Table I.
Effect of fruits and vegetables consumption on cardiovascular disease- A summary
| Author | Year | Study | Study participants (n) | Outcome variable | Assessment tool | Major findings | Confounders adjusted |
|---|---|---|---|---|---|---|---|
| Joshipura et al21 | 2001 | Prospective cohort study | 126,399 individuals (84 251 women 42 148 men) 1063 cases | CHD | FFQ | 1 vs. 5 quintile: All FVs: RR 0.80 (0.69-0.93); GLV: 0.72 (0.63-0.83) ↑ 1 serving/day: FVs: RR 0.96 (0.94-0.99); GLV: 0.77 (0.64-0.93) Vitamin C-rich FVs RR 0.94 (CI, 0.88-0.99) |
Age, smoking, alcohol, family history of myocardial infarction, BMI |
| Liu et al22 | 2001 | Physician's health study | 15,220 men 1148 incident cases | CHD | Semi- quantitative FFQ | Highest (+2.5 servings/day) vs. lowest (<1 serving/day) Vegetable RR: 0.77 (0.60-0.98; P=0.03) adjusted↑1 serving vegetable/day RR: 0.83 (0.71-0.98) Results were more evident among men with higher BMI (≥25 kg/m2) Vegetable RR: 0.71 (0.55-0.99) |
Smoking, alcohol, BMI, physical activity, history of diabetes, high cholesterol, hypertension and use of multivitamins |
| Bazzano et al23 | 2002 | Prospective cohortstudy NHANESI | 9608 individuals; 888 stroke events; 1786 IHD events; 1145 CVD deaths and 2530 all-cause mortality | CVD | FFQ | ≥3 times/day compared vs. <1 time/day Stroke incidence RR: 0.73 (0.57-0.95; P for trend=0.01); ↓27% stroke mortality RR: 0.58 (0.33-1.02; P for trend=0.05); ↓42% IHD mortality RR: 0.76 (0.56-1.03; P for trend=0.07); ↓ 24% CVD mortality RR: 0.73 (0.58-0.92 P for trend=0.008); ↓ 27% All-cause mortality RR: 085 (0.72-1.00; P for trend=0.02); ↓ 15% |
Age, sex, race, history of diabetes, physical activity, education level, regular alcohol consumption, current cigarette smoking at baseline, vitamin supplement use, and total energy intake |
| Bazzano et al24 | 2002 | Prospective cohort study NHANES I | 9764 individuals; 926 stroke events; 3758 CVD events | Stroke CVD | Single 24 dietary recall | Highest (405 µg/day) vs. lowest (99 µg/day) folate intake Stroke events RR: 0.79 (0.63-0.99, P for trend 0.03) CVD events RR: 0.86 (0.78-0.95, P for trend-0.001) | Age, race, sex, systolic blood pressure, serum cholesterol, BMI, history of diabetes, physical activity, level of education, regular alcohol consumption, current cigarette smoking, saturated fat intake, and total energy intake |
| Rissanen et al25 | 2003 | Prospective KIHD study | 2641 men | CVD-related and non-CVD - related mortality | 4-day food intake record | Highest (<405 g/day) vs. lowest (<133 g/day) quintile intake of berries, FVs intake: All-cause mortality RR: 0.66 (0.50-0.88) CVD mortality RR: 0.59 (0.33-1.06) Non-CVD mortality RR: 0.68 (0.46-1.00) | Biochemical variables and other risk factors age, BMI, systolic blood pressure, diastolic blood pressure, plasma fibrinogen, serum insulin, blood glucose, serum total cholesterol, serum LDL cholesterol, serum haptoglobin, energy, alcohol, cholesterol, saturated fat, E%/day, fiber, vitamin E, vitamin C, folate, carotene, percentage of total smokers, hypertension, family history of ischaemic heart disease, diabetes, BMI |
| Yusuf et al26 | 2004 | INTERHEART case-control study | 12,461 cases and 14637 controls (52 countries) | MI | Structured questionnaire | Daily vs. lack of daily FVs intake OR: 0·70 (0·62-0·79) | Age, sex, smoking and all other risk factors for MI |
| Rastogi et al27 | 2004 | Case-control study | 350 cases 700 controls | MI | FFQ | Highest (3.5 servings/day) vs. lowest (0.8 servings/day) intake MI RR: 0.33 (0.13-0.82; P for trend 0.006) for total vegetable Highest (3.5 servings/day) vs. lowest (0.5 servings/day) GLV intake MI RR: 0.33 (0.17-0.64; P for trend 0.0001) for GLV No association with fruits were noted | Age; sex; hospital; cigarette smoking; bidi smoking; BMI, in kg/m2; waist-to-hip ratio; leisure time physical exercise; history of hypertension; history of diabetes; history of high cholesterol; family history of IHD; alcohol intake; education; household income; and Hindu religion |
