{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T13:11:17Z","timestamp":1789996277884,"version":"4.0.1"},"reference-count":46,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T00:00:00Z","timestamp":1789603200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Study of Diet and Nutrition Assessment and Intervention Technology","award":["2020YFC2006300"],"award-info":[{"award-number":["2020YFC2006300"]}]},{"name":"Active Health and Aging Technologic Solutions Major Project of National Key R&D Program\u2014Study on Intervention Strategies of Main Nutrition Problems in China","award":["2020YFC2006305"],"award-info":[{"award-number":["2020YFC2006305"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Suboptimal diet is a major modifiable contributor to cardiovascular disease (CVD) mortality in China, and provincial disparities in dietary quality may contribute to geographic variation in CVD burden. This study aimed to quantify temporal trends in CVD mortality attributable to suboptimal dietary factors in Zhejiang Province and evaluate the potential reduction in CVD deaths in Henan Province under a counterfactual Jiangnan dietary pattern. Methods: This repeated cross-sectional study used data from multiple rounds of population-based nutrition surveillance conducted in Zhejiang Province between 2008 and 2024, with additional comparative data from Henan Province in 2015. A total of 56,018 adults were included. Dietary intake was assessed using 3-day 24-h dietary recalls combined with household condiment weighing. Ten dietary factors were evaluated, including fruits, vegetables, aquatic products, nuts, whole grains, red meat, processed meat, sugar-sweetened beverages, condiment salt, and omega-3 fatty acids. The prevalence of suboptimal dietary exposures was standardized according to the urban\u2013rural population distribution. Population-attributable fractions (PAFs) of cardiovascular disease (CVD) mortality associated with individual and combined dietary factors were estimated using a comparative risk-assessment framework based on published relative-risk estimates. A counterfactual scenario was further used to estimate the number of CVD deaths in Henan Province that might be averted if the diet-attributable PAF were reduced to the level observed in coastal Zhejiang. Results: The dietary profile in Zhejiang was characterized by relatively lower prevalences of inadequate intake of aquatic products, whole grains, and vegetables, together with a decline in excessive salt intake. The estimated proportion of CVD mortality attributable to suboptimal dietary factors based on comparative risk assessment was 49.8% (95% UI, 40.8\u201357.4) in 2008, increased numerically to 55.3% (48.1\u201361.6) in 2022, and was 52.5% (45.6\u201358.6) in 2024. Among the examined subgroups, women living in coastal Zhejiang had the lowest estimated diet-attributable PAF. Zhejiang had a healthier dietary profile and a lower PAF for diet-attributable CVD mortality than Henan. Under the specified counterfactual scenario, by matching Henan\u2019s dietary pattern to that of coastal Zhejiang, it was estimated that approximately 23,575 annual CVD deaths could be averted. Conclusions: Suboptimal dietary exposures remained responsible for a substantial and persistent proportion of CVD mortality. Although Zhejiang had a lower estimated diet-attributable CVD mortality burden than Henan, important gaps remained, particularly for low intakes of nuts, fruit, and whole grains. Refining the Jiangnan dietary pattern and adapting its favorable components to high-burden regions may inform region-specific CVD prevention.<\/jats:p>","DOI":"10.3390\/nu18183043","type":"journal-article","created":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T11:41:35Z","timestamp":1789645295000},"page":"3043","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["SuboptimalDietaryPatterns and Estimated Cardiovascular Disease Mortality Burden in China: A Repeated Cross-Sectional Comparative Risk Assessment"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5542-8149","authenticated-orcid":false,"given":"Meng-Jie","family":"He","sequence":"first","affiliation":[{"name":"National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, 29 Nanwei Road, Beijing 100050, China"},{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lichun","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5923-0316","authenticated-orcid":false,"given":"Peiwei","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danting","family":"Su","sequence":"additional","affiliation":[{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yan","family":"Zou","sequence":"additional","affiliation":[{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dan","family":"Han","sequence":"additional","affiliation":[{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gangqiang","family":"Ding","sequence":"additional","affiliation":[{"name":"National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, 29 Nanwei Road, Beijing 100050, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronghua","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Nutrition and Food Safety, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China"},{"name":"NHC Specialty Laboratory of Food Safety Risk Assessment and Standard Development, Hangzhou 310051, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pengyu","family":"Fu","sequence":"additional","affiliation":[{"name":"Public Health Institute, Henan Provincial Center for Disease Control and Prevention, Zhengzhou 450016, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,17]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2025). Cardiovascular Diseases, WHO."