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

Published on Nov 1, 2017in The Lancet 53.25
· DOI :10.1016/S0140-6736(17)32253-5
Victoria Miller2
Estimated H-index: 2
(Population Health Research Institute),
Andrew Mente30
Estimated H-index: 30
(Population Health Research Institute)
+ 352 AuthorsR Mapanga4
Estimated H-index: 4
Summary 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, p trend =0·1301), myocardial infarction (0·99, 0·74–1·31; p trend =0·2033), stroke (0·92, 0·67–1·25; p trend =0·7092), cardiovascular mortality (0·73, 0·53–1·02; p trend =0·0568), non-cardiovascular mortality (0·84, 0·68–1·04; p trend =0·0038), and total mortality (0·81, 0·68–0·96; p trend 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). Funding Full funding sources listed at the end of the paper (see Acknowledgments).
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  • References (48)
  • Citations (59)
Published on Jun 1, 2017in Nutrition Metabolism and Cardiovascular Diseases 3.32
Dagfinn Aune36
Estimated H-index: 36
(Imperial College London),
Edward Giovannucci175
Estimated H-index: 175
(Harvard University)
+ 7 AuthorsSerena Tonstad49
Estimated H-index: 49
(Oslo University Hospital)
Abstract Background and aim Epidemiological studies have reported increased risk of cardiovascular disease, cancer and all-cause mortality with greater resting heart rate, however, the evidence is not consistent. Differences by gender, adjustment for confounding factors, as well as the potential impact of subclinical disease are not clear. A previous meta-analysis missed a large number of studies, and data for atrial fibrillation have not been summarized before. We therefore aimed to clarify the...
136 Citations Source Cite
Binh Nguyen10
Estimated H-index: 10
(USYD: University of Sydney),
Adrian Bauman101
Estimated H-index: 101
(USYD: University of Sydney)
+ 3 AuthorsDing Ding26
Estimated H-index: 26
(USYD: University of Sydney)
Background There is growing evidence for a relationship between fruit and vegetable consumption and all-cause mortality. Few studies, however, specifically explored consuming raw versus cooked vegetables in relation to health and mortality outcomes. The purpose of this study was to examine the relation of all-cause mortality with: a) fruit and vegetable consumption, either combined or separately; b) the consumption of raw versus cooked vegetables in a large cohort of Australian middle-aged and o...
27 Citations Source Cite
Published on Oct 1, 2016in The Lancet Global Health 18.70
Victoria Miller2
Estimated H-index: 2
(Population Health Research Institute),
Salim Yusuf Mb Bs DPhil Frcpc209
Estimated H-index: 209
(Population Health Research Institute)
+ 36 AuthorsScott A. Lear39
Estimated H-index: 39
(SFU: Simon Fraser University)
Summary Background Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability. Methods We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study,...
61 Citations Source Cite
Published on Aug 1, 2016in British Journal of Nutrition 3.66
Pilar Buil-Cosiales20
Estimated H-index: 20
Estefanía Toledo37
Estimated H-index: 37
+ 19 AuthorsEmilio Ros72
Estimated H-index: 72
The study was financially supported by the official funding agency for biomedical research of the Spanish government, Instituto de Salud Carlos III (ISCIII), through grants provided to G03/140, to RE; RTIC RD 06/0045, to MAM-G) and through Centro de Investigacion Biomedica en Red de Fisiopatologia de la Obesidad y Nutricion (CIBERobn), and by grants from Centro Nacional de Investigaciones Cardiovasculares (CNIC 06/2007), the Fondo de Investigacion Sanitaria–Fondo Europeo de Desarrollo Regional (...
30 Citations Source Cite
Published on Sep 1, 2015in BMJ Open 2.41
Renata Micha37
Estimated H-index: 37
(Tufts University),
Shahab Khatibzadeh18
Estimated H-index: 18
(Harvard University)
+ 3 AuthorsDariush Mozaffarian113
Estimated H-index: 113
(Tufts University)
To quantify global intakes of key foods related to non-communicable diseases in adults by region (n=21), country (n=187), age and sex, in 1990 and 2010.
88 Citations Source Cite
Published on Jul 1, 2015in Journal of Pakistan Medical Association 0.72
Fatma Esra3
Estimated H-index: 3
Nese Imeryuz6
Estimated H-index: 6
+ 4 AuthorsMahshid Dehghan22
Estimated H-index: 22
Objectives: To validate the original food frequency questionnaire in Turkish adult population. Methods: The cross-sectional study was conducted in June and December 2008 and 2009, and comprised adults of either gender aged 30-70 years. All subjects were Caucasians and were native Turkish speakers. The food frequency questionnaire containing 229 most frequently consumed foods under 7 topics was used for data collection. It was completed twice and the 24-hour dietary recall four times in a year. I...
4 Citations
Published on Jul 29, 2014in BMJ 23.56
Xia Wang12
Estimated H-index: 12
(HUST: Huazhong University of Science and Technology),
Yingying Ouyang7
Estimated H-index: 7
(HUST: Huazhong University of Science and Technology)
+ 4 AuthorsFrank B. Hu202
Estimated H-index: 202
(Harvard University)
Objective To examine and quantify the potential dose-response relation between fruit and vegetable consumption and risk of all cause, cardiovascular, and cancer mortality. Data sources Medline, Embase, and the Cochrane library searched up to 30 August 2013 without language restrictions. Reference lists of retrieved articles. Study selection Prospective cohort studies that reported risk estimates for all cause, cardiovascular, and cancer mortality by levels of fruit and vegetable consumption. Dat...
