Abstract
Evidence about the response patterns of fruit and vegetable consumption with the risk of cardiovascular disease (CVD) and all-cause mortality was inconsistent. These associations were examined using a large-scale, population-based Chinese cohort comprising 100,728 participants. A food-frequency questionnaire was used to assess fruit and vegetable consumption. Outcomes were ascertained by interviewing individuals or their proxies and checking hospital records or death certificates. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). At the 736,668 person-years of follow-up, 3,677 CVD cases and 5,466 deaths were identified. The multivariable-adjusted HRs for CVD across increasing quartiles of total fruit and vegetable consumption were 1 (reference), 0.94 (95%CI=0.85–1.04), 0.89 (95%CI=0.80–0.98), and 0.85 (95% CI=0.11–0.95). Moreover, participants in the highest quartile displayed a 13% lower risk of all-cause mortality (HR=0.81; 95% CI=0.80–0.95). A nonlinear dose-response relation was found for CVD, without additional benefits beyond a consumption of 600 g d−1, whereas the all-cause mortality risk decreased along with higher consumption, with a linear trend. These associations remained significant for fruit consumption but not for vegetable consumption. Our findings indicated that greater fruit and vegetable consumption was significantly associated with a lower risk of CVD and all cause mortality. Increasing fruit and vegetable consumption, especially fruit, in the general population would prevent CVD and premature mortality.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Afshin, A., Sur, P.J., Fay, K.A., Cornaby, L., Ferrara, G., Salama, J.S., Mullany, E.C., Abate, K.H., Abbafati, C., Abebe, Z., et al. (2019). Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet 393, 1958–1972.
Alissa, E.M., and Ferns, G.A. (2017). Dietary fruits and vegetables and cardiovascular diseases risk. Crit Rev Food Sci Nutr 57, 1950–1962.
Altman, D.G., and Bland, J.M. (2003). Interaction revisited: the difference between two estimates. BMJ 326, 219.
Aune, D., Giovannucci, E., Boffetta, P., Fadnes, L.T., Keum, N.N., Norat, T., Greenwood, D.C., Riboli, E., Vatten, L.J., and Tonstad, S. (2017). Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality—a systematic review and dose-response meta-analysis of prospective studies. Int J Epidemiol 46, 1029–1056.
Bertoia, M.L., Mukamal, K.J., Cahill, L.E., Hou, T., Ludwig, D.S., Mozaffarian, D., Willett, W.C., Hu, F.B., and Rimm, E.B. (2015). Changes in intake of fruits and vegetables and weight change in United States men and women followed for up to 24 years: analysis from three prospective cohort studies. PLoS Med 12, e1001878.
Bhupathiraju, S.N., Wedick, N.M., Pan, A., Manson, J.A.E., Rexrode, K. M., Willett, W.C., Rimm, E.B., and Hu, F.B. (2013). Quantity and variety in fruit and vegetable intake and risk of coronary heart disease. Am J Clin Nutr 98, 1514–1523.
Crowe, F.L., Roddam, A.W., Key, T.J., Appleby, P.N., Overvad, K., Jakobsen, M.U., Tjønneland, A., Hansen, L., Boeing, H., Weikert, C., et al. (2011). Fruit and vegetable intake and mortality from ischaemic heart disease: results from the European prospective investigation into cancer and nutrition (EPIC)-heart study. Eur Heart J 32, 1235–1243.
Du, H., Li, L., Bennett, D., Guo, Y., Key, T.J., Bian, Z., Sherliker, P., Gao, H., Chen, Y., Yang, L., et al. (2016). Fresh fruit consumption and major cardiovascular disease in China. N Engl J Med 374, 1332–1343.
Du, S., Neiman, A., Batis, C., Wang, H., Zhang, B., Zhang, J., and Popkin, B.M. (2014). Understanding the patterns and trends of sodium intake, potassium intake, and sodium to potassium ratio and their effect on hypertension in China. Am J Clin Nutr 99, 334–343.
