Fruit, Vegetable, Legume Intake and CVD Events

Study Questions:

Is fruit, vegetable, and legume intake associated with cardiovascular disease (CVD) in a large globally diverse cohort?


Data were used from the PURE (Prospective Urban Rural Epidemiology) study, a large prospective cohort study which included adults (aged 35-70 years) from 18 countries from five continents (North America, South America, Europe, Africa, and Asia). All participants were free of CVD at baseline. Baseline diet was assessed using validated food frequency questionnaires. Additional 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 CVD. Outcomes included major CVD (defined as death from CV causes and nonfatal myocardial infarction [MI], stroke, and heart failure), fatal and nonfatal MI, fatal and nonfatal strokes, CV mortality, non-CV mortality, and total mortality. Participants were enrolled between January 1, 2003, and March 31, 2013, and outcomes were included up to March 31, 2017.


A total of 135,335 adults were enrolled between January 1, 2003, and March 31, 2013. During a median 7.4 years (5.5-9.3 years) of follow-up, 4,784 major CVD events, 1,649 CV deaths, and 5,796 total deaths occurred. Combined mean fruit, vegetable, and legume intake was 3.91 (standard deviation 2.77) servings per day. Higher total fruit, vegetable, and legume intake was inversely associated with major CVD, MI, CV mortality, non-CV mortality, and total mortality after adjustment for age, sex, and study site. After further adjustment for additional factors including current smoking, diabetes status, physical activity, education, meat intake, and bread/cereal intake, these associations were substantially attenuated. The estimates were substantially attenuated in the multivariable adjusted models. For major CVD, the hazard ratio (HR) was 0.90 (95% confidence interval [CI], 0.74-1.10), with <1 serving per day as a reference group. A similar association was observed for MI (HR, 0.99; 95% CI, 0.74-1.31), stroke (HR, 0.92; 95% CI, 0.67-1.25), CV mortality (HR, 0.73; 95% CI, 0.53-1.02), and non-CV mortality (HR, 0.84; 95% CI, 0.68-1.04). Only total mortality remained statistically significant (HR, 0.81; 95% CI, 0.68-0.96). When examined separately, fruit intake was associated with lower risk of CV, non-CV, and total mortality, while legume intake was inversely associated with non-CV death and total mortality. 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.


The investigators concluded that higher fruit, vegetable, and legume consumption was associated with a lower risk of non-CV and total mortality. Benefits appear to be maximum for both non-CV mortality and total mortality at 3-4 servings per day, which is equivalent to 375-500 g/day.


These data support recommendations to consume daily intake of fruit, vegetables, and legumes as part of a healthy lifestyle. The question remains whether adequate access to fruits, vegetables, and legumes is provided for all.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Diet, Exercise, Smoking

Keywords: Cardiovascular Diseases, Diabetes Mellitus, Diet, ESC Congress, ESC2017, Exercise, Fruit, Heart Failure, Life Style, Myocardial Infarction, Primary Prevention, Smoking, Social Class, Stroke, Vegetables

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