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      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

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          Abstract

          Background: Questions remain about the strength and shape of the dose-response relationship between fruit and vegetable intake and risk of cardiovascular disease, cancer and mortality, and the effects of specific types of fruit and vegetables. We conducted a systematic review and meta-analysis to clarify these associations.

          Methods: PubMed and Embase were searched up to 29 September 2016. Prospective studies of fruit and vegetable intake and cardiovascular disease, total cancer and all-cause mortality were included. Summary relative risks (RRs) were calculated using a random effects model, and the mortality burden globally was estimated; 95 studies (142 publications) were included.

          Results: For fruits and vegetables combined, the summary RR per 200 g/day was 0.92 [95% confidence interval (CI): 0.90–0.94, I 2 = 0%, n = 15] for coronary heart disease, 0.84 (95% CI: 0.76–0.92, I 2 = 73%, n = 10) for stroke, 0.92 (95% CI: 0.90–0.95, I 2 = 31%, n = 13) for cardiovascular disease, 0.97 (95% CI: 0.95–0.99, I 2 = 49%, n = 12) for total cancer and 0.90 (95% CI: 0.87–0.93, I 2 = 83%, n = 15) for all-cause mortality. Similar associations were observed for fruits and vegetables separately. Reductions in risk were observed up to 800 g/day for all outcomes except cancer (600 g/day). Inverse associations were observed between the intake of apples and pears, citrus fruits, green leafy vegetables, cruciferous vegetables, and salads and cardiovascular disease and all-cause mortality, and between the intake of green-yellow vegetables and cruciferous vegetables and total cancer risk. An estimated 5.6 and 7.8 million premature deaths worldwide in 2013 may be attributable to a fruit and vegetable intake below 500 and 800 g/day, respectively, if the observed associations are causal.

          Conclusions: Fruit and vegetable intakes were associated with reduced risk of cardiovascular disease, cancer and all-cause mortality. These results support public health recommendations to increase fruit and vegetable intake for the prevention of cardiovascular disease, cancer, and premature mortality.

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          Analysis and valuation of the health and climate change cobenefits of dietary change.

          What we eat greatly influences our personal health and the environment we all share. Recent analyses have highlighted the likely dual health and environmental benefits of reducing the fraction of animal-sourced foods in our diets. Here, we couple for the first time, to our knowledge, a region-specific global health model based on dietary and weight-related risk factors with emissions accounting and economic valuation modules to quantify the linked health and environmental consequences of dietary changes. We find that the impacts of dietary changes toward less meat and more plant-based diets vary greatly among regions. The largest absolute environmental and health benefits result from diet shifts in developing countries whereas Western high-income and middle-income countries gain most in per capita terms. Transitioning toward more plant-based diets that are in line with standard dietary guidelines could reduce global mortality by 6-10% and food-related greenhouse gas emissions by 29-70% compared with a reference scenario in 2050. We find that the monetized value of the improvements in health would be comparable with, or exceed, the value of the environmental benefits although the exact valuation method used considerably affects the estimated amounts. Overall, we estimate the economic benefits of improving diets to be 1-31 trillion US dollars, which is equivalent to 0.4-13% of global gross domestic product (GDP) in 2050. However, significant changes in the global food system would be necessary for regional diets to match the dietary patterns studied here.
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            The effect of fruit and vegetable intake on risk for coronary heart disease.

