Abstract
Anthocyanins, as a type of polyphenolic compound, have been discovered to offer multiple health benefits to humans, including anti-aging and anti-inflammatory properties. This prospective cohort study aims to examine the relationship of dietary intake of anthocyanin with all-cause mortality and cardiovascular diseases mortality in the US. The aim of this research was to explore the possible correlation between anthocyanin consumption and the mortality rate from all causes as well as from cardiovascular disease. Based on the Public Access NHANES-linked National Death Index files up to December 31, 2019, we identified mortality status and heart disease-specific causes of death. A multivariate Cox regression analysis was employed to evaluate the effects of anthocyanin intake on mortality outcomes, generating hazard ratios and 95% confidence intervals, adjusting for various demographic characteristics, lifestyle factors, and comorbid conditions. Additionally, we utilized Kaplan-Meier survival curves, subgroup analyses. In different scenarios, dietary anthocyanin intake was assessed using restricted cubic spline models. A total of 11,959 participants completed the final cohort, averaging 47.12 years of age (SD ± 0.35). Following adjustments for multiple variables, an inverse relationship was identified between anthocyanin intake in the highest quartile and all causes mortality, yielding a hazard ratio (HR) of 0.68 (95% CI: 0.52–0.89). Similarly, elevated anthocyanin consumption was linked to a reduction in heart disease mortality, with HR of 0.61 (95% CI: 0.38–0.97). Additionally, dose–response curve revealed a consistent decrease in both all-cause and cardiovascular mortality with increasing anthocyanin intake. Further subgroup analyses revealed that elevated intake of anthocyanins was linked to decreased all-cause mortality in White individuals and males. Moreover, high anthocyanin intake was significantly correlated with reduced all-cause mortality irrespective of hypertension or hyperlipidemia status. Our research indicates that an appropriate dietary intake of anthocyanins is associated with a reduction in overall mortality rates. Furthermore, the findings reveal a substantial association between anthocyanin intake and decreased mortality from cardiovascular diseases, suggesting that anthocyanins may effectively lower the risk of cardiovascular-related deaths.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-024-76805-z.
Keywords: Anthocyanidins, Mortality, Dietary intake, NHANES, Cardiovascular diseases mortality
Subject terms: Nutrition, Public health, Epidemiology, Plant sciences
Introduction
As a category of polyphenolic substances extensively distributed in berries and pigmented flora1,2, anthocyanins have garnered long-standing acknowledgment for their abilities in counteracting aging3, inflammation4, cancer5,6, and safeguarding neural tissues7,8. Amidst the prevalent accessibility of calorie-rich foods and the escalating consumption of processed foodstuffs, the weight of diet-related ailments like diabetes, hypertension, and cardiovascular disorders is amplifying9–11. Anthocyanins, as non-essential elements inherent in fresh edibles, hold potential in diminishing the pervasiveness of chronic illnesses.
In the realm of anthocyanin classification, six principal subtypes—cyanidin, delphinidin, pelargonidin, petunidin, malvidin, and peonidin—are recognized as representative of the majority of anthocyanins found in plants. Numerous epidemiological investigations and clinical experiments have indicated that these anthocyanins and their subtypes possess significant efficacy in preventing malignant tumors12,13, diabetes mellitus14,15, cardiovascular disease16,17, and other critical illnesses. Fresh foods abundant in anthocyanins, such as blueberries18, mulberries19, and cherries20, have been shown to confer diverse health benefits across multiple human physiological systems.
Although the consensus acknowledges the positive impact of anthocyanins on cardiac function and cardiovascular health, primarily through the stimulation of nitric oxide (NO) release or the neutralization of reactive oxygen species (ROS), there remains a lack of prospective studies on the long-term health effect pertaining to quantitative anthocyanin intake. Prior investigations have put the spotlight on the outcomes of specific plant-based foods in mitigating cardiovascular disease risks or influencing biomarkers, thereby neglecting the comprehensive evaluation of total anthocyanin consumption and its broader health implications, which has created a significant research gap in this domain. Furthermore, some studies report that anthocyanin intake may not exert a pronounced effect on cardiovascular health21,22, introducing a considerable degree of uncertainty regarding the relationship between anthocyanins and cardiovascular diseases.