| Radhika et al28 | 2008 | CURES study | 983 individuals | Cardiovascular risk | Validated semi- quantitative FFQ | SBP β=−2·6 (−5·92-1·02 mmHg; P=0·027) BMI β=−2·3 (−2·96-1·57 kg/m2; P<0·0001), waist circumference β=−2·6 (−3·69-−1·46 cm; P<0·0001) | Age, sex, smoking, alcohol and BMI adjusted |
| Total cholesterol (β=−50 (−113·9-−13·6 mg/l; P=0.017) and LDL-cholesterol β=−55 (−110·8-−11·1 mg/l; P=0·039) ↑ Higher intake of FVs elicited 48% protective effect against CVD risk factors | |||||||
| Dauchet et al29 | 2011 | Meta-analysis of cohort studies | 9 independent studies comprising 221,080 individuals and 5007 events | CHD | Literature searches | (+1) portion FVs RR: 0.96 (0.93-0.99; P=0.0027) ↓ 4%; (+1) portion fruits RR: 0.93 (0.89-0.96; P<0.0001); ↓ 7% Vegetable intake and CHD risk was heterogeneous (P=0.0043), more marked for CVD mortality RR: 0.74 (0.75-0.84, P<0.0001) Fatal and nonfatal MI RR: 0.95 (0.92-0.99, P=0.0058) | NA |
| Zhang et al30 | 2011 | Cohort study | 134,796 individuals 3442 deaths in women and 1951 deaths in men | Total and cardiovascular mortality | Validated FFQ | Quintile 1 (median-133g/d) vs. quintile 5 (median-545 g/d) for FVs intake: CVD HR: 0.78 (0.71-0.85; P<0.0001 for trend) for cruciferous vegetables HR: 0.84 (0.69-1.00; P=0.03) for total vegetables HR: 0.83 (0.76-0.92; P<0.0001 for trend) for total fruit intake | Age, education, occupation, family income, cigarette smoking, alcohol consumption, BMI, amount of regular exercise, multivitamin supplement use, intakes of total energy and saturated fat, menopausal status and hormone therapy use (for women only), and history of CHD, stroke, hypertension, or diabetes |
| Gupta et al31 | 2012 | Jaipur Heart Watch-5 | 739 individuals | Cardiovascular risk | Random sampling using house-to- house survey | Low FVs (<3 servings/day) 70 and 76% prevalence of CVD risk actors in men and women respectively | Age- and sex-adjusted |
| Shridhar et al32 | 2014 | The Indian Migration Study | 6555 individuals | Cardiovascular risk | Validated semi- quantitative- FFQ | Vegetarians vs. non-vegetarians: Total cholesterol: β - 0.1 (0.03-0.2; P=0.006) Triglyceride: β - 0.05 (0.007-0.01; P=0.02) | Age, sex, SLI, BMI, tobacco, alcohol, site, migration status, energy, physical activity and SibPair |
| LDL - cholesterol: β - 0.06 (0.050-0.1; P=0.03) HDL - Cholesterol: β - 0.01 (0.003-0.03) SBP: β - 0.9 (−0.08-1.9) DBP: β - 0.7 (0.07-1.2; P=0.02) FBS: β - 0.07 (−0.01-0.2) | |||||||
| Leenders et al33 | 2014 | EPIC and Nutrition study | >450,000 participants | Mortality | Country- specific dietary questionnaires | Highest (569 g/d) vs. lowest (249 g/d) circulatory deaths HR - 0.85 (0.770.93) | |
| Okuda et al34 | 2015 | NIPPON DATA80 prospective study | 9112 participants | CVD, stroke and CHD | 3-day weighing dietary records | Highest (290 g/1000 cal) vs. lowest quartile (130 g/1000 cal) of total FVs intake total CVD HR: 0.74 (0.61-0.91; 0.004; 0.003) Stroke HR : 0.80 (0.59-1.09; 0.105; 0.036) CHD HR: 0.57 (0.37-0.87; 0.010; 0.109) | Adjusted for age, sex, BMI, smoking habit, drinking habit, sodium intake, intakes of meat, fish and shellfish, milk and dairy products and soybeans and legumes |
| Nguyen et al35 | 2016 | Cohort study | 150,969 individuals | All-cause mortality | Validated FFQ | Highest vs. lowest Quartile: FVs combined HR: 0.90 (0.84-0.97; P for trend 0.002) Fruit intake HR: 0.83 (0.74-0.93; P for trend 0.003) Vegetable intake HR: 0.98-0.90; P for trend 1.06) | Age (categorical), sex, education level, marital status, location of residence, socio-economic status, smoking status, physical activity categories, multi-vitamin use, processed meat consumption, diabetes, and BMI |
