Association between rice intake and all-cause mortality among Chinese adults: Findings from the Jiangsu Nutrition Study

Abstract

Background and objectives:
The few studies that have assessed the association between rice intake and mortality have generated inconsistent results. We assessed whether rice intake was associated with cardiovascular disease (CVD) mortality, cancer mortality and all-cause mortality in a prospective cohort of the Chinese population.

Methods and study design:
We prospectively studied 2,832 adults aged 20 years and above with a mean follow up of 10 years. Rice intake was measured by a 3-day weighed food record (WFR) in 2002. Hazard ratios (HRs) and 95% CI were calculated by competing risks regression (CVD and cancer mortality) and Cox proportional hazards analysis (all-cause mortality).

Results:
We documented 184 deaths (including 70 CVD deaths and 63 cancer deaths) during 27,742 person-years of follow-up. No association between rice intake and all-cause mortality was found. After adjusting for sociodemographic and lifestyle factors as well as energy and fat intake, HRs for CVD mortality across tertiles of rice intake were 1.00,0.47 (95% CI 0.25-0.87), and 0.49 (95% CI 0.21-1.13) (p for trend 0.049).

Conclusions:
There was no association between rice intake and all-cause mortality.

Full text

1152 Asia Pac J Clin Nutr 2017;26(6):1152-1157
Original Article
Association between rice intake and all-cause mortality
among Chinese adults: findings from the Jiangsu
Nutrition Study
Zumin Shi PhD1,2, Shiqi Zhen PhD1, Lu Qi PhD3, Yijing Zhou MD1, Anne W Taylor PhD2
1Department of Nutrition and Foodborne Disease Prevention, Jiangsu Provincial Centre for Disease
Control and Prevention, Nanjing, China
2Discipline of Medicine, University of Adelaide, Adelaide, Australia
3School of Public Health and Tropical Medicine, Tulane University, USA
Background and Objectives: The few studies that have assessed the association between rice intake and mor-
tality have generated inconsistent results. We assessed whether rice intake was associated with cardiovascular
disease (CVD) mortality, cancer mortality and all-cause mortality in a prospective cohort of the Chinese popula-
tion. Methods and Study Design: We prospectively studied 2,832 adults aged 20 years and above with a mean
follow up of 10 years. Rice intake was measured by a 3-day weighed food record (WFR) in 2002. Hazard ratios
(HRs) and 95% CI were calculated by competing risks regression (CVD and cancer mortality) and Cox propor-
tional hazards analysis (all-cause mortality). Results: We documented 184 deaths (including 70 CVD deaths and
63 cancer deaths) during 27,742 person-years of follow-up. No association between rice intake and all-cause mor-
tality was found. After adjusting for sociodemographic and lifestyle factors as well as energy and fat intake, HRs
for CVD mortality across tertiles of rice intake were 1.00,0.47 (95% CI 0.25-0.87), and 0.49 (95% CI 0.21-1.13)
(p for trend 0.049). Conclusions: There was no association between rice intake and all-cause mortality.
Key Words: rice intake, mortality, Chinese, cohort study, epidemiology
INTRODUCTION
Rice is the main staple food in many countries especially
in Asia.1 Despite a substantial decline in rice intake over
the past several decades, the mean rice intake was still as
high as 280 g/day in China in 2004.2 In Japan, rice pro-
vides 43% of carbohydrate and 29% of energy intake.3
Based on the degree of processing, rice is categorized into
two groups (brown rice and white rice). The refining pro-
cess associated with white rice destroys the structure of
the grain kernel and removes dietary fibre and other es-
sential micronutrients. Currently the majority of rice con-
sumed in China is white rice.
White rice has a high glycaemic index but is low in so-
dium and is free of cholesterol. A recent systematic re-
view showed that white rice intake was positively associ-
ated with the risk of diabetes.4 However, when compared
with wheat consumption, rice consumption was inversely
related to weight gain.5 In general, rice consuming na-
tions (e.g. China, Japan) have a low prevalence of over-
weight/obesity. A rice diet has been used to treat hyper-
tension6 and an inverse association between rice intake
and blood pressure and triglycerides has also been found.5
Previously we have found that there was no association
between rice consumption and the risk of incident meta-
bolic syndrome.5
Because diabetes increases the risk of cardiovascular
disease (CVD) and cancer mortality, of interest is whether
the positive association between rice and diabetes leads to
an increased risk of mortality especially from CVD and
cancer. Currently, only two population studies have as-
sessed such association but found inconsistent results.7,8
In the Japanese Collaborative Cohort (JACC) Study, rice
intake was associated with a reduced risk of CVD mortal-
ity in Japanese men but not women.7 However, findings
from the Japan Public Health Centre-based (JPHC) study
showed that rice intake was not related to all-cause mor-
tality or CVD mortality among Japanese adults.8 In addi-
tion, another study suggests that rice intake was associat-
ed with an increased risk of stomach cancer mortality in
Japanese.9
There is no study assessing the association between
rice intake and mortality in the Chinese population. Using
data from Jiangsu Nutrition Study, we aimed to assess the
association between rice intake and 10-year mortality
among adults aged 20 years and above.
Corresponding Author: Dr Zumin Shi, Discipline of Medi-
cine, University of Adelaide, Level 7 SAHMRI, North Terrace,
Adelaide, Australia, 5005.
Phone: +61 8 8313 1188; Fax: +61 8 8313 1228; Mobile phone:
+61 0432281068
Email: Zumin.shi@adelaide.edu.au
Manuscript received 05 June 2016. Initial review completed 26
July 2016. Revision accepted 13 August 2016.
doi: 10.6133/apjcn.012017.05