Consequently, the comprehensive wellness benefits in body system of dietary anthocyanins and their protective effects on cardiovascular health remain inconclusive. This study synthesizes data from the National Health and Nutrition Examination Survey (NHANES) for the periods 2007–2010 and 2017–2018 to examine the association between anthocyanin intake and both all-cause mortality and cardiovascular disease-specific mortality. Moreover, we analyzed the dose–response relationship to further elucidate how varying levels of anthocyanin consumption impact these health outcomes.
Method
Study design and participants
NHANES is a multicenter program to give researcher instant access to information on nationally representative survey based on USA adults. The program was meticulously formulated to appraise the state of health and nutritional situation of the U.S. population systematically. It utilizes a sophisticated, layered, multi-step sampling approach and has been widely used as a sizable long-term study. This sample accurately mirrors the nation demographic composition through connections to a subsequent survey23. NHANES data acquisition methodology includes initial in-home interviews, health screenings at mobile examination centers, and the further investigation of telephone interviews. To evaluate the dietary habits of the U.S. population, the intake levels of dietary Anthocyanidins were determined using the Food and Nutrient Database for Dietary Studies developed by USDA. This resource is based on data from the NHANES outcomes. The study received ethical approval from the NHANES review board at the Centers for Disease Control and Prevention, and written informed consent agreements were secured from all participants. A total of 18,611 participants, who were at least 18 years old at the time of the initial assessment, were enrolled in the study during the 2007–2010 and 2017–2018 NHANES cycles. Initially, we excluded 182 participants who were pregnant. Subsequently, we eliminated 27 participants without mortality data. Additionally, we excluded 4,062 participants who did not participate in the dietary questionnaire survey assessing Anthocyanidins intake and 2,381 participants were excluded owing to the deficiency of essential covariate data, which included education, smoking, hypertension, body mass index (BMI), hyperlipidemia, alcohol drinking status, eating healthy index, diabetes mellitus (DM), total energy intake, protein intake, etc. Ultimately, 11,959 participants with complete covariates were selected for inclusion (Fig. 1).
Fig. 1.
Flowchart of the participants included in the final analysis.
Dietary anthocyanidin intake
Anthocyanidin intake in this study was based on the consumption of food and beverages, excluding Anthocyanidin medications or supplements. The collected foods were coded using the U.S. Department of Agriculture FNDDS database to calculate primary flavonoid compound intake types for each participant on both the initial and subsequent recording dates. To investigate the relationship between dietary Anthocyanidin intake and human health, this research utilized the average intake of Anthocyanidins, obtained through two 24-hour dietary recalls. The initial dietary data were gathered by experienced interviewers, and the subsequent information was obtained through telephone interviews conducted 3 to 10 days later.
Dietary Anthocyanidin intake was defined as the cumulative sum of six Anthocyanin subclasses intakes: delphinidin, peonidin, malvidin, petunidin, cyanidin and pelargonidin24. Participants were categorized into four groups (Q1, Q2, Q3, Q4) based on the quartiles of each Anthocyanidin intake.
Ascertainment of mortality
A unique study identifier was utilized to ascertain all-cause and cardiovascular disease mortality. This identifier was matched against the National Death Index using a probability matching algorithm developed by the National Center for Health Statistics to determine the survival status of the follow-up population. In cases where no match was found, it was presumed that the individual remained alive as of that date. The follow-up period, calculated in person-years, spanned from baseline to either the participant’s death or the end of the follow-up period on December 31, 2019.
Following the guidelines of the ICD-10, deaths due to all causes and cardiovascular diseases were identified. All-cause mortality encompassed deaths resulting from cardiovascular diseases (codes I00-I09, I11, I13, I20-I51, and I60-I69), malignant neoplasms (codes C00-C97), pneumonia and influenza (codes J09-J18), along with all other causes. Additionally, only participants who died from heart-related causes were included in a separate subgroup analysis to determine whether the independent variable had a distinct effect on the cause of heart-related deaths. For a comprehensive understanding of mortality outcomes, further data is available at the following link: Available from: [https://www.cdc.gov/nchs/data-linkage/mortality-methods.htm]
Covariate assessment
Our covariates included age, sex, healthy eating index (HEI)25,26, ethnicity, education level, BMI, Hyperlipidemia27, total energy, protein, carbohydrate and total sugars intake. Smoking status was recorded as never smoked, former smoker, or current smoker (now). Specifically, smoking status was defined as: now (smoked over 100 cigarettes in their lifetime and continues to smoke at present), former (smoked over 100 cigarettes in their lifetime but has quit smoking now), and never (smoked below 100 cigarettes in their lifetime). We have categorized physical activity levels into quartiles based on the Metabolic Equivalent of Task (MET) calculated on a weekly basis. These quartiles are defined as: very low, low, moderate, and high28. Alcohol consumption status was categorized as heavy, moderate, mild, former, and never29,30.