Finkel, T., and Holbrook, N.J. (2000). Oxidants, oxidative stress and the biology of ageing. Nature 408, 239–247.
Gan, Y., Tong, X., Li, L., Cao, S., Yin, X., Gao, C., Herath, C., Li, W., Jin, Z., Chen, Y., et al. (2015). Consumption of fruit and vegetable and risk of coronary heart disease: a meta-analysis of prospective cohort studies. Int J Cardiol 183, 129–137.
Gil, M.I., Aguayo, E., and Kader, A.A. (2006). Quality changes and nutrient retention in fresh-cut versus whole fruits during storage. J Agric Food Chem 54, 4284–4296.
Global Burden of Disease Collaborative Network. (2020). Global burden of disease study 2017 (GBD 2017) results. Available from: URL: http://ghdx.healthdata.org/gbd-results-tool.
Han, C., Liu, F., Yang, X., Chen, J., Li, J., Cao, J., Li, Y., Shen, C., Yu, L., Liu, Z., et al. (2018). Ideal cardiovascular health and incidence of atherosclerotic cardiovascular disease among Chinese adults: the China-PAR project. Sci China Life Sci 61, 504–514.
He, Y., Li, Y., Yang, X., Hemler, E.C., Fang, Y., Zhao, L., Zhang, J., Yang, Z., Wang, Z., He, L., et al. (2019). The dietary transition and its association with cardiometabolic mortality among Chinese adults, 1982–2012: a cross-sectional population-based study. Lancet Diabetes Endocrinol 7, 540–548.
Joshipura, K.J., Hu, F.B., Manson, J.A.E., Stampfer, M.J., Rimm, E.B., Speizer, F.E., Colditz, G., Ascherio, A., Rosner, B., Spiegelman, D., et al. (2001). The effect of fruit and vegetable intake on risk for coronary heart disease. Ann Intern Med 134, 1106–1114.
Juraschek, S.P., Kovell, L.C., Appel, L.J., Miller III, E.R., Sacks, F.M., Christenson, R.H., Rebuck, H., Chang, A.R., and Mukamal, K.J. (2020). Associations between dietary patterns and subclinical cardiac injury: an observational analysis from the DASH trial. Ann Intern Med 172, 786–794.
Liu, M.W., Yu, H.J., Yuan, S., Song, Y., Tang, B.W., Cao, Z.K., Yang, X.H., Towne, S.D., and He, Q.Q. (2018). Association between fruit and vegetable intake and the risk of hypertension among Chinese adults: a longitudinal study. Eur J Nutr 57, 2639–2647.
Miller, V., Mente, A., Dehghan, M., Rangarajan, S., Zhang, X., Swaminathan, S., Dagenais, G., Gupta, R., Mohan, V., Lear, S., et al. (2017). Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study. Lancet 390, 2037–2049.
Mirmiran, P., Bahadoran, Z., Moslehi, N., Bastan, S., and Azizi, F. (2015). Colors of fruits and vegetables and 3-year changes of cardiometabolic risk factors in adults: Tehran lipid and glucose study. Eur J Clin Nutr 69, 1215–1219.
National Center for Chronic and Non-communicable Disease Control and Prevention. (2016). Report on Chronic Disease Risk Factor Surveillance in China 2013 (in Chinese). Beijing: Military Medical Science Press.
National Health Commission of China, and Chinese Center for Disease Control and Prevention. (2017). Report on Chinese Residents’ Life Expectancy and Risk Factors (in Chinese). Beijing: Peking Union Medical College Press.
Olofsson, C., Discacciati, A., Åkesson, A., Orsini, N., Brismar, K., and Wolk, A. (2017). Changes in fruit, vegetable and juice consumption after the diagnosis of type 2 diabetes: a prospective study in men. Br J Nutr 117, 712–719.