Rice intake and mortality 1153
METHOD
Study population
The Jiangsu Nutrition Study (JIN) is an ongoing cohort
study investigating the association of nutrition and other
factors with the risk of non-communicable chronic dis-
ease.10-12 The sample was based on a subsample of the
Chinese national nutrition and health survey representing
Jiangsu province and the year 2002 was used as a base
line. The rural sample was selected from six counties
(Jiangyin, Taichang, Shuining, Jurong, Sihong and
Haimen) (Figure 1). From each of the six counties, three
smaller towns were randomly selected. The urban sample
was selected from the capital cities of the two prefectures,
Nanjing and Xuzhou; and from each capital city three
streets were randomly selected. The six counties and the
two prefectures represented a geographically and eco-
nomically diverse population. In each town/street, two
villages/neighbourhoods were randomly selected, and 90
households were further selected randomly from each
village/neighbourhood. All the members in the house-
holds were invited to take part in the study. In addition,
one third of the households were interviewed regarding
dietary intake. In 2002, 2,832 adults aged 20 and above
supplied dietary information and had fasting blood meas-
ured for glucose and haemoglobin.
This study was conducted according to the guidelines
laid down in the Declaration of Helsinki, and all proce-
dures involving human subjects/patients were approved
by Jiangsu Provincial Centre for Disease Control and
Prevention. Written informed consent was obtained from
all participants.
Data collection and measurements
Participants were interviewed at their homes by health
workers using a standard questionnaire. All health work-
ers were intensively trained before the survey.
Independent variables (dietary measurements)–3-day
weighed food records (WFR)
Food intake including rice intake were assessed using a 3-
day weighed food diary which recorded all foods con-
sumed by each individual, on three consecutive days (in-
cluding one weekend). At the beginning and end of the 3-
day survey, health workers weighed all the food stocked
in the household. Each day, all purchases, home produc-
tion, and processed snack foods were weighed and rec-
orded. Food intakes of each individual in the household
were recorded in detail each day. During the interview,
the health workers would check any intake value for a
particular food that fell below or above the usual intake
value by the population in the region. For the current
study, rice intake (presented as raw rice, g/d) for each
individual was calculated based on the 3-day records. We
did not consider under- and over-reporting of energy in-
take as an issue of concern because any unreliable data
were checked by the health workers during the survey.
Food consumption data were analysed using the Chinese
Food Composition Table.13
Covariates
Cigarette-smoking was assessed by asking frequency of
daily cigarette smoking. Alcohol consumption was as-
sessed by asking the frequency and amount of alco-
hol/wine intake. Information on physical activity was
collected using a validated physical activity questionnaire
covering a time period of one year.14 Questions on the
daily commuting return journey were categorized into
three categories: (1) using motorized transportation, or no
work (0 minute of walking or cycling); (2) walking or
bicycling 1-29 minutes; and (3) walking or bicycling for
30 minutes. Daily leisure time physical activity was
classified into three categories: 0, 1-29 and ≥30 minutes.
Education was recoded into three categories based on a
Figure 1. Map of study sites in Jiangsu province