557 Citations Source Cite
Published on Jul 1, 2014in The American Journal of Clinical Nutrition 6.55
Ashkan Afshin29
Estimated H-index: 29
Renata Micha37
Estimated H-index: 37
+ 1 AuthorsDariush Mozaffarian113
Estimated H-index: 113
Background: Relations between the consumption of nuts and legumes and risk of ischemic heart disease (IHD), stroke, and diabetes have not been well established. Objective: We systematically investigated and quantified associations of nut and legume consumption with incident IHD, stroke, and diabetes. Design: We systematically searched multiple databases to identify randomized controlled trials or observational studies that examined the relations. Studies were excluded if they reported only inter...
176 Citations Source Cite
Published on Oct 1, 2013in Public Health Nutrition 2.48
Mahshid Dehghan22
Estimated H-index: 22
(Population Health Research Institute),
Solange Martinez1
Estimated H-index: 1
(UFRO: University of La Frontera)
+ 4 AuthorsAnwar T. Merchant ScD Mph Dmd36
Estimated H-index: 36
(USC: University of South Carolina)
Objective FFQ are commonly used to rank individuals by their food and nutrient intakes in large epidemiological studies. The purpose of the present study was to develop and validate an FFQ to rank individuals participating in an ongoing Prospective Urban and Rural Epidemiological (PURE) study in Chile. Design An FFQ and four 24 h dietary recalls were completed over 1 year. Pearson correlation coefficients, energy-adjusted and de-attenuated correlations and weighted kappa were computed between th...
13 Citations Source Cite
Published on Oct 1, 2013in American Heart Journal 4.17
Daniel J. Corsi15
Estimated H-index: 15
(Harvard University),
S. V. Subramanian80
Estimated H-index: 80
(Harvard University)
+ 22 AuthorsAnnamarie Kruger23
Estimated H-index: 23
(NWU: North-West University)
Background The PURE study was established to investigate associations between social, behavioural, genetic, and environmental factors and cardiovascular diseases in 17 countries. In this analysis we compare the age, sex, urban/rural, mortality, and educational profiles of the PURE participants to national statistics. Methods PURE employed a community-based sampling and recruitment strategy where urban and rural communities were selected within countries. Within communities, representative sample...
52 Citations Source Cite
Cited By59
Published on Jun 1, 2019in International Journal of Cardiology 4.03
Paul A. Camacho11
Estimated H-index: 11
(UNAB: Autonomous University of Bucaramanga),
Johanna Otero2
Estimated H-index: 2
+ 16 AuthorsCarlos Cure2
Estimated H-index: 2
(Universidad del Norte, Colombia)
Abstract Background Dyslipidemia is a major risk factor for cardiovascular diseases (CVD). Worldwide, a third of ischemic heart disease is due to abnormal cholesterol levels and it is the most common cause of cardiovascular deaths in Colombia. In Colombia, no representative, large-scale study has assessed the prevalence of dyslipidemia. The aim of the present analysis was to identify the magnitude of the problem in Colombia, a middle-income-country with large regional, geographic, and socio-econ...
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Published on May 1, 2019in Trends in Endocrinology and Metabolism 10.77
Jan Martel4
Estimated H-index: 4
(CGU: Chang Gung University),
David M. Ojcius7
Estimated H-index: 7
(UOP: University of the Pacific (United States))
+ 4 AuthorsJohndingeyoung45
Estimated H-index: 45
Caloric restriction, intermittent fasting, and exercise activate defensive cellular responses such as autophagy, DNA repair, and the induction of antioxidant enzymes. These processes improve health and longevity by protecting cells and organs against damage, mutations, and reactive oxygen species. Consuming a diet rich in vegetables, fruits, and mushrooms can also improve health and longevity. Phytochemicals such as alkaloids, polyphenols, and terpenoids found in plants and fungi activate the sa...
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Published on May 24, 2019in Nutrients 4.20
Carla Cavallo3
Estimated H-index: 3
Gianni Cicia12
Estimated H-index: 12
+ 2 AuthorsRiccardo Vecchio13
Estimated H-index: 13
The presence of some healthy phytochemicals in food can be paired with high bitterness, and consumers have a widespread avoidance toward bitter-tasting food. This causes a gap between preferences and healthy needs of consumers. Therefore, this review collected insights from literature belonging to different discipline domains in order to have a broad view of the current state-of-the-art about biochemical aspects and consumers’ perceptions and preferences toward foods with an enhanced bitter tast...
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Published on May 21, 2019in European Heart Journal 23.43
Chuangshi Wang1
Estimated H-index: 1
(Peking Union Medical College),
Shrikant I. Bangdiwala8
Estimated H-index: 8
(Population Health Research Institute)
+ 28 AuthorsZhiguang Liu1
Estimated H-index: 1
(CUHK: The Chinese University of Hong Kong)
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Published on May 4, 2019in Ecology of Food and Nutrition 1.34
Penny Farrell3
Estimated H-index: 3
(USYD: University of Sydney),
Anne Marie Thow16
Estimated H-index: 16
(USYD: University of Sydney)
+ 2 AuthorsJoel Negin21
Estimated H-index: 21
(USYD: University of Sydney)
ABSTRACTThe adult obesity prevalence in Samoa is the third highest globally, and diet is a significant contributor. Our study aimed to explore the behavioral and demographic factors which influence diets in Samoa. The most important findings for strategic policy design were: i) cost was the most important reason for food choice, ii) participants reported high rates of consumption of sugary and fatty energy foods – along with high rates of food insecurity, and iii) the food frequency questionnair...
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