| Aune et al36 | 2017 | Systematic review and dose-response meta-analysis | 95 studies | Cardiovascular risk | Literature searches (PubMed and Embase) | About 200 g/day FVs RR: 0.92 (0.90-0.95) for CHD; RR: 0.84 (0.76-0.92) for stroke; RR: 0.92 (95% CI: 0.90-0.95) for CVD Inverse associations were observed between the intake of apples and pears, citrus fruits, GLVs, CVs, salads and CVD and all-cause mortality | NA |
| Miller et al37 | 2017 | Prospective cohort study | 135,335 participants from 18 countries | CVD and death | Country- specific FFQ | Fruits (<3 servings/wk vs. >3 servings/day) CVD mortality HR: 0·83 (0·65-1·06; P for trend=0·0458); All-cause mortality HR: 0·81 (0·72-0·93; P for trend <0.0001) Vegetables (<1 serving vs. >2 servings/day) Major CVD events HR: 0·71 (0·58-0·87; P for trend=0.0056) hIGH FVs and legumes intake together was associated with only lower cardiovascular and total mortality | For fruits confounders adjusted include age, sex, centre (random effect), energy intake, current smoker, diabetes, urban or rural location, physical activity, education level and tertiles of white meat, red meat, and intake of breads, cereals, and vegetables. For vegetables confounders adjusted include age, sex, and centre (random effect) |
| Joshipura et al38 | 1999 | Prospective cohort study | 75,596 women and 38,683 men | Stroke | Semi quantitative FFQ | Highest vs. Lowest quintile: FVs RR: 0.69 (0.52-0.92) Cruciferous vegetables, +1 serving RR: 0.68 (0.49-0.94) GLVs RR: 0.79 (0.62-0.99) citrus fruit+juice RR: 0.81 (0.68-0.96) Citrus fruit juice RR: 0.75 (0.61-0.93) 6% reduction in stroke for (1+) serving of FVs RR: 0.94; (0.90-0.99; P for trend=0.01) | |
| Sauvaget et al39 | 2003 | Lifespan study | 40,349 Japanese men and women 1926 Stroke events | Stroke | Food- frequency questionnaires | Daily vs. lack of daily intake. Green yellow vegetables: Men HR: 0.77 (0.62-0.95; P=0.01); Women HR: 0.81 (0.68-0.96; P=0.012); 26% ↓ Fruit: Men HR: 0.65 (0.53-0.80; P<0.0001) Women HR: 0.75 (0.64-0.88; P<0.0001) 35% men and 25% women ↓ | Age-stratified, and adjusted for radiation dose, city, BMI, smoking status, alcohol habits, education level, medical history of hypertension, myocardial infarction, diabetes, and consumption of animal products (egg, dairy, fish) |
| Johnsen et al40 | 2003 | Prospective study | 54,506 men and women 266 cases | Stroke | Semi- quantitative FFQ | Highest vs. lowest quintile (673 vs. 147 g/d): FVs RR: 0.72 (0.47-1.12, P for trend=0.04) Fruits RR: 0.60 (0.38-0.95; P for trend=0.02) | Sex, total energy intake, smoking status, systolic blood pressure, diastolic blood pressure, total serum cholesterol, history of diabetes, BMI, alcohol intake, intake of red meat, intake of n-3 polyunsaturated fatty acids, physical activity, and education |
| Dauchet et al41 | 2005 | Meta-analysis of cohort studies | 7 studies; 232049 individuals and 2955 events | Stroke | Literature searches | (+1) portion fruit RR: 0.89 (0.85 to 0.93) ↓ 11%; (+1) portion FVs RR: 0.95 (0.92 to 0.97)↓ 5%; (+1) portion vegetable RR: 0.97 (0.92 to 1.02) ↓ 3% | NA |
| He et al42 | 2006 | Meta-analysis of cohort studies | 8 studies; 257,551 individuals and 4917 events | Stroke | Literature searches | 3-5 portions vs. >5 portions Fruits RR: 0·89 (0·82-0·98) vs. 0·74 (0·66-0·79) Vegetables RR: 0·93 (0·82-1·06) vs. 0·81 (0·72-0·90) | NA |
| Oude Griep et al43 | 2011 | Population- based cohort study | 20,069 participants | Stroke | Food- frequency questionnaires | Highest vs. lowest quartile: Total FVs (475 vs. 241g/d): HR-0.66 (0.45-0.99) Raw FVs (>262 vs. <92) HR: 0.70; 95% CI: 0.47-1.04) for CHD; HR: 0.70 (0.47-1.03) for stroke Deep orange vegetables: 0.74 (0.55-1.00) for CHD White FVs: 0.48 (0.29-0.77) for stroke | Age, gender, alcohol, energy intake, smoking, educational level, dietary supplement use, BMI, intake of fish, whole grain foods and processed meat |
