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.
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.



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.



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.



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.
Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.|Department of Epidemiology and Biostatistics, Imperial College London, London, UK.|Bjørknes University College, Oslo, Norway.
Dagfinn
D
Aune
Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.|Department of Epidemiology.|Department of Nutrition, Harvard T. Chan School of Public Health, Boston, MA, USA.
Edward
E
Giovannucci
Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Paolo
P
Boffetta
Department of Global Public Health and Primary Care & Department of Clinical Dentistry, University of Bergen, Bergen, Norway.
Lars T
LT
Fadnes
Department of Epidemiology.|Department of Nutrition, Harvard T. Chan School of Public Health, Boston, MA, USA.
NaNa
N
Keum
Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
Teresa
T
Norat
Biostatistics Unit, University of Leeds, Leeds, UK.
Darren C
DC
Greenwood
Department of Epidemiology and Biostatistics, Imperial College London, London, UK.
Elio
E
Riboli
Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
Lars J
LJ
Vatten
Department of Preventive Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.
Serena
S
Tonstad
D002318:Cardiovascular Diseases / Q000401:mortality*; D004032:Diet; D005638:Fruit; D006801:Humans; D009026:Mortality; D009369:Neoplasms / Q000401:mortality*; D011446:Prospective Studies; D040242:Risk Reduction Behavior; D014675:Vegetables
Fruit and vegetables; all-cause mortality; cancer; cardiovascular disease; cohort; diet; global assessment; nutrition