},{"key":"ref_2","unstructured":"World Health Organization (2025). SEAHEARTS: Accelerating Prevention and Control of Cardiovascular Diseases in the South-East Asia Region, WHO."},{"key":"ref_3","unstructured":"National Center For Cardiovascular Diseases, and the Writing Committee of the Report on Cardiovascular Health and Diseases in China (2025). Report on cardiovascular health and diseases in China 2024. Chin. Circ. J., 40, 521\u2013559."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"100249","DOI":"10.1016\/j.advnut.2024.100249","article-title":"Dietary Patterns and Cardiovascular Diseases in Asia: A Systematic Review and Meta-Analysis","volume":"15","author":"Lim","year":"2024","journal-title":"Adv. Nutr."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1477","DOI":"10.1161\/CIRCRESAHA.120.316101","article-title":"Obesity Phenotypes, Diabetes, and Cardiovascular Diseases","volume":"126","author":"Tchernof","year":"2020","journal-title":"Circ. Res."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Fukumoto, Y. (2021). Nutrition and Cardiovascular Diseases. Nutrients, 14.","DOI":"10.3390\/nu14010094"},{"key":"ref_7","first-page":"2942","article-title":"Modifiable behavioral factors as causes of death","volume":"2942","author":"Blairr","year":"2004","journal-title":"JAMA"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1297","DOI":"10.1016\/S0140-6736(68)91784-4","article-title":"Diet and cardiovascular disease","volume":"14","author":"Watson","year":"1968","journal-title":"Lancet"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1415","DOI":"10.1161\/CIRCRESAHA.120.315892","article-title":"Nutrition, Thrombosis, and Cardiovascular Disease","volume":"126","author":"Violi","year":"2020","journal-title":"Circ. Res."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1389","DOI":"10.1126\/science.3375821","article-title":"Chinese diet study","volume":"240","author":"Campbell","year":"1988","journal-title":"Science"},{"key":"ref_11","unstructured":"National Health Commission of the People\u2019s Republic of China (2020). Report on Nutrition and Chronic Disease Status of Chinese Residents (2020), People\u2019s Medical Publishing House."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1016\/S2213-8587(19)30152-4","article-title":"The dietary transition and its association with cardiometabolic mortality among Chinese adults, 1982\u20132012: A cross-sectional population-based study","volume":"7","author":"He","year":"2019","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_13","first-page":"37","article-title":"Dietary patterns of Chinese adults in nine provinces","volume":"34","author":"Zhang","year":"2013","journal-title":"Chin. J. Epidemiol."},{"key":"ref_14","unstructured":"Chinese Nutrition Society (2022). Dietary Guidelines for Chinese Residents (2022), People\u2019s Medical Publishing House."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1111\/1753-0407.13015","article-title":"The Jiangnan diet, a healthy diet pattern for Chinese","volume":"12","author":"Wang","year":"2020","journal-title":"J. Diabetes"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"He, M., Zou, Y., Zhang, R., Su, D., and Xu, P. (2025). Association Between the Jiangnan Diet and Mild Cognitive Impairment Among the Elderly. Nutrients, 17.","DOI":"10.3390\/nu17203189"},{"key":"ref_17","first-page":"1159","article-title":"Consumption of sugar-sweetened beverages and artificially sweetened beverages and risk of cardiovascular disease: A meta-analysis","volume":"55","author":"Jiang","year":"2021","journal-title":"Chin. J. Prev. Med."},{"key":"ref_18","first-page":"22","article-title":"Consumption of sugar-sweetened beverages among 18 years old and over adults in 2010\u20132012 in China","volume":"47","author":"Guo","year":"2018","journal-title":"J. Hyg. Res."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Pan, F., Zhang, T., Mao, W., Zhao, F., Luan, D., and Li, J. (2023). Ultra-Processed Food Consumption and Risk of Overweight or Obesity in Chinese Adults: Chinese Food Consumption Survey 2017\u20132020. Nutrients, 15.","DOI":"10.3390\/nu15184005"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Li, H., Wang, Y., Sonestedt, E., and Born\u00e9, Y. (2023). Associations of ultra-processed food consumption, circulating protein biomarkers, and risk of cardiovascular disease. BMC Med., 21.","DOI":"10.1186\/s12916-023-03111-2"},{"key":"ref_21","unstructured":"National Center for Cardiovascular Diseases, Fuwai Hospital (2025). Report on Cardiovascular Health and Diseases in Henan Province 2025."},{"key":"ref_22","first-page":"1239","article-title":"Establishment and evaluation of cardio-cerebrovascular disease prediction model in Henan","volume":"38","author":"Wang","year":"2023","journal-title":"Dis. Surveill."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"193","DOI":"10.46234\/ccdcw2021.058","article-title":"China Nutrition and Health Surveys (1982\u20132017)","volume":"3","author":"Yu","year":"2021","journal-title":"China CDC Wkly."},{"key":"ref_24","unstructured":"Yang, Y., Wang, G., and Pan, X. (2002). China Food Composition Tables, Peking University Medical Press."},{"key":"ref_25","unstructured":"Chinese Nutrition Society (2013). Dietary Reference Intakes for Chinese Residents, People\u2019s Medical Publishing House."},{"key":"ref_26","first-page":"105","article-title":"Chinese Dietary Reference Intakes: A Historical Overview","volume":"43","author":"Cheng","year":"2021","journal-title":"Acta Nutr. Sin."