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. 2016 Apr 7;374(14):1332-43.
doi: 10.1056/NEJMoa1501451.

Fresh Fruit Consumption and Major Cardiovascular Disease in China

Huaidong Du  1 , Liming Li  1 , Derrick Bennett  1 , Yu Guo  1 , Timothy J Key  1 , Zheng Bian  1 , Paul Sherliker  1 , Haiyan Gao  1 , Yiping Chen  1 , Ling Yang  1 , Junshi Chen  1 , Shanqing Wang  1 , Ranran Du  1 , Hua Su  1 , Rory Collins  1 , Richard Peto  1 , Zhengming Chen  1 ; China Kadoorie Biobank Study
Collaborators, Affiliations

Fresh Fruit Consumption and Major Cardiovascular Disease in China

Huaidong Du et al. N Engl J Med. .

Abstract

Background: In Western populations, a higher level of fruit consumption has been associated with a lower risk of cardiovascular disease, but little is known about such associations in China, where the consumption level is low and rates of stroke are high.

Methods: Between 2004 and 2008, we recruited 512,891 adults, 30 to 79 years of age, from 10 diverse localities in China. During 3.2 million person-years of follow-up, 5173 deaths from cardiovascular disease, 2551 incident major coronary events (fatal or nonfatal), 14,579 ischemic strokes, and 3523 intracerebral hemorrhages were recorded among the 451,665 participants who did not have a history of cardiovascular disease or antihypertensive treatments at baseline. Cox regression yielded adjusted hazard ratios relating fresh fruit consumption to disease rates.

Results: Overall, 18.0% of participants reported consuming fresh fruit daily. As compared with participants who never or rarely consumed fresh fruit (the "nonconsumption" category), those who ate fresh fruit daily had lower systolic blood pressure (by 4.0 mm Hg) and blood glucose levels (by 0.5 mmol per liter [9.0 mg per deciliter]) (P<0.001 for trend for both comparisons). The adjusted hazard ratios for daily consumption versus nonconsumption were 0.60 (95% confidence interval [CI], 0.54 to 0.67) for cardiovascular death, and 0.66 (95% CI, 0.58 to 0.75), 0.75 (95% CI, 0.72 to 0.79), and 0.64 (95% CI, 0.56 to 0.74), respectively, for incident major coronary events, ischemic stroke, and hemorrhagic stroke. There was a strong log-linear dose-response relationship between the incidence of each outcome and the amount of fresh fruit consumed. These associations were similar across the 10 study regions and in subgroups of participants defined by baseline characteristics.

Conclusions: Among Chinese adults, a higher level of fruit consumption was associated with lower blood pressure and blood glucose levels and, largely independent of these and other dietary and nondietary factors, with significantly lower risks of major cardiovascular diseases. (Funded by the Wellcome Trust and others.).

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Conflict of interest statement

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Figures

Figure 1
Figure 1. Adjusted Mean Body-Mass Index (BMI), Waist Circumference, Blood Pressure, and Blood Glucose According to the Frequency of Fresh Fruit Consumption.
Mean values for BMI (Panel A) and waist circumference (Panel B) were adjusted for age (10 categories), area of China (10 regions), educational level (4 categories), annual household income (4 categories), smoking status (4 categories, with the category of “Never” subdivided into “Never” and “Occasional”), alcohol intake (4 categories, with the category of “Never” subdivided into “Never” and “Occasional”), physical activity (continuous variable), survey season (4 categories), and consumption of meat (3 categories), dairy products (3 categories), and preserved vegetables (5 categories). Mean values for systolic blood pressure (Panel C) and random blood glucose measurements (Panel D) were adjusted for the listed variables plus BMI and waist circumference. Blood glucose values were missing for 7503 study participants. To convert the values for glucose to milligrams per deciliter, divide by 0.05551. Vertical lines indicate 95% confidence intervals. P<0.001 for trend, for all comparisons.
Figure 2
Figure 2. Adjusted Hazard Ratios for Major Cardiovascular Events According to the Level of Fresh Fruit Consumption.
Analyses were adjusted for educational level, income, alcohol intake, smoking status, physical activity, survey season, and consumption of dairy products, meat, and preserved vegetables and were stratified according to age at risk, sex, and region. The black boxes represent hazard ratios, with the size inversely proportional to the variance of the logarithm of the hazard ratio, and the vertical lines represent 95% confidence intervals. The numbers above the vertical lines are point estimates for hazard ratios, and the numbers below the lines are numbers of events.
Figure 3
Figure 3. Adjusted Hazard Ratios for Cardiovascular Death with One Daily Portion of Fresh Fruit, According to Baseline Characteristics.
Analyses were adjusted for educational level, income, alcohol intake, smoking status, physical activity, survey season, and consumption of dairy products, meat, and preserved vegetables and were stratified according to age at risk, sex, and region, as appropriate. The black boxes represent hazard ratios, with the size inversely proportional to the variance of the logarithm of the hazard ratio, and the horizontal lines represent 95% confidence intervals. The open diamonds represent the overall hazard ratios and 95% confidence intervals. Chi-square tests (χ2) were performed to examine either trend (with 1 df) or heterogeneity (with n –1 df, where n represents the number of categories). To convert the values for glucose to milligrams per deciliter, divide by 0.05551.
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