Document Type : Original Article


1 Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

2 Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

3 Students' Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran

4 Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

5 Department of Community Nutrition, School of Nutrition and Food Science, Nutrition and Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

6 Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran



INTRODUCTION: The aim of the present study was to ascertain the correlation between the intake of whole and refined grains and the risk of stroke in the Iranian adult population.
METHOD: This hospital-based case-control study was conducted at Alzahra University Hospital, Isfahan, Iran, in 2008. The cases (n=195) were stroke patients admitted to the neurology ward, and the controls (n=195) were patients admitted to other wards in this center, with no prior history of cerebrovascular accident or any neurological disorders. The usual dietary intakes of the study participants during the previous year were assessed using a validated semi-quantitative food frequency questionnaire. Whole and refined grains were defined according to the definition of the American Association of Cereal Chemists International; foods that contained at least 8 g per 30 g of their weight were considered as whole grains.
RESULTS: The mean age of the case and control groups was 68.0 (±13.5) and 61.5 (±10.5) years, respectively; 40% of the cases and 53.3% of the controls were female. The total intake of whole grains (27.8±4.3 vs. 29.4±3.6 g/d, P=0.77) and refined grains (264±11 vs. 296±13 g/d, P=0.07) was not significantly different between the cases and controls. After adjusting for potential confounders, individuals in the second tertile of refined grain intake had a two-fold higher odds of stroke (OR: 2.02; 95% CI: 1.08-3.71), compared to those in the first tertile. Furthermore, no significant relationships were observed between the consumption of whole grains and the risk of stroke, before or after adjustment for confounding variables. No significant trend was found between the tertiles of refined or whole grain intake and the risk of stroke.
CONCLUSION: The authors did not find a statistically significant association between the intake of whole and refined grains and the risk of stroke. Further prospective studies on the relationship between both whole and refined grains and stroke are warranted.