},{"key":"ref_27","unstructured":"Yang, Y., Wang, G., and Pan, X. (2009). China Food Composition Tables, Peking University Medical Press. [2nd ed.]."},{"key":"ref_28","unstructured":"Chinese Nutrition Society (2023). Dietary Reference Intakes for Chinese Residents, People\u2019s Medical Publishing House."},{"key":"ref_29","unstructured":"Yang, Y. (2019). China Food Composition Tables Standard Edition, Peking University Medical Press."},{"key":"ref_30","unstructured":"Henan Provincial Bureau of Statistics (2016). Henan Statistical Yearbook 2016, China Statistics Press."},{"key":"ref_31","unstructured":"Zhejiang Provincial Bureau of Statistics (2024). Zhejiang Statistical Yearbook, China Statistics Press."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1650","DOI":"10.1080\/10408398.2015.1008980","article-title":"Fruit and vegetable consumption and risk of cardiovascular disease: A meta-analysis of prospective cohort studies","volume":"57","author":"Zhan","year":"2017","journal-title":"Crit. Rev. Food Sci. Nutr."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1123","DOI":"10.1093\/advances\/nmaa029","article-title":"Fish Consumption and the Risk of Chronic Disease: An Umbrella Review of Meta-Analyses of Prospective Cohort Studies","volume":"11","author":"Jayedi","year":"2020","journal-title":"Adv. Nutr."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Aune, D., Keum, N., Giovannucci, E., Fadnes, L.T., Boffetta, P., Greenwood, D.C., Tonstad, S., Vatten, L.J., Riboli, E., and Norat, T. (2016). Nut consumption and risk of cardiovascular disease, total cancer, all-cause and cause-specific mortality: A systematic review and dose-response meta-analysis of prospective studies. BMC Med., 14.","DOI":"10.1186\/s12916-016-0730-3"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2626","DOI":"10.1093\/eurheartj\/ehad336","article-title":"Red meat consumption, cardiovascular diseases, and diabetes: A systematic review and meta-analysis","volume":"44","author":"Shi","year":"2023","journal-title":"Eur. Heart J."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1093\/advances\/nmaa084","article-title":"Intake of Sugar-Sweetened and Low-Calorie Sweetened Beverages and Risk of Cardiovascular Disease: A Meta-Analysis and Systematic Review","volume":"12","author":"Yin","year":"2021","journal-title":"Adv. Nutr."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"164","DOI":"10.3945\/ajcn.115.122432","article-title":"Whole-grain intake and total, cardiovascular, and cancer mortality: A systematic review and meta-analysis of prospective studies","volume":"104","author":"Chen","year":"2016","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Ricci, H., Gaeta, M., Franchi, C., Poli, A., Battino, M., Dolci, A., Schmid, D., and Ricci, C. (2023). Fish Intake in Relation to Fatal and Non-Fatal Cardiovascular Risk: A Systematic Review and Meta-Analysis of Cohort Studies. Nutrients, 15.","DOI":"10.3390\/nu15214539"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"710","DOI":"10.1093\/aje\/kwt326","article-title":"Intake of Long-Chain -3 Fatty Acids From Diet and Supplements in Relation to Mortality","volume":"179","author":"Bell","year":"2014","journal-title":"Am. J. Epidemiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"k757","DOI":"10.1136\/bmj.k757","article-title":"Population attributable fraction","volume":"360","author":"Mansournia","year":"2018","journal-title":"BMJ Br. Med. J."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Danaei, G., Ding, E.L., Mozaffarian, D., Taylor, B., Rehm, J., Murray, C.J.L., and Ezzati, M. (2009). The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med., 6, Erratum in PLoS Med.\u00a02011, 8, e1000058.","DOI":"10.1371\/journal.pmed.1000058"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1959708","DOI":"10.1080\/16549716.2021.1959708","article-title":"Burden of cardiovascular disease from 1990 to 2017 in Henan Province, China","volume":"14","author":"Zhao","year":"2021","journal-title":"Glob. Health Action"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"102230","DOI":"10.1016\/j.eclinm.2023.102230","article-title":"Ranking age-specific modifiable risk factors for cardiovascular disease and mortality: Evidence from a population-based longitudinal study","volume":"64","author":"Tian","year":"2023","journal-title":"EClinicalMedicine"},{"key":"ref_44","first-page":"628","article-title":"Cardiovascular Disease Burden Attributable to High Body Mass Index in Taiwan","volume":"39","author":"Yeh","year":"2023","journal-title":"Acta Cardiol. Sin."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"3261","DOI":"10.1111\/dom.15653","article-title":"Cardiometabolic factors and population risks of cardiovascular disease in community-dwelling adults with varied blood pressure statuses","volume":"26","author":"Qiu","year":"2024","journal-title":"Diabetes Obes. Metab."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1001\/jamainternmed.2019.6969","article-title":"Associations of Processed Meat, Unprocessed Red Meat, Poultry, or Fish Intake With Incident Cardiovascular Disease and All-Cause Mortality","volume":"180","author":"Zhong","year":"2020","journal-title":"JAMA Intern. Med."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/18\/3043\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T12:52:07Z","timestamp":1789995127000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/18\/3043"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,17]]},"references-count":46,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["nu18183043"],"URL":"https:\/\/doi.org\/10.3390\/nu18183043","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,17]]}}}