Data_Sheet_1_The association of energy and macronutrient intake at breakfast and cardiovascular disease in Chinese adults: From a 14-year follow-up cohort study.docx

BackgroundWe aimed to examine the associations between energy and macronutrient intakes at breakfast and the incidence of cardiovascular events among Chinese adults.
MethodsThere were 12,937 participants from the China Health and Nutrition Survey who met the study criteria and completed six rounds of questionnaires in 1997, 2000, 2004, 2006, 2009, and 2011. Combined weighing methods with 24-h dietary recall were used to measure dietary intake throughout the day. Intakes of macronutrients at breakfast were calculated using energy provided by nutrients as a percentage of breakfast energy. We calculated hazard ratios using a multivariable Cox frailty model with random intercepts to account for household clustering.
ResultsDuring follow-up, we documented 453 (3.6 per 1,000 person-years) major cardiovascular events, 195 (1.5 per 1,000 person-years) myocardial infarctions, and 293 (2.3 per 1,000 person-years) strokes. In Chinese adults, more breakfast carbohydrates or less proteins intake was associated with the reduced risk of cardiovascular diseases. Especially for women, higher intake of breakfast carbohydrates was associated with a lower risk of major cardiovascular events (quintile 5 vs. quintile 1, HR 0.47 [95%CI 0.30–0.74]; ptrend = 0.0008) and stroke (quintile 5 vs. quintile 1, HR 0.48 [95%CI 0.26–0.88]; ptrend = 0.0006). Higher intake of breakfast proteins was associated with a higher risk of major cardiovascular events (quintile 5 vs. quintile 1, HR 1.77 [95%CI 1.12–2.79]; ptrend = 0.1162), myocardial infarction (quintile 5 vs. quintile 1, HR 2.49 [95%CI 1.21–5.11]; ptrend = 0.2641). There was a significant association between breakfast fat intake and cardiovascular diseases in the adult population, but less significant correlation was found in Chinese men or women. Breakfast fat intake was positively associated with the risk of major cardiovascular events (quintile 5 vs. quintile 1, HR 1.74 [95%CI 1.27–2.36]; ptrend = 0.0070), myocardial infarction (quintile 5 vs. quintile 1, HR 2.03 [95%CI 1.23–3.37]; ptrend = 0.0168), and stroke (quintile 5 vs. quintile 1, HR 1.64 [95%CI 1.12–2.41]; ptrend = 0.0732). There was a significant reduction in major cardiovascular events and stroke when breakfast energy intake was moderated, even if the independence of skipping breakfast.
ConclusionHigh carbohydrate intake and low protein and fat intake at breakfast may contribute to cardiovascular health while maintaining a moderate energy intake.

## 研究背景
本研究旨在探讨中国成年人早餐能量与宏量营养素（macronutrient）摄入情况与心血管事件发生率之间的关联。
## 研究方法
本研究纳入中国健康与营养调查（China Health and Nutrition Survey）中符合研究纳入标准、且完成1997、2000、2004、2006、2009及2011年共6轮问卷的12937名参与者。采用称重法结合24小时膳食回顾法评估研究对象全天膳食摄入情况。以营养素供能占早餐总能量的比例计算早餐宏量营养素摄入量。本研究采用带有随机截距项的多变量Cox脆弱模型（multivariable Cox frailty model）计算风险比（hazard ratio, HR），以校正家庭聚类效应。
## 研究结果
随访期间，本研究共记录到453例主要心血管事件（发生率为3.6例/1000人年）、195例心肌梗死（1.5例/1000人年）及293例卒中（2.3例/1000人年）。在中国成年人中，早餐碳水化合物摄入较高或蛋白质摄入较低与心血管疾病发病风险降低相关。其中女性群体尤为显著：早餐碳水化合物摄入较高与主要心血管事件（五分位第5组 vs 第1组，HR=0.47，95%置信区间CI:0.30~0.74；趋势检验P=0.0008）及卒中（五分位第5组 vs 第1组，HR=0.48，95%CI:0.26~0.88；趋势检验P=0.0006）的发病风险降低显著相关。而早餐蛋白质摄入较高则与主要心血管事件（五分位第5组 vs 第1组，HR=1.77，95%CI:1.12~2.79；趋势检验P=0.1162）、心肌梗死（五分位第5组 vs 第1组，HR=2.49，95%CI:1.21~5.11；趋势检验P=0.2641）的发病风险升高相关。早餐脂肪摄入与全人群心血管疾病存在显著关联，但在中国男性及女性群体中该关联的显著性较弱。具体而言，早餐脂肪摄入较高与主要心血管事件（五分位第5组 vs 第1组，HR=1.74，95%CI:1.27~2.36；趋势检验P=0.0070）、心肌梗死（五分位第5组 vs 第1组，HR=2.03，95%CI:1.23~3.37；趋势检验P=0.0168）及卒中（五分位第5组 vs 第1组，HR=1.64，95%CI:1.12~2.41；趋势检验P=0.0732）的发病风险升高呈正相关。此外，即使校正了不吃早餐的独立混杂因素，维持适中的早餐能量摄入仍可显著降低主要心血管事件及卒中的发病风险。
## 研究结论
维持适中的早餐能量摄入，同时提高早餐碳水化合物占比、降低蛋白质与脂肪摄入，或有助于维护心血管健康。