Diagnosis criterion of Hypertension was identified as self-reported diagnosis, systolic blood pressure (SBP) ≥ 140 mmHg, diastolic blood pressure (DBP) ≥ 90 mmHg31, or use of antihypertensive drugs. Diabetes Mellitus (DM) and related abnormalities were classified as follows32,33: (1) DM: diabetes mellitus; (2) IFG: impaired fasting glycemia; (3) IGT: impaired glucose tolerance; (4) no diabetes. Detailed definitions of general population characteristics, lifestyle habits, and disease conditions are provided in Supplementary Methods.
Statistical analysis
As a summary of baseline characteristics, continuous variables were presented as averages (standard deviations), while categorical variables were represented as frequencies (percentiles). Quartiles of dietary Anthocyanidin intake were documented (Q1, Q2, Q3, Q4). Follow-up person-years were calculated from the baseline date until the occurrence of death, loss to follow-up, or the study end date (December 31, 2019), whichever occurred first. In all analyses, we applied the specialized dietary weights “wtdr2d” provided by NHANES to ensure accurate data weighting.
We stratified the average anthocyanin intake by age (12 groups: 20–25, 25–30, 30–35, 35–40, 40–45, 45–50, 50–55, 55–60, 60–65, 65–70, 70–75, 75–80 years), BMI (5 groups: <18.5, 18.5–25, 25–30, 30–35, ≥ 35 kg/m²), education level, and ethnicity. To illustrate variations in anthocyanin consumption across different demographic groups, we generated bar charts and spline curves. These visualizations enabled us to analyze trends in average anthocyanin intake among groups with different attributes. Differences in characteristics, disease status, and other parameters between anthocyanin intake quartiles were examined using weighted Pearson’s Chi-squared tests were performed on categorical variables, and the weighted Wilcoxon rank-sum tests were performed on continuous variables.
The relationships between anthocyanin consumption and the risks of all-cause mortality or cardiovascular disease (CVD) mortality were evaluated using a multivariate Cox regression model. This model estimated hazard ratios (HRs) and their 95% confidence intervals (CIs). Three progressively adjusted models were employed: Model 1: Adjusted solely for baseline age (years, continuous). Model 2: Adjusted for ethnicity, age, sex, protein intake, smoking status, BMI (kg/m², continuous), physical activity level, total energy intake, carbohydrate intake, and total sugar intake. Model 3: Adjusted for all covariate, in addition to other mortality risk factors such as DM, hypertension, alcohol consumption, and hyperlipidemia. Additionally, multivariate Cox regression analyses were stratified by sex, education level, BMI group, smoking status, hyperlipidemia, Diabetes Mellitus, and ethnicity. The survey-weighted Likelihood Ratio test was utilized to evaluate the significance of interaction effects.
To visualize the relationship between dietary anthocyanin intake and fatality risk over the follow-up period, weighted Kaplan-Meier survival curves were constructed, stratified by levels of anthocyanin intake. Age-standardized death rates were computed utilizing the population based on the 2000 census as a reference. The relationship between anthocyanin intake and mortality from all causes and cardiovascular disease was also investigated using restricted cubic spline curves (RCS). All statistical analyses were conducted utilizing the “nhanesR” package within R software in version 4.3.2, deemed statistically significant if the P-value is below 0.05.
