.28; 95% CI: 1.15, 1.42; P-trend < 0.001), CV mortality (HR: 1.17; 95% CI: 0.98, 1.41; P-trend = 0.04), and non-CV mortality (HR: 1.32; 95% CI 1.17, 1.50; P-trend < 0.001). We did not find a significant association between UPF intake and risk of major CVD. CONCLUSIONS: A diet with a high intake of UPFs was associated with a higher risk of mortality in a diverse multinational study. Globally, limiting the consumption of UPFs should be encouraged.

Role of cash transfers in mitigating food insecurity in India during the COVID-19 pandemic: a longitudinal study in the Bihar state.

OBJECTIVE: There are scant empirical data on the impacts of the COVID-19 pandemic on food security across the globe. India is no exception, with insights into the impacts of lockdown on food insecurity now emerging. We contribute to the empirical evidence on the prevalence of food insecurity in Bihar state before and after lockdown, and whether the government's policy of cash transfer moderated negative effects of food insecurity or not. DESIGN: This was a longitudinal study. SETTINGS: The study was conducted in Gaya and Nalanda district of Bihar state in India from December 2019 to September 2020. PARTICIPANTS: A total of 1797 households were surveyed in survey 1, and about 52% (n=939) were followed up in survey 2. Valid data for 859 households were considered for the analysis. MAIN OUTCOME MEASURES: Using the Food Insecurity Experience Scale, we found that household conditions were compared before and after lockdown. The effect of cash transfers was examined in a quasi-experimental method using a longitudinal study design. Logistic regression and propensity score adjusted analyses were used to identify factors associated with food insecurity. RESULTS: Household food insecurity worsened considerably during lockdown, rising from 20% (95% CI 17.4 to 22.8) to 47% (95% CI 43.8 to 50.4) at the sample mean. Households experiencing negative income shocks were more likely to have been food insecure before the lockdown (adjusted OR 6.4, 95% CI 4.9 to 8.3). However, households that received cash transfers had lower odds of being food insecure once the lockdown was lifted (adjusted OR 0.75, 95% CI 0.56 to 0.99). CONCLUSION: These findings provide evidence on how the swift economic response to the pandemic crises using targeted income transfers was relatively successful in mitigating potentially deep impacts of food insecurity.

Iron Fortification through Universal Distribution of Double-Fortified Salt Can Increase Wages and Be Cost-Effective: An Ex-Ante Modeling Study in India.

BACKGROUND: The alleviation of iron deficiency through iron supplementation has not effectively reduced anemia in India, mainly due to low compliance. Food fortification with iron is considered a viable alternative, and the provision of double-fortified salt (DFS; with iron and iodine) has been mandated in public health programs. Limited evidence exists on its benefit-cost ratio. OBJECTIVE: In this study we sought to estimate the economic benefit in terms of increased wages in relation to introduction of DFS in reduction of anemia and the cost of doing so. METHODS: The economic benefit of introducing DFS in India was derived using a series of mathematical, statistical, and econometric models using data from national surveys capturing earnings and dietary iron intake of the population. Anemia status was predicted from data on dietary intake, sanitation, and for women, menstrual losses. The impact of iron deficiency anemia (IDA) on wages was estimated using a Heckman Selection model and 2-stage least squares procedure. Benefit of DFS was estimated through increased wages attributed to anemia reduction compared with its cost. RESULTS: Men and women with IDA had lower wages (by 25.9%, 95% CI: 11.3, 38.1; and by 3.9%, 95% CI: 0.0, 7.7, respectively) than those without IDA. Additional iron intake through DFS was predicted to reduce prevalence of IDA (from 10.6% to 0.7% in men and 23.8% to 20.9% in women). The economic benefit-cost ratio of introducing DFS at a national level was estimated to be 4.2:1. CONCLUSIONS: Iron fortification delivered through DFS under a universal program can improve wages and be sufficiently cost-effective for its implementation at scale in India.

Animal source foods, rich in essential amino acids, are important for linear growth and development of young children in low- and middle-income countries.

Growth faltering under 5 years of age is unacceptably high worldwide, and even more children, while not stunted, fail to reach their growth potential. The time between conception and 2 years of age is critical for development. The period from 6 to 23 months, when complementary foods are introduced, coincides with a time when growth faltering and delayed neurocognitive developments are most common. Fortunately, this is also the period when diet exercises its greatest influence. Growing up in an adverse environment, with a deficient diet, as typically seen in low- and middle-income countries (LMICs), hampers growth and development of children and prevents them from realising their full developmental and economic future potential. Sufficient nutrient availability and utilisation are paramount to a child's growth and development trajectory, especially in the period after breastfeeding. This review highlights the importance of essential amino acids (EAAs) in early life for linear growth and, likely, neurocognitive development. The paper further discusses signalling through mammalian target of rapamycin complex 1 (mTORC1) as one of the main amino acid (AA)-sensing hubs and the master regulator of both growth and neurocognitive development. Children in LMICs, despite consuming sufficient total protein, do not meet their EAA requirements due to poor diet diversity and low-quality dietary protein. AA deficiencies in early life can cause reductions in linear growth and cognition. Ensuring AA adequacy in diets, particularly through inclusion of nutrient-dense animal source foods from 6 to 23 months, is strongly encouraged in LMICs in order to compensate for less than optimal growth during complementary feeding.