1154 Z Shi, S Zhen, L Qi, Y Zhou and AW Taylor
six categories of education levels in the questionnaire:
‘Low’- illiteracy, primary school; ‘Medium’- junior
middle school; ‘High’- high middle school or higher.
Occupation was recoded into manual or non-manual
based on a question with 12 occupational categories. We
defined diabetes as fasting plasma glucose (FPG) >7.0
mmol/L or having known diabetes (self-reported doctor
diagnosed). Hypertension was defined as systolic blood
pressure above 140 mmHg and/or diastolic blood pressure
above 90 mmHg, or using antihypertensive drugs.
Overweight was defined as BMI ≥24 kg/m2. Anaemia
was defined as a Hb level below 13 g/dL for men and 12
g/dL for women.15
Death ascertainment
The underlying cause of mortality was defined according
to the World Health Organization International Classifi-
cation of Disease, 10th revision (ICD-10). Death
information was collected in 2012 during the household
visit as well as by linking with the death registry database
in the local Centre for Disease Control and Prevention.
Thus, the identification of death of the participants was
virtually complete. CVD mortality included ICD-10
codes I00–99. Cancers mortality was defined as ICD-10
C00–97.
Statistical analysis
The chi square test was used to compare differences in
categorical and ANOVA in continuous variables. The
cohort was divided into tertiles on the basis of rice intake.
For each participant, person-years of follow-up were cal-
culated from the date of baseline survey to the date of
death or the date of last follow-up (1 December 2012),
whichever came first. The association between rice intake
and the risk of CVD and cancer mortality was analysed
using competing risks regression (stcrreg syntax in Stata)
and the association between rice intake and all-cause
mortality was analysed using Cox proportional hazard
models, adjusting for multiple covariates, with the first
tertile as the reference category. Two models assessed the
association between rice intake and mortality. The first
model controlled for age (continuous), gender, and intake
of energy and fat; and the second model further adjusted
for sociodemographic and lifestyle factors, chronic dis-
eases (anaemia, diabetes, overweight, and hypertension),
energy intake and selected food intake (total meat, fruit
and vegetable). As the sample size in the full model was
2,771 (97.8% of the whole sample), we did not impute for
missing data. In the sensitivity analyses, we excluded
those who died within three years of the baseline survey.
The proportional hazards assumption in the Cox model
was assessed with graphical methods and with models
including time-by-covariate interactions. In general, all
proportionality assumptions were appropriate.
In the sensitivity analysis, we excluded those with rice
intakes of 0 or ≥500 g/d and used restricted cubic spline
regressions16 to graphically model the associations be-
tween rice intake (continuous) and the risk of CVD mor-
tality. Three knots were put at the 5, 50 and 95 percentiles
of rice intake.
Sensitivity analysis was conducted by excluding partic-
ipants with diabetes. Interactions between rice intake and
gender, overweight and anaemia were conducted by add-
ing a multiplicative term with gender, overweight, and
anaemia as a binary variable and the tertile of consump-
tion of rice as a categorical variable in fully adjusted
models. Because there was no significant gender by rice
interaction, we only presented the combined results. We
tested for linear trends across categories of rice intake by
assigning each participant the median value for the cate-
gory and modelling this value as a continuous variable.
We used a cluster-robust variance estimator [stata com-
mand: vce(cluster clustvar)] to account for the clustering
at the household level in the estimation of the variance.
Statistical significance was considered when p<0.05 (two-
sided). All analyses were performed using Stata 13 (Stata
Corp., College Station, TX, USA).
RESULTS
At baseline, compared with participants in the lowest ter-
tile of rice intake, those in the highest tertile of rice intake
were older and more likely to have hypertension and
anaemia, and to live in the south (Table 1). Across the
tertiles of rice intake, fat intake increased. Income was
inversely related to rice intake.
Among the 2,832 adults aged 20 years and above at the
baseline, there were 184 deaths (including 70 CVD deaths
and 63 cancer deaths) during on average 9.8 years follow
up (in total 27,742 person-years). No association between
rice intake and all-cause mortality was found. In the fully
adjusted model, across tertiles of rice intake, HR (95% CI)
for all-cause mortality was 1.00, 0.99 (95% CI 0.65-1.51)
and 0.96 (95% CI 0.59-1.55), respectively (Table 2).
There was a dose-response inverse association between
rice intake and CVD mortality. In the fully adjusted mod-
el, the HRs (95% CI) for CVD mortality across tertiles of
rice intake were 1.00, 0.47 (95% CI 0.25-0.87), and 0.49
(0.21-1.13) (p for trend 0.049). The inverse association
became stronger when we further excluded those who
died within three years of follow-up. There was a margin-
ally significant gender by rice intake interaction (p for
interaction 0.08), where the inverse association appeared
stronger in women: HR (95% CI) for CVD mortality
across quartiles of rice intake was 1.00, 0.22 (0.07-0.69),
and 0.23 (0.05-1.18) in women; 1.00, 0.89 (0.33-2.38)
and 0.98 (0.32-2.94) in men. No interaction between rice
intake and anaemia, overweight, diabetes, and hyperten-
sion was found (data not shown). In the sensitivity analy-
sis, after excluding those with extreme rice intake (0 or
≥500 g/d), there was a linear inverse association between
rice intake and CVD mortality (Figure 2). Excluding
those with diabetes did not change the findings (data not
shown).
There was a borderline significant trend of increased
risk of cancer mortality across tertiles of rice intake.
DISCUSSION
In this Chinese cohort study, we found no association
between rice intake and all-cause mortality. However,
rice consumption was inversely related to CVD mortality
and marginally associated with an increased risk of can-
cer mortality.
In line with a large study in China,17 we found CVD
and cancer deaths contributed to the highest proportion of