Results
Baseline characteristics
According to the established exclusion standards, an aggregate of 11,959 participants were included in the study, with a mean (SD) age of 47.12 (± 0.35) years; of these, 5,814 (48.2%) were female. Over an average follow-up duration of 8.05 years (96,279 total person-years) the study documented 1,421 deaths. Table 1 presents the sample sizes and weighted percentages, along with significance levels for differences within various variable categories, representing 196,230,521 non-hospitalized inhabitants of the United States. Notably, significant differences were observed in demographic characteristics and baseline clinical features between participants with lower Anthocyanidin intake (Q1) and those with higher Anthocyanidin intake (Q4). Participants with higher Anthocyanidin intake tended to have higher total energy intake (P = 0.01), higher healthy eating index scores (P < 0.0001), and higher protein intake (P = 0.01). Survival status was not observed to be significantly associated with higher Anthocyanidin intake (P = 0.21). The Anthocyanidin intake was higher in participants who were at a higher level of education, BMI 18.5–25 kg/m2, White race, higher age (Fig. 2). Additionally, survival status was used as a baseline characteristic for stratification, as detailed in Supplementary Table 1.
Table 1.
Characteristics study subjects classified by quartiles of anthocyanidin consumption.
| Characteristica | Quintiles of dietary anthocyanidins intaked | P-valueb | |||
|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | ||
| Number (no.) | 3005 | 2979 | 2985 | 2990 | |
| BMIc (kg/m2) | 30.06 ± 0.20 | 29.37 ± 0.22 | 29.25 ± 0.21 | 28.08 ± 0.16 | < 0.0001 |
| HEI-scorec | 42.61 ± 0.39 | 49.01 ± 0.35 | 52.97 ± 0.40 | 57.71 ± 0.38 | < 0.0001 |
| Age (years) | 43.33 ± 0.41 | 45.81 ± 0.45 | 48.18 ± 0.63 | 50.66 ± 0.60 | < 0.0001 |
| Total energy(kcal/day) | 2033.43 ± 23.92 | 2078.68 ± 23.41 | 2125.97 ± 28.05 | 2155.02 ± 23.81 | 0.01 |
| Protein (g/day) | 79.57 ± 1.03 | 81.98 ± 1.04 | 83.03 ± 1.15 | 84.52 ± 1.13 | 0.01 |
| Carbohydrate (g/day) | 237.01 ± 3.12 | 244.58 ± 2.40 | 258.08 ± 2.95 | 258.30 ± 2.83 | < 0.0001 |
| Total sugars (g/day) | 105.05 ± 1.80 | 106.67 ± 1.70 | 111.81 ± 1.76 | 116.65 ± 1.99 | < 0.001 |
| Alcohol status | < 0.0001 | ||||
| Former | 481(12.32) | 501(13.64) | 474(11.20) | 319(8.23) | |
| Heavy | 787(28.69) | 635(23.49) | 534(19.36) | 460(16.69) | |
| Mild | 877(31.73) | 966(35.82) | 1090(40.97) | 1329(45.30) | |
| Moderate | 499(18.62) | 453(16.04) | 429(16.06) | 535(20.79) | |
| Never | 361(8.64) | 424(11.02) | 460(12.41) | 347(8.99) | |
| Ethnicity | < 0.0001 | ||||
| Mexican American | 325(6.51) | 626(11.62) | 608(10.59) | 323(5.21) | |
| Black | 794(14.95) | 609(11.81) | 558(11.52) | 454(7.15) | |
| White | 1432(67.51) | 1224(63.41) | 1250(64.02) | 1656(76.29) | |
| Hispanic | 214(3.83) | 329(6.61) | 371(6.95) | 296(4.94) | |
| Other race | 240(7.20) | 191(6.55) | 198(6.92) | 261(6.41) | |
| Education | < 0.0001 | ||||
| 9–11th grade | 563(13.40) | 478(12.19) | 416(10.32) | 250(5.75) | |
| College graduate | 434(18.87) | 504(22.79) | 686(30.17) | 1050(44.50) | |