| Sharma et al44 | 2013 | Cohort study | >215,000 individuals | Stroke | Validated FFQ | ↑ vegetable RR: 0.60 (CI: 0.36-0.99) ↓ risk 40% in African women; ↑Fruit RR: 0.43 (0.22-0.85)↓ risk 57% in Japanese American women | Adjusted for ethnicity, time on study, years of education, energy intake, smoking, BMI, physical activity, history of diabetes, and alcohol intake. The models for women were additionally adjusted for history of hormone replacement therapy |
| Larsson et al45 | 2013 | Prospective study | 74961 individuals 4089 cases | Stroke | Food- frequency questionnaires | Highest vs. lowest Total FVs RR: 0.87 (0.78-0.97; P for trend=0.01) | Adjusted for age, sex, smoking status and pack-years of smoking, education, |
| Apple and pears RR: 0.89 (0.80-0.98; P for trend=0.02) GLV RR: 0.92 (0.81-1.04; P for trend=0.03) | BMI, total physical activity, aspirin use, history of hypertension, diabetes, family history of myocardial infarction, and intakes of total energy, alcohol, coffee, fresh red meat, processed meat, and fish. Total fruit and total vegetable consumption was mutually adjusted by including both variables in the same multivariable model | ||||||
| Wang et al46 | 2014 | Meta-analysis of cohort studies | 16 studies; 833,234 individuals | Cardiovascular risk | Literature searches | (+1) portion FVs HR: 0.96 (0.92-0.99; P=0.001); (+1) portion Fruits HR: 0.95 (0.91-1.00; P=0.002); (+1) portion. Vegetable HR: 0.96 (0.93-0.99; P=0.006) | |
| Alonso et al47 | 2004 | SUN study | 4393 individuals | Blood pressure | Food- frequency questionnaires | Highest vs. lowest quintile: Prevalence of undiagnosed hypertension (OR) combined FVs, OR: 0·23 (0·10-0·55; P for trend 0·001) Vegetables OR: 0·58 (0·36-0·91; P for trend 0·01) Fruits OR: 0·68 (0·43-1·09; P for trend 0·10) | Adjusted for age, sex, BMI, energy-adjusted alcohol consumption, Na consumption, hypercholesterolaemia and physical activity during leisure time |
| Chan et al48 | 2014 | INTERMAP study | 2195 individuals | Blood pressure | Four standardized multi-pass 24 h dietary recalls and eight BP measurements | Average systolic blood pressure difference: Raw vegetable (68 g/1000 cal): −1.3 mm Hg (−2.4-0.2; P=0.02) Cooked vegetable (92 g/1000cal): −0.9 mm Hg (−2.0-0.2; P=0.1) | Adjusted for BMI age, gender, sample, education, physical activity, smoking status, history of CVD or diabetes mellitus, family history of high BP, use of special diet, use of dietary supplement, urinary sodium, and alcohol, polyunsaturated fatty acids, saturated fatty acids, and cholesterol, total fruit |
| Li et al49 | 2016 | Review article | 25 studies with 334,468 individuals; 41,713 events | Hypertension | Literature search | Highest vs. lowest consumption (RR): Combined FVs RR: 0.81 (0.74-0.89; P heterogeneity=0.000); Fruits RR: 0.73 (0.62-0.86; P heterogeneity=0.002); Vegetable RR: 0.97 (0.91-1.02) Significantly inverse association between fruit consumption and hypertension risk was found in studies carried out in Asia RR: 0.70; (0.61-0.79; P heterogeneity=0.000) | NA |
FVs, fruits and vegetables; RR, response rate; CI, confidence interval; GLVs, green leafy vegetables; BMI, body mass index; CHD, coronary heart disease; CVD, cardiovascular disease; KIHD, Kuopio Ischaemic Heart Disease Risk Factor; LDL, low-density lipoprotein; MI, myocardial infraction; IHD, ischaemic heart disease; SUN, Seguimiento Universidad de Navarra; NA, not available; FFQ, food frequency questionnaire; SLI, standard of living index; HR, hazard ratio; ↓, decrease; ↑, increase