Miller V, et al. - This study executed an inquiry of the correlation between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths in the Middle East, South America, Africa, or south Asia. A link was brought to light between increased fruit, vegetable, and legume consumption with a lower risk of non-cardiovascular and total mortality. Maximum benefits could be yielded for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375–500 g/day).

Methods

• A prospective cohort study (Prospective Urban Rural Epidemiology [PURE] was pursued among 135335 individuals aged 35 to 70 years without cardiovascular disease.
• Enrollees were selected 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.
• Their diet was documented via country-specific food frequency questionnaires at baseline.
• Standardised questionnaires cumulated the data regarding 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.
• There was a variation in the follow-up period 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 contemplated the correlations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality.

Results

• Candidates were recruited between Jan 1, 2003, and March 31, 2013.
• All unrefuted outcome events were included in the PURE study database through March 31, 2017.
• 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, the following events were reported: 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths.
• Higher total fruit, vegetable, and legume intake displayed an inverse correlation 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 significantly 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<0·0001).
• The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group.
• There was no additional apparent decrease in HR with higher consumption.
• Fruit intake was related to lower risk of cardiovascular, non-cardiovascular, and total mortality.
• Legume intake was inversely linked with non-cardiovascular death and total mortality (in fully adjusted models).
• For vegetables, raw vegetable intake strongly correlated with a lower risk of total mortality.
• In contrast, cooked vegetable intake exhibited a modest benefit against mortality.
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