| High school graduate/GED | 848(30.43) | 758(28.86) | 641(23.13) | 597(17.90) | |
| Less than 9th | 262(4.50) | 388(6.13) | 386(6.00) | 173(2.90) | |
| Some college or AA degree | 898(32.81) | 851(30.03) | 856(30.38) | 920(28.96) | |
| Smoke | < 0.0001 | ||||
| Former | 642(21.37) | 741(24.01) | 766(24.72) | 857(27.47) | |
| Never | 1397(47.81) | 1572(54.65) | 1748(59.35) | 1794(62.46) | |
| Now | 966(30.83) | 666(21.35) | 471(15.92) | 339(10.07) | |
| Physical activity level | < 0.001 | ||||
| Very low | 851(22.49) | 856(23.09) | 783(19.90) | 679(18.01) | |
| Low | 702(24.18) | 718(24.41) | 785(26.16) | 833(26.61) | |
| Intermediate | 638(23.34) | 654(24.86) | 711(27.59) | 819(31.43) | |
| High | 814(30.00) | 751(27.64) | 706(26.36) | 659(23.96) | |
| Hypertension | 0.51 | ||||
| No | 1775(65.41) | 1714(64.69) | 1728(62.86) | 1736(65.39) | |
| Yes | 1230(34.55) | 1265(35.31) | 1257(37.14) | 1254(34.61) | |
| Diabetes mellitus | 0.20 | ||||
| DMc | 533(13.69) | 597(13.57) | 629(15.52) | 493(12.02) | |
| IFGc | 160(4.46) | 164(5.26) | 138(4.07) | 143(4.90) | |
| IGTc | 78(2.15) | 104(2.73) | 108(3.19) | 113(3.30) | |
| No | 2234(79.70) | 2114(78.44) | 2110(77.23) | 2241(79.78) | |
| Hyperlipidemia | 0.58 | ||||
| No | 898(31.21) | 832(29.15) | 817(30.40) | 847(31.90) | |
| Yes | 2107(68.79) | 2147(70.85) | 2168(69.60) | 2143(68.10) | |
| Status | 0.21 | ||||
| Alive | 2631(91.74) | 2617(91.97) | 2618(91.93) | 2672(93.27) | |
| Death | 374(8.26) | 362(8.03) | 367(8.07) | 318(6.73) | |
aValues are numbers (%) for categorical variables and means ± SDs for continuous variables.
bP-value for the comparisons between quintiles.
cBMI, Body Mass Index; HEI-score, Healthy eating index; DM, Diabetes mellitus; IFG, Impaired Fasting Glycaemia; IGT, Impaired Glucose Tolerance.
dThe NHANES participants was weighted differently to adjust for the probability of cluster sampling and oversampling of Hispanics and African Americans or aged 60 and above. Therefore the actual number does not match the weighted percentage.
Fig. 2.
The anthocyanidin intake by baseline characteristics.
Anthocyanidin intake and mortality
Utilizing a multivariable adjusted model, it was established that the cohort with the highest anthocyanidin intake (Q4) displayed a reduced total mortality rate in comparison to those with minimal anthocyanidin consumption (Q1). Specifically, the age-adjusted hazard ratio (HR) for all-cause mortality in the highest quartile(Q4) of anthocyanidin intake was 0.48 (95% CI: 0.39–0.59). When further adjustments were made for demographic characteristics and nutrient intake, the HR for all-cause mortality was ascertained to be 0.66 (95% CI: 0.51–0.84) in individuals with high anthocyanidin consumption. Additional adjustments for diseases, nutrient intake, alcohol use, and the healthy eating index revealed a similarly substantial difference, with an HR of 0.68 (95% CI: 0.52–0.89). An analogous correlation was noted regarding cardiovascular disease mortality, with multivariable adjustments yielding an HR of 0.61 (95% CI: 0.38–0.97) for the highest quartile versus the lowest quartile of anthocyanidin intake (P = 0.022) (Table 2).
Table 2.
