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Exposure was quasi-experimentally assigned on the basis of birth date relative to the end of sugar rationing in 1953. External validation cohorts from the Health and Retirement Study and the English Longitudinal Study of Ageing were used.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>Primary outcomes were incident cardiovascular disease, myocardial infarction, heart failure, atrial fibrillation, stroke, and cardiovascular disease mortality, ascertained through linked health records. Hazard ratios were estimated using Cox and parametric hazard models adjusted for demographic, socioeconomic, lifestyle, parental health, and genetic factors and geographical controls. Multiple cardiac parameters were measured in a subset undergoing cardiac magnetic resonance imaging.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Longer exposure to sugar rationing was associated with progressively lower cardiovascular risks in adulthood. Compared with people never exposed to rationing, those exposed in utero plus 1-2 years had hazard ratios of 0.80 (95% confidence interval (CI) 0.73 to 0.90) for cardiovascular disease, 0.75 (0.63 to 0.90) for myocardial infarction, 0.74 (0.59 to 0.95) for heart failure, 0.76 (0.66 to 0.92) for atrial fibrillation, 0.69 (0.53 to 0.89) for stroke, and 0.73 (0.54 to 0.98) for cardiovascular disease mortality. Incident diabetes and hypertension jointly mediated 31.1% of the sugar rationing-cardiovascular disease association, whereas birth weight contributed only 2.2%. Sugar rationing was also associated with a modest increase in left ventricular stroke volume index (0.73 (95% CI 0.05 to 1.41) mL\/m\n                      <jats:sup>2<\/jats:sup>\n                      ) and ejection fraction (0.84%, 95% CI 0.40% to 1.28%).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Exposure to sugar rationing during the first 1000 days of life was associated with lower cardiovascular risks in adulthood and slightly more favourable cardiac indices, suggesting long term cardiovascular benefits of early life sugar restriction.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmj-2024-083890","type":"journal-article","created":{"date-parts":[[2025,10,23]],"date-time":"2025-10-23T00:00:16Z","timestamp":1761177616000},"page":"e083890","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":22,"title":["Exposure to sugar rationing in first 1000 days after conception and long term cardiovascular outcomes: natural experiment study"],"prefix":"10.1136","volume":"391","author":[{"given":"Jiazhen","family":"Zheng","sequence":"first","affiliation":[{"name":"Bioscience and Biomedical Engineering Thrust, Systems Hub, The Hong Kong University of Science and Technology (Guangzhou), Guangzhou, Guangdong, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhen","family":"Zhou","sequence":"additional","affiliation":[{"name":"School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jinghan","family":"Huang","sequence":"additional","affiliation":[{"name":"Biomedical Genetics Section, School of Medicine, Boston University, Boston, MA, USA"},{"name":"Department of Chemical Pathology, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong Special Administrative Region"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiang","family":"Tu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, University of Sydney, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haisheng","family":"Wu","sequence":"additional","affiliation":[{"name":"School of Public Health, LKS Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Quan","family":"Yang","sequence":"additional","affiliation":[{"name":"Cardiac and Vascular Center, University of Hong Kong-Shenzhen Hospital, Shenzhen, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peng","family":"Qiu","sequence":"additional","affiliation":[{"name":"Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenbo","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Clinical Epidemiology and Health Economics, University of Tokyo, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Junchun","family":"Shen","sequence":"additional","affiliation":[{"name":"Bioscience and Biomedical Engineering Thrust, Systems Hub, The Hong Kong University of Science and Technology (Guangzhou), Guangzhou, Guangdong, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1405-0960","authenticated-orcid":false,"given":"Chuang","family":"Yang","sequence":"additional","affiliation":[{"name":"Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory Y H","family":"Lip","sequence":"additional","affiliation":[{"name":"Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK"},{"name":"Department of Clinical Medicine, Aalborg University, Aalborg, Denmark"},{"name":"Medical University of Bialystok, Bialystok, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,10,22]]},"reference":[{"key":"2026012013250988000_391.oct22_14.e083890.1","unstructured":"United Nations, Department of Economic and Social Affairs. 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