Quantity and variety in fruit and vegetable intake and risk of coronary heart disease

The American Journal of Clinical Nutrition, Dec 2013

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Quantity and variety in fruit and vegetable intake and risk of coronary heart disease

Quantity and variety in fruit and vegetable intake and risk of coronary heart disease1-3 Shilpa N Bhupathiraju Nicole M Wedick An Pan JoAnn E Manson Kathyrn M Rexrode Walter C Willett Eric B Rimm Frank B Hu 0 Supported by grants from the NIH ( P01 CA87969, P01 CA055075, R01 HL034594 , and HL60712). SNB is a recipient of a postdoctoral fellowship grant from the American Heart Association (13POST14370012). School of Public Health , 655 Huntington Avenue, Boston, MA 02115 , USA 1 From the Department of Nutrition, Harvard School of Public Health , Boston, MA (SNB, NMW, WCW , and FBH); Saw Swee Hock School of Public Health and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (AP); the Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School , Boston , MA (JEM and KMR); the Department of Epidemiology, Harvard School of Public Health , Boston, MA (JEM, WCW, EBR , and FBH); and the Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School , Boston, MA, WCW, EBR, and FBH 2 Abbreviations used: CHD, coronary heart disease; FFQ, food-frequency questionnaire; HPFS, Health Professionals Follow-Up Study; NHS, Nurses' Health Study. First published online Background: Dietary guidelines recommend increasing fruit and vegetable intake and, most recently, have also suggested increasing variety. Objective: We prospectively examined the independent roles of quantity and variety in fruit and vegetable intake in relation to incident coronary heart disease (CHD). Design: We prospectively followed 71,141 women from the Nurses' Health Study (1984-2008) and 42,135 men from the Health Professionals Follow-Up Study (1986-2008) who were free of diabetes, cardiovascular diseases, and cancer at baseline. Diet was assessed by using a validated questionnaire and updated every 4 y. Variety was defined as the number of unique fruit and vegetables consumed at least once per week. Potatoes, legumes, and fruit juices were not included in our definition of fruit and vegetables. Results: During follow-up, we documented 2582 CHD cases in women and 3607 cases in men. In multivariable analyses, after adjustment for dietary and nondietary covariates, those in the highest quintile of fruit and vegetable intake had a 17% lower risk (95% CI: 9%, 24%) of CHD. A higher consumption of citrus fruit, green leafy vegetables, and b-carotene- and vitamin C-rich fruit and vegetables was associated with a lower CHD risk. Conversely, quantity-adjusted variety was not associated with CHD. Conclusions: Our data suggest that absolute quantity, rather than variety, in fruit and vegetable intake is associated with a significantly lower risk of CHD. Nevertheless, consumption of specific fruit and vegetable subgroups was associated with a lower CHD risk. Am J Clin Nutr 2013;98:1514-23. INTRODUCTION Of the several dietary factors implicated in coronary heart disease (CHD)4 prevention, the evidence is most consistent for fruit and vegetables ( 1, 2 ). Dietary recommendations have repeatedly underscored the value of increasing intakes of fruit and vegetables in the diet, and, most recently, have also highlighted the importance of greater variety. For example, the most recent American Heart Association diet and lifestyle guidelines for cardiovascular disease risk reduction have issued a recommendation to consume a variety of fruit and vegetables (3). Likewise, the 2010 Dietary Guidelines for Americans emphasize the importance of increased fruit and vegetable intake and greater variety ( 4 ). In a few cross-sectional studies, higher variety scores for fruit and vegetable intake were associated with lower odds of the metabolic syndrome, obesity, hypercholesterolemia, and hypertension ( 5, 6 ). However, these studies did not entirely separate the concept of variety from quantity, because those with greater variety also had greater intakes of fruit and vegetables. Therefore, it is not clear whether the observed associations for variety were independent of quantity of consumption. We previously reported on the association of fruit and vegetable intake with risk of CHD over 8–14 y of follow-up and observed that for every one serving greater intake of fruit and vegetables per day, risk of CHD was lower by 4% (7). The primary objective of this study was to examine the independent associations of quantity and variety in fruit and vegetable intake in relation to incident CHD over a longer period of time in the Nurses’ Health Study (NHS) and the Health Professionals Follow-Up Study (HPFS). SUBJECTS AND METHODS Study population The NHS was initiated in 1976 as a prospective cohort study of 121,701 female registered nurses, 30–55 y of age, from 11 US states. The HPFS is a prospective cohort study of 51, 529 male health professionals, 40–75 y of age, from all 50 states that began in 1986. In both cohorts, information on medical history, lifestyle, potential (...truncated)


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Bhupathiraju, Shilpa N, Wedick, Nicole M, Pan, An, Manson, JoAnn E, Rexrode, Kathyrn M, Willett, Walter C, Rimm, Eric B, Hu, Frank B. Quantity and variety in fruit and vegetable intake and risk of coronary heart disease, The American Journal of Clinical Nutrition, 2013, pp. 1514-1523, Volume 98, Issue 6, DOI: 10.3945/ajcn.113.066381