Hazard ratios (95% CIs) of mortality with weighted anthocyanin.
| Characteristic | Quintiles of dietary anthocyanidins intake | P-Trend | |||
|---|---|---|---|---|---|
| Q1 | Q2 | Q3 | Q4 | ||
| Participants, no. | 3005 | 2979 | 2985 | 2990 | NA |
| Followtime, years | 7.52 ± 0.23 | 7.98 ± 0.17 | 7.89 ± 0.19 | 7.46 ± 0.26 | |
| Anthocyanidins intake, median (range), mg/d |
0.000 [0.000,0.135] |
0.900 (0.135,2.1] |
4.735 (2.1,11.412] |
27.990 (11.412,756.1] |
NA |
| All-cause mortality | |||||
| Death/person-years | 374/2,176 | 362/2,139 | 367/2,209 | 318/1,958 | |
| Model 1 [HR (95% CI)] a | Referent | 0.73(0.60,0.90) | 0.61(0.50,0.75) | 0.48(0.39,0.59) | < 0.0001 |
| Model 2 [HR (95% CI)] b | Referent | 0.83(0.69,1.01) | 0.76(0.62,0.94) | 0.66(0.51,0.84) | < 0.001 |
| Model 3 [HR (95% CI)] c | Referent | 0.83(0.68,1.01) | 0.75(0.61,0.93) | 0.68(0.52,0.89) | 0.004 |
| Cardiovascular mortality | |||||
| Death/person-years | 104/588 | 95/560 | 106/648 | 100/625 | |
| Model 1 [HR (95% CI)] a | Referent | 0.75(0.48,1.19) | 0.57(0.38,0.85) | 0.44(0.30,0.65) | < 0.0001 |
| Model 2 [HR (95% CI)] b | Referent | 0.87(0.56,1.35) | 0.76(0.51,1.13) | 0.64(0.44,0.95) | 0.017 |
| Model 3 [HR (95% CI)] c | Referent | 0.84(0.52,1.34) | 0.72(0.48,1.09) | 0.61(0.38,0.97) | 0.022 |
aCox proportional hazard model adjusted for age.
bCox proportional hazards model adjusted by age sex, ethnicity, smoke, BMI, education level, Physical activity level, total energy intake, protein intake, carbohydrate intake, sugars intake.
cFurther adjusted for alcohol user, healthy eating index, Hypertension, Diabetes mellitus, Hyperlipidemia.
Multivariable adjustment Cox regression incorporating RCS was employed to investigate the dose–response relationship between dietary anthocyanin consumption and the risk of mortality. The analysis revealed a monotonic decreasing trend in both all-cause mortality (P for overall = 0.0068; P for nonlinear = 0.2433) and cardiovascular disease mortality (P for overall = 0.13; P for nonlinear = 0.4157), with no evidence of a non-linear relationship (Fig. 3).
Fig. 3.
Dose–response association between dietary anthocyanidins intake and risk of mortality. A For all-cause mortality, B for cardiovascular diseases mortality.
The Kaplan-Meier survival curve assessment revealed that participants in the top quartile of anthocyanin consumption (Q4) demonstrated reduced rates of overall mortality and cardiovascular mortality when contrasted with those in the remaining three quartiles (Fig. 4). Age-standardized mortality rates, calculated based on the 2000 census, revealed that men and women in the lowest quartile of anthocyanin intake (Q1) had age-standardized mortality rates of 10.6% and 8.32%, respectively. In contrast, those in the higher level of anthocyanin intake (Q4) demonstrated substantially lower age-standardized mortality rates, at 6.38% for men and 4.69% for women (Fig. 5).
Fig. 4.
Kaplan-Meier Survival Curves in relationship with anthocyanidins intake. A For all-cause mortality, B for cardiovascular diseases mortality.
Fig. 5.
The relationship stratified by gender between age-standardized mortality rates and anthocyanin intake.
Subgroup and sensitivity analyses
The stratified assessment examining the relationship between dietary anthocyanin intake and all-cause mortality revealed consistent findings across various subgroups. These subgroups were stratified by age (≥ 60, 40–60, < 40 years), sex, race, smoking status, hypertension, and hyperlipidemia after multivariable adjustments. There were no significant interactions observed among these subgroups (P > 0.05). However, significant linear trends were detected within specific subgroups: individuals aged ≥ 60 years (p = 0.042), males (p = 0.035), whites (p = 0.003), never-smokers (p = 0.013), those with hypertension (p = 0.003), and those with hyperlipidemia (p = 0.003) during the trend tests. (Fig. 6)
Fig. 6.
Associations between anthocyanin intake and all-cause mortality stratified by baseline age, sex, race, smoking status, hypertension and hyperlipidemia. *Covariate adjustment using a fully adjusted model: age, alcohol consumption, sex, ethnicity, smoke, body mass index, education, healthy eating index score, Hypertension, Diabetes mellitus, Hyperlipidemia, total energy, protein, carbohydrate and sugars intake.