Rice intake and mortality 1155
Table 1
.
Sample characteristics according to tertiles of rice intake among Chinese adults (
n
=2832)
Rice intake p value
T1 T2 T3
n 960 931 941
Raw rice intake (g/day), mean (SD) 92.3 (58.4) 246.2 (36.5) 414.6 (81.6) <0.001
Age (years), mean (SD) 46.0 (15.0) 47.7 (15.3) 47.6 (12.9) 0.018
BMI (kg/m
2
), mean (SD) 23.6 (3.5) 23.5 (3.6) 23.5 (3.4) 0.880
Sex, n (%)
<0.001
Men 400 (41.7) 396 (42.5) 504 (53.6)
Women 560 (58.3) 535 (57.5) 437 (46.4)
Income, n (%)
<0.001
Low 531 (55.5) 229 (24.8) 152 (16.4)
Medium 234 (24.5) 264 (28.5) 406 (43.8)
High 191 (20.0) 432 (46.7) 368 (39.7)
Education, n (%) <0.001
Low 451 (47.0) 417 (44.8) 482 (51.2)
Medium 357 (37.2) 327 (35.2) 344 (36.6)
High 152 (15.8) 186 (20.0) 115 (12.2)
Region, n (%)
<0.001
South 183 (19.1) 608 (65.3) 701 (74.5)
North 777 (80.9) 323 (34.7) 240 (25.5)
Manual, n (%) 519 (54.2) 373 (40.1) 612 (65.0) <0.001
Hypertension, n (%) 243 (25.3) 303 (32.6) 279 (29.6) 0.002
Diabetes, n (%) 42 (4.4) 39 (4.2) 21 (2.2) 0.022
Anemia, n (%) 165 (17.3) 278 (30.1) 274 (29.3) <0.001
Urban, n (%) <0.001
Urban 351 (36.6) 276 (29.6) 81 (8.6)
Rural 609 (63.4) 655 (70.4) 860 (91.4)
Smoking, n (%) 241 (25.3) 218 (23.9) 296 (32.1) <0.001
Alcohol drinking, n (%) 239 (24.9) 208 (22.4) 247 (26.3) 0.14
Energy intake (kcal/d), mean (SD) 2246 (730.4) 2179 (630.1) 2628 (606.8) <0.001
Fat intake (g/d), mean (SD) 74.7 (37.2) 80.9 (35.3) 86.8 (37.8) <0.001
Protein intake (g/d), mean (SD) 68.8 (23.3) 70.0 (22.6) 79.0 (24.0) <0.001
Carbohydrate intake (g/d), mean (SD) 315 (118.5) 285 (96.7) 372 (84.1) <0.001
Table 2. HRs (95 CI) of mortality from all-cause, CVD and cancer according to tertiles of rice consumption
(n=2832)
Q1 Q2 Q3 p for trend
Participants at risk (n) 960 931 941
Person-years 9405 9072 9265
All-cause mortality
Cases 66 67 51
Model 1, HR (95% CI)
†
1.00 (reference) 0.96 (0.66-1.39) 0.83 (0.56-1.22) 0.367
Model 2, HR (95% CI)
‡
1.00 (reference) 0.99 (0.65-1.51) 0.96 (0.59-1.55) 0.862
Model 3, HR (95% CI)
§
1.00 (reference) 1.08 (0.64-1.82) 1.15 (0.64-2.07) 0.632
CVD mortality
Cases 33 23 14
Model 1, HR (95% CI)
†
1.00 (reference) 0.61 (0.34-1.09) 0.48 (0.23-0.98) 0.032
Model 2, HR (95% CI)
‡
1.00 (reference) 0.47 (0.25-0.87) 0.49 (0.21-1.13) 0.049
Model 3, HR (95% CI)
§
1.00 (reference) 0.55 (0.25-1.21) 0.30 (0.11-0.81) 0.015
Cancer mortality
Cases 20 20 23
Model 1, HR (95% CI)
†
1.00 (reference) 0.98 (0.51-1.89) 1.08 (0.58-2.00) 0.815
Model 2, HR (95% CI)
‡
1.00 (reference) 1.32 (0.58-3.02) 1.36 (0.57-3.25) 0.484
Model 3, HR (95% CI)
§
1.00 (reference) 1.18 (0.44-3.16) 2.16 (0.74-6.25) 0.158
†Model 1 adjusted for age, gender, intake of energy and fat.
‡Model 2 further adjusted for smoking (0, 1-19, ≥20 cigarettes/day), alcohol drinking (no, 1-2 times/wk, 3-4 times/wk, daily), active
commuting (n o, 1-29 minutes/day, ≥30 minutes/day), leisure time physical activity (no, 1-29 minutes/day, >30 minutes/day), sedentary
activity(<1 hrs/day, 1-1.9 hrs/day, 2-2.9 hrs/day,≥3 hrs/day), education (low, medium, high), occupation (manual/non-manual), over-
weight, selected food intake (fruit, vegetable, and total meat), total energy and fat intake, anemia, diabetes, and hypertension.
§Model 3, further excluded those who died within three years.

