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Dean Pomerleau

Eating Fruits & Veggies When Young MAY Prevent Artery Calcification

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Your mom didn't know how right she was when she told you to eat your fruits & vegetables (F/V), at least if you are a girl...

 

This new study [1] in the journal Circulation assessed the diets of 2500 young black and white men and women (~25 years of age, 62% female) and then measured their level of artery calcification 20 years later using computed tomography - arguably the 'gold standard' for assessing artery health.

 

It found that people eating the most F/V (highest tertile - 7-9 servings / day) were 25% less likely 20 years later to have developed calcified arteries relative to the lowest F/V eaters (2-4 servings / day).

 

From the full text, here are a few of the highlights, including one kicker:

  • Fruits and vegetables were about equally protective
  • Including legumes in with the vegetable category kept the association about the same - i.e. legumes were about as good for arteries as fruits & veggies.
  • Of course people eating lots of F/V had healthier diets in other ways as well, but the inverse association between F/V and artery calcification was still significant even after controlling for these other dietary factors.
  • Shockingly left out of the abstract was the fact that the inverse relationship between F/V intake and artery calcification (CAC) was only observed in women!  To quote the full text:

[R]eported intake of F/V did not appear to be associated with prevalent CAC among men: OR (95% CI) 1.0 (ref), 0.77 (0.52-1.12), 0.89 (0.60-1.31), p-value for trend 0.67

 

Here was their explanation for this surprising results:

 

The lack of association between F/V intake and CAC in men in our study may be due to a lack of power, as our study included only 935 male participants. However, a less significant association between CVD and F/V intake in men has been seen in other studies. Data from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study demonstrated a 15% (95% CI: 6% to 23%) lower risk for CHD mortality per 80gram/day increase in fruit and vegetable intake in women, but a non-significant 2% (95% CI: -2% to +2%) CHD mortality reduction in men (p-value for heterogeneity 0.007) [2] Similar findings were reported in a cohort of Japanese women and men.3 In the CHD risk factor study INTERHEART, the 3 lifestyle behaviors associated with a lower risk of CHD were F/V intake, exercise, and moderate alcohol consumption, and the protective effects of exercise and moderate alcohol consumption were larger in women compared to men with a trend towards F/V intake being more protective in women as well.[3]
 

 

So why did the researchers leave out this surprising lack of inverse relationship between F/V intake and later artery calcification in men from both the abstract and from the popular press coverage of this study?  Perhaps so as to avoid undermining the credibility of their (laudable) public health message, as summarized in the concluding sentence of the abstract:

 

Our results reinforce the importance of establishing a high intake of F/V as part of a healthy dietary pattern early in life.

 

Somehow I was unaware of the attenuated CVD benefits men seem to get from eating lots fruits and vegetables.

 

--Dean

 

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[1] Circulation. 2015 Oct 26. pii: CIRCULATIONAHA.114.012562. [Epub ahead of print]

The Association of Fruit and Vegetable Consumption During Early Adulthood With
the Prevalence of Coronary Artery Calcium After 20 Years of Follow-Up: The CARDIA
Study.

Miedema MD(1), Petrone A(2), Shikany JM(3), Greenland P(4), Lewis CE(3), Pletcher
MJ(5), Gaziano JM(2), Djousse L(2).

 

Free full text: http://circ.ahajournals.org/content/early/2015/10/14/CIRCULATIONAHA.114.012562.long

BACKGROUND: -The relationship between intake of fruits and vegetables (F/V)
during young adulthood and coronary atherosclerosis later in life is unclear.
METHODS AND RESULTS: -We studied participants of the Coronary Artery Risk
Development in Young Adults (CARDIA) study, a cohort of young, healthy black and
white individuals at baseline (1985-1986). Intake of F/V at baseline was assessed
using a semi-quantitative interview administered diet history and CAC was
measured at year 20 (2005-2006) using computed tomography. We used logistic
regression to adjust for relevant variables and estimate the adjusted odds ratios
(OR) and 95% confidence intervals (CI) across energy-adjusted, sex-specific
tertiles of total servings of F/V per day. Among our sample (n=2,506), the mean
(SD) age at baseline was 25.3 (3.5) years and 62.7% were female. After adjustment
for demographics and lifestyle variables, higher intake of F/V was associated
with a lower prevalence of CAC: OR (95% CI) =1.00 (reference), 0.78 (0.59-1.02),
and 0.74 (0.56-0.99), from the lowest to the highest tertile of F/V, p-value for
trend <0.001. There was attenuation of the association between F/V and CAC after
adjustment for other dietary variables but the trend remained significant: OR
(95% CI): 1.00 (reference), 0.84 (0.63-1.11), and 0.92 (0.67-1.26), p-value for
trend <0.002].
CONCLUSIONS: -In this longitudinal cohort study, higher intake of F/V during
young adulthood was associated with lower odds of prevalent CAC after 20 years of
follow-up. Our results reinforce the importance of establishing a high intake of
F/V as part of a healthy dietary pattern early in life.