In the sensitivity analysis, omitting individuals who had a follow-up duration shorter than 24 months did not alter the consistent results regarding anthocyanins and all-cause mortality. Nonetheless, there were minor variations in the results for cardiovascular mortality within the multiple-adjusted models. (Supplemental Table 2)
Discussion
Within the framework of this prospective cohort investigation, part of the NHANES involving United States adults, we observed that elevated dietary anthocyanidin intake tied to a diminished risk of all-cause mortality, exhibiting dose-dependent protective effects. The age-adjusted hazard ratio (HR) and multivariate adjustment HR for all-cause mortality in the higher level of anthocyanidin consumption were 0.48 (95% CI: 0.39–0.59) and 0.68 (95% CI: 0.52–0.89), respectively. For cardiovascular disease mortality, the age-adjusted HR and multivariate adjustment HR were 0.44 (95% CI: 0.30–0.65) and 0.61 (95% CI: 0.38–0.97) in the respective sequence. Moreover, analyzing the trend relationship between increasing quartiles of anthocyanin intake and both all-cause and cardiovascular disease-specific mortality revealed a significant linear trend (P < 0.05). Therefore, we employed RCS to explore the dose–response relationship, which identified a consistent decreasing trend in both all-cause and cardiovascular disease mortality with higher anthocyanidin intake, with devoid of nonlinear associations.
In the stratified analyses, a significant association between the highest quartile dietary anthocyanidin intake in the quartile group and all-cause mortality was found in males [HR = 0.63, 95%CI: (0.42–0.93)] but without statistical significance in females. Simultaneously, notable associations were found in subgroups of never smokers [HR = 0.61, 95% CI: (0.41–0.92)] and individuals of white ethnicity [HR = 0.64, 95% CI: (0.47–0.86)], remaining significant regardless of the presence of hypertension or hyperlipidemia (P < 0.05). In addition, we used dietary anthocyanidin intakes to demonstrate the intake levels and trends of dietary anthocyanin different demographic groups with distinct characteristics (Fig. 2). In US adults, the total intake of anthocyanidin gradually increases with a rise in educational background, namely from Less Than 9th Grade to College Graduate or above. In the same way, the trend of anthocyanidin intake shows an increasing fluctuation with age.
Kaplan-Meier survival curve analysis demonstrated that participants in the uppermost quartile of anthocyanin consumption (Q4) showed reduced overall mortality and cardiovascular mortality rates when contrasted with those in the bottom quartile of anthocyanidin intake (Q1). In addition, the age-standardized mortality rate in accordance with the 2000 census decreased with a higher intake of anthocyanidin; the age-standardized mortality rate was 4.69% among those with the highest intake of anthocyanidin in female. There was a 3.63% reduction compared to the lowest quartile of anthocyanidin intake in female (Fig. 5).
Previous epidemiological research has explored the correlation between anthocyanin-rich foods (such as grapes, blueberries, blackberries, and other pigmented berries) and human health. Mink et al.34 conducted a prospective study that spanned 16 years, focusing on postmenopausal women. Their findings revealed that participants who consumed strawberries or blueberries at least once a week experienced a significantly lower risk of cardiovascular disease-related mortality. Similarly, in a cohort study conducted in France35, the cardioprotective benefits of wine were noted. This study was the first to identify the “French Paradox,” which suggests that moderate red wine consumption is linked to a reduced risk of coronary heart disease. In a study conducted on American adults12, it was observed that that increasing daily anthocyanin intake to no more than 20 milligrams might strengthen their protective effects against lung cancer. But the dose–response analysis suggested that the effective anthocyanin intake for preventing lung cancer is unlikely to exceed 20 milligrams per day. However, there is currently no prospective study on the total intake of anthocyanins and all-cause mortality or cardiovascular mortality. This lack of research has prevented the acquisition of convincing epidemiological evidence on dietary anthocyanin intake levels. Therefore, we initiated a study to address this gap and to explore possible mechanisms overlooked in prior research.