1156 Z Shi, S Zhen, L Qi, Y Zhou and AW Taylor
mortality (in total more than 70%). There was a signifi-
cant geographic difference in rice intake with the south
having much higher consumption than the north. Overall,
rice intake in our study was higher than western countries
and Japan.
The inverse association between rice intake and CVD
mortality in our study is consistent with findings from the
JACC study, though inconsistent with those from the
JPHC study. In the JACC study, an inverse association
between rice intake and CVD mortality was found in men
but not women,7,8 Comparing extreme quintiles of rice
intake, the HR for CVD mortality in Japanese men was
0.82 (95% CI 0.70-0.97).7 However, in our study, we
found a significant reduced risk of CVD mortality in
women with high rice intake. Although there was no sig-
nificant interaction between gender and rice intake, the
inverse association between rice intake and CVD mortali-
ty appeared stronger in women than men. As the preva-
lence of smoking is much higher in Chinese men than
women (52.9% in men vs 2.4% in women),18 the associa-
tion between rice intake and CVD mortality could be con-
founded by smoking. Although we adjusted in the analy-
sis for smoking, residual confounding might possibly
exist. We did not have information on the long term
smoking history (i.e. pack-years).
We have previously reported that high rice consump-
tion is related to less weight gain and a lower risk of hy-
pertension despite a positive association with diabetes.19
Overall rice intake has been shown not to be associated
with the risk of metabolic syndrome.5 Although rice has a
high glycemic index, it has a low level of cholesterol and
sodium.5 A rice diet has previously been used to treat
hypertension.6 In USA, findings from a pooled analysis of
3 cohorts suggested that rice intake was not associated
with the risk of incident CVD.20 It could be due to these
mixed beneficial and adverse aspects of rice that we did
not see any association between rice intake and all-cause
mortality. It is well known that both diabetes and hyper-
tension are positively related to CVD mortality. In our
study sample, impaired fasting glucose and diabetes were
related to an increased risk of all-cause mortality and
CVD mortality.21 As the prevalence of hypertension is
much higher than diabetes in the Chinese population,22,23
if rice intake is beneficial for hypertension, it may partly
explain the inverse association between rice and CVD
mortality.
Although statistically not significant, there was a trend
of positive association between rice intake and cancer
mortality in the sample. This finding is supported by ex-
isting observational studies. In Japan, rice intake was pos-
itively associated with stomach cancer mortality: compar-
ing extreme tertiles of rice intake, the HR for stomach
cancer mortality was 1.81 (95% CI 1.06-3.08).9 Accord-
ing to data from the Chinese National Program of Cancer
Registry, the incidence of stomach cancer was the highest
among all the cancers and the mortality of stomach
ranked second among all cancer mortality in 2009 in rural
China.24 Whether there is a causal relationship and what
may be the mechanisms underlying the association, war-
rant further investigations. Other factors including diabe-
tes,25 and environmental pollution (e.g. irrigation water