Factors influencing household pulse consumption in India: A multilevel model analysis.

Pulses (also known as legumes) are important in achieving nutrient adequacy in India due to their quality protein content. This study compared district-level pulse production and consumption across India, and household and district-level determinants of pulse intake, including availability, accessibility and affordability, using multi-level models in nationally representative datasets for 2011-12. The per capita consumption was about 50% of recommended intake (80 g/day), even in high-producing districts. District-level pulse production was associated with household pulse intake (2.73 × 10-8 [5.19 × 10-9, 4.94 × 10-8]) and market accessibility (-0.0077 [-0.0133, -0.0021]). Affordability (absolute price of pulse) was also associated with household intake. While agricultural policies relating to pulses have been oriented towards improving pulse output and productivity, forward-looking policies to improve pulse intake should focus on demand-side factors, such as improved market accessibility and the affordability of pulses relative to other foods.

Associations of unprocessed and processed meat intake with mortality and cardiovascular disease in 21 countries [Prospective Urban Rural Epidemiology (PURE) Study]: a prospective cohort study.

BACKGROUND: Dietary guidelines recommend limiting red meat intake because it is a major source of medium- and long-chain SFAs and is presumed to increase the risk of cardiovascular disease (CVD). Evidence of an association between unprocessed red meat intake and CVD is inconsistent. OBJECTIVE: The study aimed to assess the association of unprocessed red meat, poultry, and processed meat intake with mortality and major CVD. METHODS: The Prospective Urban Rural Epidemiology (PURE) Study is a cohort of 134,297 individuals enrolled from 21 low-, middle-, and high-income countries. Food intake was recorded using country-specific validated FFQs. The primary outcomes were total mortality and major CVD. HRs were estimated using multivariable Cox frailty models with random intercepts. RESULTS: In the PURE study, during 9.5 y of follow-up, we recorded 7789 deaths and 6976 CVD events. Higher unprocessed red meat intake (≥250 g/wk vs. <50 g/wk) was not significantly associated with total mortality (HR: 0.93; 95% CI: 0.85, 1.02; P-trend = 0.14) or major CVD (HR: 1.01; 95% CI: 0.92, 1.11; P-trend = 0.72). Similarly, no association was observed between poultry intake and health outcomes. Higher intake of processed meat (≥150 g/wk vs. 0 g/wk) was associated with higher risk of total mortality (HR: 1.51; 95% CI: 1.08, 2.10; P-trend = 0.009) and major CVD (HR: 1.46; 95% CI: 1.08, 1.98; P-trend = 0.004). CONCLUSIONS: In a large multinational prospective study, we did not find significant associations between unprocessed red meat and poultry intake and mortality or major CVD. Conversely, a higher intake of processed meat was associated with a higher risk of mortality and major CVD.

Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries.

Importance: Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ω-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown. Objective: To examine whether the associations of fish consumption with risk of CVD or of mortality differ between individuals with and individuals without vascular disease. Design, Setting, and Participants: This pooled analysis of individual participant data involved 191 558 individuals from 4 cohort studies-147 645 individuals (139 827 without CVD and 7818 with CVD) from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study and 43 413 patients with vascular disease in 3 prospective studies from 40 countries. Adjusted hazard ratios (HRs) were calculated by multilevel Cox regression separately within each study and then pooled using random-effects meta-analysis. This analysis was conducted from January to June 2020. Exposures: Fish consumption was recorded using validated food frequency questionnaires. In 1 of the cohorts with vascular disease, a separate qualitative food frequency questionnaire was used to assess intake of individual types of fish. Main Outcomes and Measures: Mortality and major CVD events (including myocardial infarction, stroke, congestive heart failure, or sudden death). Results: Overall, 191 558 participants with a mean (SD) age of 54.1 (8.0) years (91 666 [47.9%] male) were included in the present analysis. During 9.1 years of follow-up in PURE, compared with little or no fish intake (≤50 g/mo), an intake of 350 g/wk or more was not associated with risk of major CVD (HR, 0.95; 95% CI, 0.86-1.04) or total mortality (HR, 0.96; 0.88-1.05). By contrast, in the 3 cohorts of patients with vascular disease, the HR for risk of major CVD (HR, 0.84; 95% CI, 0.73-0.96) and total mortality (HR, 0.82; 95% CI, 0.74-0.91) was lowest with intakes of at least 175 g/wk (or approximately 2 servings/wk) compared with 50 g/mo or lower, with no further apparent decrease in HR with consumption of 350 g/wk or higher. Fish with higher amounts of ω-3 fatty acids were strongly associated with a lower risk of CVD (HR, 0.94; 95% CI, 0.92-0.97 per 5-g increment of intake), whereas other fish were neutral (collected in 1 cohort of patients with vascular disease). The association between fish intake and each outcome varied by CVD status, with a lower risk found among patients with vascular disease but not in general populations (for major CVD, I2 = 82.6 [P = .02]; for death, I2 = 90.8 [P = .001]). Conclusions and Relevance: Findings of this pooled analysis of 4 cohort studies indicated that a minimal fish intake of 175 g (approximately 2 servings) weekly is associated with lower risk of major CVD and mortality among patients with prior CVD but not in general populations. The consumption of fish (especially oily fish) should be evaluated in randomized trials of clinical outcomes among people with vascular disease.

