Title

Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study.

Authors

Victoria Miller, McMaster University, Hamilton, ON, Canada
Andrew Mente, McMaster University, Hamilton, ON, Canada
Mahshid Dehghan, McMaster University, Hamilton, ON, Canada
Sumathy Rangarajan, McMaster University, Hamilton, ON, Canada
Xiaohe Zhang, McMaster University, Hamilton, ON, Canada
Sumathi Swaminathan, St John's Research Institute, Bangalore, India
Gilles Dagenais, Université Laval, QC, Canada
Rajeev Gupta, Eternal Heart Care Centre and Research Institute, Jaipur, India
Viswanathan Mohan, Dr Mohan's Diabetes Specialties Centre, Chennai, India
Scott Lear, Simon Fraser University, Vancouver, BC, Canada
Shrikant I. Bangdiwala, McMaster University, Hamilton, ON, Canada
Aletta E. Schutte, South African Medical Research Council/North-West University, Potchefstroom, South Africa
Edelweiss Wentzel-Viljoen, South African Medical Research Council/North-West University, Potchefstroom, South Africa
Alvaro Avezum, University Santo Amaro, São Paulo, Brazil
Yuksel Altuntas, Istanbul Sisli Hamidiye Etfal Health Training and Research Center, Istanbul, Turkey
Khalid Yusoff, UCSI University, Cheras, Kuala Lumpur, Malaysia
Noorhassim Ismail, University of Kebangsaan Malaysia, Kuala Lumpur, Malaysia
Nasheeta Peer, South African Medical Research Council, Durban, South Africa
Jephat Chifamba, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
Rafael Diaz, Estudios Clinicos Latinoamerica ECLA, Rosaria, Argentina
Omar Rahman, Independent University, Dhaka, Bangladesh
Noushin Mohammadifard, Isfahan University of Medical Sciences, Isfahan, Iran
Fernando Lana, Universidad de La Frontera, Temuco, Chile
Katarzyna Zatonska, Medical University of Wroclaw, Wroclaw, Poland
Andreas Wielgosz, University of Ottawa, Ottawa, ON, Canada
Afzalhussein Yusufali, Dubai Health Authority and Dubai Medical College, Dubai, United Arab Emirates
Romaina Iqbal, Aga Khan UniversityFollow
Patricio Lopez-Jaramillo, FOSCAL and MASIRA Institute, Medical Studies, UDES, Bucaramanga, Colombia
Rasha Khatib, Stritch School of Medicine, IL, USA
Annika Rosengren, University of Gothenburg and Sahlgrenska University Hospital/Őstra, Gőteborg, Sweden
V Raman Kutty, Health Action by People, Trivandrum, India
Wei Li, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Jiankang Liu, Jianshe Road Community Health Center, Chengdu, Sichuan Province, China
Xiaoyun Liu, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Lu Yin, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Koon Teo, McMaster University, Hamilton, ON, Canada
Sonia Anand, McMaster University, Hamilton, ON, Canada
Salim Yusuf, McMaster University, Hamilton, ON, Canada

Document Type

Article

Department

Community Health Sciences

Abstract

BACKGROUND:

The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia.

METHODS:

We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality.

FINDINGS:

Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5-9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74-1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74-1·31; ptrend=0·2033), stroke (0·92, 0·67-1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53-1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68-1·04; ptrend =0·0038), and total mortality (0·81, 0·68-0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality.

INTERPRETATION:

Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day).

Publication

Lancet

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This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.