used in growing rice) in regions where rice is grown
should also be explored given the known link with cancer.
The level of arsenic in rice is of increasing concern espe-
cially in Asia. In China, the majority of arsenic in rice is
inorganic and toxic.26 A study in the same province
showed that 6.7% of the adults had a dietary intake of
arsenic exceeding the proposed reference limit.27 The
urine arsenic level in East China is 14.14 µg/L,28 which is
much higher than in USA (8.09 µg/L).29 A study from
USA found that when water arsenic is low, 93% of total
arsenic exposure is from diet.29 A study from a neigh-
bouring province found that rice arsenic levels different
by regions substantially (as high as five times).30
Several limitations in our study should be acknowl-
edged. Firstly, although we had a 5-year follow-up, due to
the high attrition rate, we were not able to incorporate the
food intake data at follow up. Secondly, due to the small
number of deaths, we could not further analyse mortality
due to specific CVD outcomes or cancer. Further research
with larger sample sizes is needed. Thirdly, as partici-
pants with a low rice intake are usually poor, access to
health services may be limited. This may confound the
association between rice intake and CVD mortality. It
may also partly explain the difference between our study
and the Japanese studies, where no difference in rice in-
take was found among different SES groups. However, in
the sensitivity analysis, after excluding those with ex-
treme rice intake, the inverse association between CVD
mortality remained.
The strength of the study is the use of 3-day WFR to
measure rice intake as well as its detailed information on
a variety of confounding factors including biomedically
measured chronic diseases. As rice is a staple food, sea-
sonal variations of rice intake may be smaller than other
food items like vegetables and fruit. WFR-measured rice
intake may provide a more robust estimate than the com-
monly used food frequency questionnaire (FFQ) method.
Further, the study included both urban and rural partici-
pants and its results can be generalized in the study popu-
lation in the province. However, whether the findings can
be generalized in the whole Chinese population remains
to be further studied.
1 5 10
Hazard ratio (95%CI)
0 100 200 300 400 500
Rice intake (g/day)
CVD mortality
Figure 2.Rice intake and CVD mortality. Multivariable analysis
adjusted for variables cited in model 2 of Table 2. Those with
rice intakes of 0 (n=147) or ≥500 g/d (n=149) were excluded.
Solid line represents HR and dash line represents 95% CI.

Rice intake and mortality 1157
In conclusion, rice intake was not associated with all-
cause mortality. An inverse association between rice in-
take and CVD mortality was found in women but not in
men.
ACKNOWLEDGEMENTS
The research was supported by The University of Adelaide and
Jiangsu Provincial Centre for Disease Control and Prevention.
The authors thank the participating regional Centers for Disease
Control and Prevention in Jiangsu province, including the Nan-
jing, Xuzhou, Jiangyin, Taicang, Suining, Jurong, Sihong, and
Haimen Centres for their support for data collection.
AUTHOR DISCLOSURES
No competing interests are reported.
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