Glycemic Index, Glycemic Load, and Cardiovascular Disease and Mortality.

BACKGROUND: Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population. METHODS: This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used country-specific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause. RESULTS: In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease. CONCLUSIONS: In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death. (Funded by the Population Health Research Institute and others.).

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

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.

Association between mustard oil consumption and BMI in India.

OBJECTIVE: This study examined the association between predominant vegetable oil consumed and BMI of adult women and men in India, with emphasis on predominant consumption of mustard oil. DESIGN: Two nationally representative data, the consumer expenditure survey of National Sample Survey Office (NSSO)-68th round (2011-2012) for food consumption and National Family Health Survey-4 (2015-2016) for weight status, were analysed. Data from both surveys were combined by matching households through common matching variables ('family size', 'religion', etc.) using Nearest-Neighbour Hot-Deck matching. The association of overweight/obesity with predominant mustard oil consumption in the household was examined using logistic regression adjusted for confounders. The NSSO reports household consumption of mustard, groundnut, coconut, refined oils (sunflower, safflower, soyabean) and all other edible oils. SETTING: Two nationally representative surveys from India. PARTICIPANTS: Total of 638 445 women and 92 312 men, respectively. RESULTS: Mustard oil was the most predominantly consumed oil (51 %) followed by refined oils (32·4 %). Prevalence of overweight/obesity in women and men was lower in households with predominant mustard oil consumption (17 and 15 %) v. all other refined and other oils combined (27 and 26 %). The adjusted OR for predominant mustard oil use was 0·88 (95 % CI 0·86, 0·87) for women and 0·80 (95 % CI 0·76, 0·83) for men. A similar analysis with predominant groundnut oil consumption showed no association with overweight/obesity. CONCLUSIONS: The data from a large national level survey suggest an inverse association between mustard oil consumption and overweight/obesity which needs to be explored with further research studies.

The Association of General and Central Obesity with Dietary Patterns and Socioeconomic Status in Adult Women in Botswana.

Dietary patterns and their association with general and central obesity among adult women were studied using a cross-sectional survey with multistage cluster sampling in urban and rural areas nationwide in Botswana. The participants in the study were adult women (N = 1019), 18-75 years old. The dietary patterns were identified using principal component analysis, and their associations with the body mass index and the weight-for-height ratio were examined. Factor analysis with varimax rotation was used to identify six dietary patterns (fast foods, refined carbohydrates, vegetables and fruits, fish and nuts, Botswana traditional foods, and organ and red meat dietary pattern). Overall, 24.5% of the women were overweight (BMI 25.0-29.99 kg/m2) and 24.5% were obese (BMI > 30 kg/m2). A waist-to-height ratio greater than 0.5 was observed for 42.2% of the women. With adjustment for age and education, individuals in the highest tertile of the Botswana traditional food pattern had a significantly higher risk of general obesity (RR = 1.40, 95% CI: 1.07-1.84) and central obesity (RR = 1.20, 95% CI: 0.97-1.48). With respect to the fish and nut pattern, a significant association was observed with central obesity only (RR = 1.43, 95% CI: 1.18-1.72). The Botswana traditional food pattern, characterised by a high carbohydrate intake, was found to be associated with a high risk of obesity in this study. However, more research is required to assess other factors contributing to obesity in women so that appropriate intervention programs can be put in place to help control this epidemic.

White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries.

OBJECTIVE: Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study. RESEARCH DESIGN AND METHODS: Data on 132,373 individuals aged 35-70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model. RESULTS: During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02-1.40; P for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13-2.30; P for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08-1.86; P for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77-1.40; P for trend = 0.38). CONCLUSIONS: Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.