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Many studies have examined associations between dietary isoflavones and atherosclerosis, but few used objective biomarkers. We examined the associations of isoflavone biomarkers (primary analyses) and equol production (secondary analyses) with the progression of carotid intima-media thickness (cIMT), and whether inflammation, systolic blood pressure (SBP), blood lipids, and sex hormone-binding globulin (SHBG) mediated these associations, in Chinese adults. This 8.8-y prospective study included 2572 subjects (40-75 y old) from the GNHS