Rockhill, B., Newman, B., and Weinberg, C. (1998). Use and misuse of population attributable fractions. Am J Public Health 88, 15–19.
Stefler, D., Malyutina, S., Nikitin, Y., Nikitenko, T., Rodriguez-Artalejo, F., Peasey, A., Pikhart, H., Sabia, S., and Bobak, M. (2019). Fruit, vegetable intake and blood pressure trajectories in older age. J Hum Hypertens 33, 611–618.
Tang, G.Y., Meng, X., Li, Y., Zhao, C.N., Liu, Q., and Li, H.B. (2011). Effects of vegetables on cardiovascular diseases and related mechanisms. Nutrients 9, 857.
The China Nutrition Society. (2016). The Chinese Dietary Guidelines (2016) (in Chinese). Beijing: People’s Medical Publishing House.
Wang, X., Ouyang, Y., Liu, J., Zhu, M., Zhao, G., Bao, W., and Hu, F.B. (2014). Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ 349, g4490.
Wang, X., Liu, F., Li, J., Yang, X., Chen, J., Cao, J., Wu, X., Lu, X., Huang, J., Li, Y., et al. (2020). Tea consumption and the risk of atherosclerotic cardiovascular disease and all-cause mortality: The China-PAR project. Eur J Prev Cardiol 27, 1956–1963.
WHO. (2020). Promoting fruit and vegetable consumption around the world. Available from: URL: https://www.who.int/dietphysicalactivity/fruit/en/.
Yang, X., Li, J., Hu, D., Chen, J., Li, Y., Huang, J., Liu, X., Liu, F., Cao, J., Shen, C., et al. (2016). Predicting the 10-year risks of atherosclerotic cardiovascular disease in Chinese population. Circulation 134, 1430–1440.
Yu, D., Zhang, X., Gao, Y.T., Li, H., Yang, G., Huang, J., Zheng, W., Xiang, Y.B., and Shu, X.O. (2014). Fruit and vegetable intake and risk of CHD: results from prospective cohort studies of Chinese adults in Shanghai. Br J Nutr 111, 353–362.
Zhang, X., Shu, X.O., Xiang, Y.B., Yang, G., Li, H., Gao, J., Cai, H., Gao, Y.T., and Zheng, W. (2011). Cruciferous vegetable consumption is associated with a reduced risk of total and cardiovascular disease mortality. Am J Clin Nutr 94, 240–246.
Zhao, C.N., Meng, X., Li, Y., Li, S., Liu, Q., Tang, G.Y., and Li, H.B. (2011). Fruits for prevention and treatment of cardiovascular diseases. Nutrients 9, 598.
Zhao, W.H., Huang, Z.P., Zhang, X., He, L., Willett, W., Wang, J.L., Hasegawa, K., and Chen, J.S. (2010). Reproducibility and validity of a Chinese food frequency questionnaire. Biomed Environ Sci 23, 1–38.
Zhu, F., Du, B., and Xu, B. (2018). Anti-inflammatory effects of phytochemicals from fruits, vegetables, and food legumes: A review. Crit Rev Food Sci Nutr 58, 1260–1270.
Acknowledgements
This work was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2017-I2M-1-004, 2019-I2M-2-003), National Key Research and Development Program of China (2017YFC0211700, 2018YFE0115300), and the National Natural Science Foundation of China (91643208). We acknowledge the staff and participants of the China-PAR project for their important participation and contribution.
Author information
Authors and Affiliations
Corresponding author
Additional information
Compliance and ethics
The author(s) declare that they have no conflict of interest. This study was approved by the institutional review board at Fuwai Hospital in Beijing, China.
Supporting Information
Rights and permissions
About this article
Cite this article
Wang, J., Liu, F., Li, J. et al. Fruit and vegetable consumption, cardiovascular disease, and all-cause mortality in China. Sci. China Life Sci. 65, 119–128 (2022). https://doi.org/10.1007/s11427-020-1896-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11427-020-1896-x