In addition to the epidemiological evidence, various experimental studies at different levels further elucidate the mechanisms by which anthocyanin intake confers protective benefits across multiple human body systems. Notably, anthocyanins demonstrate antioxidant capabilities by actively neutralizing reactive oxygen species (ROS), within biological systems36. Furthermore, anthocyanins indirectly contribute to anti-aging processes by enhancing the activities of superoxide dismutase (SOD) and catalase (CAT)37. A French in vitro study38 found that anthocyanins have anti-apoptotic effects in aortic endothelial cells through the NO-guanylate cyclase pathway. Simultaneously, anthocyanins upregulate endothelial nitric oxide synthase (eNOS) expression via the MEK1/2 pathway, significantly increasing nitric oxide (NO) production by the eNOS isoform. This upregulation plays a pivotal role in safeguarding cardiovascular endothelial cells from apoptosis. Additionally, several studies indicate that anthocyanins can activate nuclear factor erythroid 2-related factor 2 (Nrf2). Through the heme oxygenase-1 (HO-1) pathway39,40, anthocyanins induce extensive Nrf2 expression in high oxygen-consuming organs such as the heart, lungs, and brain41,42. In the response to oxidative stress and inflammation, Nrf2 accumulates in the cell nucleus and triggers protective defenses, thereby bolstering cellular resistance to oxidative damage.
To date, this study remains the most extensive population-based investigation into the relationship between dietary anthocyanidin intake with all-causes mortality and cardiovascular diseases mortality in adults. Nevertheless, some limitations should be considered in the interpretation of our findings. Firstly, in comparison to interventional studies, cohort studies based on observational data face significant challenges in completely eliminating potential confounding factors, thereby limiting their ability to establish causality. Additionally, considering that red wine is a notable source of anthocyanins, there is insufficient evidence regarding the potential synergistic effects of simultaneous alcohol and anthocyanin consumption. Furthermore, dietary anthocyanin intake was obtained through 24-hour dietary recalls; the potential recall bias was challenging to overcome. Moreover, our findings are confined to the analysis of anthocyanin intake and do not include the evaluation of anthocyanin plasma levels. To better mirror real-world scenarios, this study exclusively focuses on the intake of anthocyanins from fresh food sources, deliberately excluding any intake from anthocyanin supplements.
Conclusions
In summary, we found that an inverse relationship between anthocyanin intake and the risk of all-cause mortality among U.S. adults. We observed a similar inverse relationship between cardiovascular disease (CVD) mortality and anthocyanin intake, suggesting a potential reduction in CVD-related deaths. In the RCS regression analysis, the dose–response curve demonstrated a monotonic decrease in both all-cause mortality and CVD mortality with increasing anthocyanin consumption. These results imply that dietary anthocyanin intake may confer protective effects against all-cause and CVD mortality, thereby recommending the incorporation of anthocyanin-rich foods into the diets of specific populations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Thanks to Zhang Jing (Second Department of Infectious Disease, Shanghai Fifth People’s Hospital, Fudan University) for his work on the NHANES database. His outstanding work, nhanesR package and webpage, makes it easier for us to explore NHANES database.
Author contributions
J.L. and Y.Y.; methodology, J.L. and Y.Y.; software, J.L. and Y.Y.; validation, J.L. and Y.Y.; formal analysis, Y.Y.; resources, Y.Y.; data curation, Y.Y.; original draft preparation, Y.Y.; paper review and editing, J.L. and Y.Y.; visualization, Y.Y.; supervision, J.L.; project administration, J.L.; funding acquisition, J.L. All authors have read and agreed to the published version of the manuscript.
Funding
J.L. received support from the Guangdong Medical Science and Technology Research Fund, grant number: A2019319.
Data availability
Publicly available datasets were analyzed in this study. These data can be found here: https://www.cdc.gov/nchs/nhanes/index.htm. And the datasets have analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Informed consent
This study was performed using public data from the National Center for Health Statistics and the National Health and Nutrition Examination Survey (NHANES). Prior to enrollment, all participants furnished informed consent. The study requires no further approval and follows ethical guidelines.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Publicly available datasets were analyzed in this study. These data can be found here: https://www.cdc.gov/nchs/nhanes/index.htm. And the datasets have analysed during the current study are available from the corresponding author on reasonable request.