1. Zafar F, Tariq W, Shoaib RF, Shah A, Siddique M, Zaki A, et al. Frequency of ischemic stroke subtypes ‎based on toast classification at a tertiary care center in Pakistan. Asian J Neurosurg 2018; 13(4): 984.
2. Avan A, Digaleh H, Di Napoli M, Stranges S, Behrouz R, Shojaeianbabaei G, et al. Socioeconomic status ‎and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the Global Burden of Disease Study 2017. BMC Med 2019; 17(1): 1-30.
3. Katan M, Luft A, editors. Global burden of stroke. Semin Neurol; 2018: Thieme Medical Publishers.
4. Tadi P, Lui F. Acute stroke (cerebrovascular accident). StatPearls. 2020. Available from:‎
5. Ghandehari K. Epidemiology of stroke in Iran. Galen Med J 2016; 5: 3-9.
6. Hosseini AA, Sobhani-Rad D, Ghandehari K, Benamer HT. Frequency and clinical patterns of stroke in Iran-Systematic and critical review. BMC Neurol 2010; 10(1): 1-10.
7. Farhoudi M, Mehrvar K, Sadeghi-Bazargani H, Hashemilar M, Seyedi-Vafaee M, Sadeghi-Hokmabad E, et al. Stroke subtypes, risk factors and mortality rate in northwest of Iran. Iran J Neurol 2017; 16(3): 112.
8. Bin Q, Hu X, Cao Y, Gao F. The role of vitamin E (tocopherol) supplementation in the prevention of stroke. Thromb Haemost 2011; 105(04): 579-85.
9. Spence JD. Nutrition and risk of stroke. Nutrients 2019; 11(3): 647.
10. Manolescu BN, Oprea E, Farcasanu IC, Berteanu M, Cercasov C. Homocysteine and vitamin therapy in ‎stroke prevention and treatment: a review. Acta Biochim Pol 2010; 57(4).
11. Deng C, Lu Q, Gong B, Li L, Chang L, Fu L, et al. Stroke and food groups: an overview of systematic ‎reviews and meta-analyses. Public Health Nutr 2018; 21(4): 766-76.
12. Larsson SC, Männistö S, Virtanen MJ, Kontto J, Albanes D, Virtamo J. Dietary fiber and fiber-rich food ‎intake in relation to risk of stroke in male smokers. Eur J Clin Nutr 2009; 63(8): 1016-24.
13. Flight I, Clifton P. Cereal grains and legumes in the prevention of coronary heart disease and stroke: a ‎review of the literature. Eur J Clin Nutr 2006; 60(10): 1145-59.
14.‎ Sherzai A, Heim LT, Boothby C, Sherzai AD. Stroke, food groups, and dietary patterns: a systematic ‎review. Nutr Rev 2012; 70(8): 423-35.
15.‎ Seal CJ. Whole grains and CVD risk. Proc Nutr Soc 2006; 65(1): 24-34.
16. Joye IJ. Dietary fibre from whole grains and their benefits on metabolic health. Nutrients 2020; 12(10): 3045.
17. Jones JM, Engleson J. Whole grains: benefits and challenges. Annu Rev Food Sci Technol. 2010;1:19-40.
18. Gaesser GA. Perspective: refined grains and health: genuine risk, or guilt by association?. Adv Nutr 2019; 10(3): 361-71.
19. Jacobs Jr DR, Meyer KA, Kushi LH, Folsom AR. Whole-grain intake may reduce the risk of ischemic heart disease death in postmenopausal women: the Iowa Women’s Health Study. Am J Clin Nutr 1998; 68(2): 248-57.
20. McKeown NM, Troy LM, Jacques PF, Hoffmann U, O’Donnell CJ, Fox CS. Whole-and refined-grain ‎intakes are differentially associated with abdominal visceral and subcutaneous adiposity in healthy adults: the Framingham Heart Study. Am J Clin Nutr 2010; 92(5): 1165-71.
21. Good CK, Holschuh N, Albertson AM, Eldridge AL. Whole grain consumption and body mass index in adult women: an analysis of NHANES 1999-2000 and the USDA pyramid servings database. J Am Coll Nutr 2008; 27(1): 80-7.
22. Esmaillzadeh A, Mirmiran P, Azizi F. Whole-grain consumption and the metabolic syndrome: a favorable association in Tehranian adults. Eur J Clin Nutr 2005; 59(3): 353-62.
23. Reynolds AN, Akerman AP, Mann J. Dietary fibre and whole grains in diabetes management: Systematic ‎review and meta-analyses. PLoS Med 2020; 17(3): e1003053.
24. Bhupathiraju SN, Hu FB. Whole Grains and Type 2 Diabetes. Whole Grains and Health 2021: 167-93.
25. Sun T, Zhang Y, Huang H, Wang X, Zhou L, Li S, et al. Plasma alkylresorcinol metabolite, a biomarker ‎of whole-grain wheat and rye intake, and risk of ischemic stroke: a case-control study. Am J Clin Nutr 2019; 109(2): 1-7.
26. Williams PG. Evaluation of the evidence between consumption of refined grains and health outcomes. Nutr Rev 2012; 70(2): 80-99.
27. Hur IY, Reicks M. Relationship between whole-grain intake, chronic disease risk indicators, and weight status among adolescents in the National Health and Nutrition Examination Survey, 1999-2004. J Acad Nutr Diet 2012; 112(1): 46-55.
28. Gaesser GA. Whole grains, refined grains, and cancer risk: A systematic review of meta-analyses of observational studies. Nutrients 2020; 12(12): 3756.
29. Guo H, Ding J, Liang J, Zhang Y. Associations of whole grain and refined grain consumption with metabolic syndrome. A meta-analysis of observational studies. Front Nutr 2021; 8.
30. Liu S, Manson JE, Stampfer MJ, Rexrode KM, Hu FB, Rimm EB, et al. Whole grain consumption and ‎risk of ischemic stroke in women: a prospective study. Jama 2000; 284(12): 1534-40.
31. Chen J, Huang Q, Shi W, Yang L, Chen J, Lan Q. Meta-analysis of the association between whole and ‎refined grain consumption and stroke risk based on prospective cohort studies. Asia Pac J Public Health 2016; 28(7): 563-75.
32. Steffen LM, Jacobs Jr DR, Stevens J, Shahar E, Carithers T, Folsom AR. Associations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) Study. Am J Clin Nutr 2003; 78(3): 383-90.
33. Bahreynian M, Esmaillzadeh A. Quantity and quality of carbohydrate intake in Iran: a target for nutritional intervention. Arch Iran Med 2012; 15: 648-649.
34. Esmaillzadeh A, Mirmiran P, Azizi F. Whole-grain intake and the prevalence of hypertriglyceridemic ‎waist phenotype in Tehranian adults. Am J Clin Nutr 2005; 81(1): 55-63.
35. Esmaillzadeh A, Kimiagar M, Mehrabi Y, Azadbakht L, Hu FB, Willett WC. Dietary patterns and markers of systemic inflammation among Iranian women. J Nutr 2007; 137(4): 992-8.
36. American Association of Cereal Chemists (AACC) International. Whole grain definition. Cereal Foods World 2000; 45: 79.
37. Saadatnia M, Shakeri F, Hassanzadeh Keshteli A, Saneei P, Esmaillzadeh A. Dietary patterns in relation to stroke among Iranians: a case-control study. J Am Coll Nutr 2015; 34(1): 32-41.