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

Published on Nov 1, 2017in The Lancet59.10
· DOI :10.1016/S0140-6736(17)32253-5
Victoria Miller2
Estimated H-index: 2
(Population Health Research Institute),
Andrew Mente32
Estimated H-index: 32
(Population Health Research Institute)
+ 352 AuthorsR Mapanga4
Estimated H-index: 4
View in Source
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).
Figures & Tables
  • References (47)
  • Citations (73)
#1Dagfinn Aune (Imperial College London)H-Index: 36
#2Edward Giovannucci (Harvard University)H-Index: 180
Last.Serena Tonstad (Oslo University Hospital)H-Index: 44
view all 10 authors...
181 CitationsSource
#1Binh Nguyen (USYD: University of Sydney)H-Index: 12
#2Adrian Bauman (USYD: University of Sydney)H-Index: 103
Last.Ding Ding (USYD: University of Sydney)H-Index: 26
view all 6 authors...
29 CitationsSource
#1Victoria Miller (Population Health Research Institute)H-Index: 2
#2Salim Yusuf Mb Bs DPhil Frcpc (Population Health Research Institute)H-Index: 214
Last.Andrew Mente (Population Health Research Institute)H-Index: 32
view all 39 authors...
80 CitationsSource
35 CitationsSource
#1Renata Micha (Tufts University)H-Index: 40
#2Shahab Khatibzadeh (Harvard University)H-Index: 20
Last.Dariush Mozaffarian (Tufts University)H-Index: 120
view all 6 authors...
106 CitationsSource
#1Fatma EsraH-Index: 3
#2Nese ImeryuzH-Index: 21
Last.Mahshid DehghanH-Index: 24
view all 7 authors...
4 Citations
#1Xia Wang (HUST: Huazhong University of Science and Technology)H-Index: 13
#2Yingying Ouyang (HUST: Huazhong University of Science and Technology)H-Index: 7
Last.Frank B. Hu (Harvard University)H-Index: 205
view all 7 authors...
616 CitationsSource
196 CitationsSource
#1Mahshid Dehghan (Population Health Research Institute)H-Index: 24
#2Solange Martinez (UFRO: University of La Frontera)H-Index: 1
Last.Anwar T. Merchant ScD Mph Dmd (USC: University of South Carolina)H-Index: 36
view all 7 authors...
14 CitationsSource
#1Daniel J. Corsi (Harvard University)H-Index: 17
#2S. V. Subramanian (Harvard University)H-Index: 82
Last.Salim Yusuf Mb Bs DPhil Frcpc (Population Health Research Institute)H-Index: 214
view all 25 authors...
57 CitationsSource
Cited By73
#1Xiuting Mo (Kyoto University)H-Index: 2
Last.Rintaro MoriH-Index: 47
view all 7 authors...
#1Yuling Chen (Capital Medical University)
#2Fangqin Wu (Capital Medical University)H-Index: 1
Last.Yan Zhang (Capital Medical University)
view all 10 authors...
#1Kufre Joseph Okop (UWC: University of the Western Cape)H-Index: 2
#2Kululwa Ndayi (UWC: University of the Western Cape)H-Index: 1
Last.Thandi Puoane (UWC: University of the Western Cape)H-Index: 27
view all 5 authors...
#1Junling Gao (Fudan University)H-Index: 10
#2Y. Jia (Fudan University)
Last.X. Nie (Fudan University)
view all 8 authors...
#1Deborah CosmiH-Index: 3
#2B MariottoniH-Index: 1
Last.Franco CosmiH-Index: 8
view all 3 authors...
#1Gustavo C. Román (Cornell University)H-Index: 35
#2R.E. Jackson (Cornell University)H-Index: 1
Last.J. Reis (UDS: University of Strasbourg)H-Index: 2
view all 5 authors...
#1Juhani KnuutiH-Index: 85
#2William WijnsH-Index: 102
Last.Brian ClappH-Index: 1
view all 130 authors...
6 CitationsSource
#1Krzysztof Przybyl (Life Sciences Institute)H-Index: 10
#2Agnieszka Pilarska (PUT: Poznań University of Technology)H-Index: 6
Last.Łukasz Gierz (PUT: Poznań University of Technology)H-Index: 3
view all 10 authors...