            Many constituents of fruits and vegetables may reduce the risk for coronary heart disease, but data on the relationship between fruit and vegetable consumption and risk for coronary heart disease are sparse. To evaluate the association of fruit and vegetable consumption with risk for coronary heart disease. Prospective cohort study. The Nurses' Health Study and the Health Professionals' Follow-Up Study. 84 251 women 34 to 59 years of age who were followed for 14 years and 42 148 men 40 to 75 years who were followed for 8 years. All were free of diagnosed cardiovascular disease, cancer, and diabetes at baseline. The main outcome measure was incidence of nonfatal myocardial infarction or fatal coronary heart disease (1127 cases in women and 1063 cases in men). Diet was assessed by using food-frequency questionnaires. After adjustment for standard cardiovascular risk factors, persons in the highest quintile of fruit and vegetable intake had a relative risk for coronary heart disease of 0.80 (95% CI, 0.69 to 0.93) compared with those in the lowest quintile of intake. Each 1-serving/d increase in intake of fruits or vegetables was associated with a 4% lower risk for coronary heart disease (relative risk, 0.96 [CI, 0.94 to 0.99]; P = 0.01, test for trend). Green leafy vegetables (relative risk with 1-serving/d increase, 0.77 [CI, 0.64 to 0.93]), and vitamin C-rich fruits and vegetables (relative risk with 1-serving/d increase, 0.94 [CI, 0.88 to 0.99]) contributed most to the apparent protective effect of total fruit and vegetable intake. Consumption of fruits and vegetables, particularly green leafy vegetables and vitamin C-rich fruits and vegetables, appears to have a protective effect against coronary heart disease.
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              Fruit and vegetable consumption and stroke: meta-analysis of cohort studies.

              Increased consumption of fruit and vegetables has been shown to be associated with a reduced risk of stroke in most epidemiological studies, although the extent of the association is uncertain. We quantitatively assessed the relation between fruit and vegetable intake and incidence of stroke in a meta-analysis of cohort studies. We searched MEDLINE, EMBASE, the Cochrane Library, and bibliographies of retrieved articles. Studies were included if they reported relative risks and corresponding 95% CIs of stroke with respect to frequency of fruit and vegetable intake. Eight studies, consisting of nine independent cohorts, met the inclusion criteria. These groups included 257,551 individuals (4917 stroke events) with an average follow-up of 13 years. Compared with individuals who had less than three servings of fruit and vegetables per day, the pooled relative risk of stroke was 0.89 (95% CI 0.83-0.97) for those with three to five servings per day, and 0.74 (0.69-0.79) for those with more than five servings per day. Subgroup analyses showed that fruit and vegetables had a significant protective effect on both ischaemic and haemorrhagic stroke. Increased fruit and vegetable intake in the range commonly consumed is associated with a reduced risk of stroke. Our results provide strong support for the recommendations to consume more than five servings of fruit and vegetables per day, which is likely to cause a major reduction in strokes.
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                Author and article information

                Journal
                Int J Epidemiol
                Int J Epidemiol
                ije
                International Journal of Epidemiology
                Oxford University Press
                0300-5771
                1464-3685
                June 2017
                22 February 2017
                22 February 2017
                : 46
                : 3
                : 1029-1056
                Affiliations
                [1 ]Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
                [2 ]Department of Epidemiology and Biostatistics, Imperial College London, London, UK
                [3 ]Bjørknes University College, Oslo, Norway
                [4 ]Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
                [5 ]Department of Epidemiology
                [6 ]Department of Nutrition, Harvard T. Chan School of Public Health, Boston, MA, USA
                [7 ]Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
                [8 ]Department of Global Public Health and Primary Care & Department of Clinical Dentistry, University of Bergen, Bergen, Norway
                [9 ]Biostatistics Unit, University of Leeds, Leeds, UK
                [10 ]Department of Preventive Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
                Author notes
                [* ]Corresponding author. Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St Mary’s Campus, Norfolk Place, London W2 1PG, UK. E-mail: d.aune@ 123456imperial.ac.uk
                Article
                dyw319
                10.1093/ije/dyw319
                5837313
                28338764
                d6545007-f4db-4922-a4c1-7fba5df5bde6
                © The Author 2017. Published by Oxford University Press on behalf of the International Epidemiological Association

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 13 October 2016
                Page count
                Pages: 28
                Funding
                Funded by: NIH 10.13039/100000002
                Categories
                Miscellaneous

                Public health
                fruit and vegetables,diet,nutrition,cardiovascular disease,cancer,all-cause mortality,cohort,global assessment

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