PMID: 26503880

 

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[2] Eur Heart J. 2011;32:1235–1243.

 

Fruit and vegetable intake and mortality from ischaemic heart disease: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Heart study. 

 

Crowe FL, Roddam AW, Key TJ, Appleby PN, Overvad K, Jakobsen MU, Tjønneland A, Hansen L, Boeing H, Weikert C, Linseisen J, Kaaks R, Trichopoulou A, Misirli G, Lagiou P, Sacerdote C, Pala V, Palli D, Tumino R, Panico S, Bueno-de-Mesquita HB, Boer J, van Gils CH, Beulens JW, Barricarte A, Rodríguez L, Larrañaga N, Sánchez MJ, Tormo MJ, Buckland G, Lund E, Hedblad B, Melander O, Jansson JH, Wennberg P, Wareham NJ, Slimani N, Romieu I, Jenab M, Danesh J, Gallo V, Norat T, Riboli E;

 

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[3] Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): casecontrol study. Lancet. 2004;364:937–952.

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This seems like an interesting kicker to me -- "Fruits and vegetables were about equally protective."  "Legumes were about as good for arteries as fruits..."

 

I tend to associate fruits with sugar and fructose, which makes me think of glycation / insulin resistance, etc.  So, if I eat something like 5 dates, an apple, and a watermelon wedge for breakfast (~120 grams of sugar, a little more than half of which is fructose), this is roughly as cardio-protective as if I had a bunch of white potatoes (tons of high-GI carbohydrates), and this roughly is as cardio-protective as if I had a bunch of low-GI nutrient-dense vegetables with olive oil and legumes?

Edited by sirtuin

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I tend to associate fruits with sugar and fructose, which makes me think of glycation / insulin resistance, etc.  So, if I eat something like 5 dates, an apple, and a watermelon wedge for breakfast (~120 grams of sugar, a little more than half of which is fructose), this is roughly as cardio-protective as if I had a bunch of white potatoes (tons of high-GI carbohydrates), and this roughly is as cardio-protective as if I had a bunch of low-GI nutrient-dense vegetables with olive oil and legumes?

 

Yes - your intuition about the ill effects of whole fruit are mistaken, or at least grossly exaggerated, probably by the demonizing of fructose in the media by looneys like Robert Lustig. Fruit in whole form has repeatedly been shown to be at least as healthy as vegetables and other low-GI foods, despite what you may have heard.

 

From [1]:

 

Pooled hazard ratios of all cause mortality were ... 0.94 (0.90 to 0.98) for fruit (P=0.002), and 0.95 (0.92 to 0.99) for vegetables (P=0.006).

 

From [2]:

 

 The risk of CHD was decreased by 4% [RR (95% CI): 0.96 (0.93-0.99), P = 0.0027] for each additional portion per day of fruit and vegetable intake and by 7% [0.93 (0.89-0.96), P < 0.0001] for fruit intake.

 

In other words, in this study eating an additional serving of fruit was more beneficial than eating an additional serving of "either fruit or vegetable" (7% vs. 4%), so the vegetables were 'dragging down' the benefits of the fruit.

 

So overall, whole fruit appears at least as protective as vegetables for CVD and all-cause mortality, at least as both categories are commonly consumed.

 

That last qualification may be significant however. While some studies consider fruits juice as part of the fruit category (presumably bringing down the health benefits of the fiber-containing whole fruit), some foods considered as part of the vegetable category by some studies (like potatoes and potentially even french fries!) may not be as healthy as others, and the method of preparation of vegetables can more significantly impact their healthfulness than the typical small range of preparation methods for fruits. 

 

--Dean

 

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[1] BMJ. 2014 Jul 29;349:g4490. doi: 10.1136/bmj.g4490.

Fruit and vegetable consumption and mortality from all causes, cardiovascular

disease, and cancer: systematic review and dose-response meta-analysis of

prospective cohort studies.

 

Wang X(1), Ouyang Y(2), Liu J(2), Zhu M(3), Zhao G(4), Bao W(5), Hu FB(6).

 

 

OBJECTIVE: To examine and quantify the potential dose-response relation between

fruit and vegetable consumption and risk of all cause, cardiovascular, and cancer

mortality.

DATA SOURCES: Medline, Embase, and the Cochrane library searched up to 30 August

2013 without language restrictions. Reference lists of retrieved articles.

STUDY SELECTION: Prospective cohort studies that reported risk estimates for all

cause, cardiovascular, and cancer mortality by levels of fruit and vegetable

consumption.

DATA SYNTHESIS: Random effects models were used to calculate pooled hazard ratios

and 95% confidence intervals and to incorporate variation between studies. The

linear and non-linear dose-response relations were evaluated with data from

categories of fruit and vegetable consumption in each study.

RESULTS: Sixteen prospective cohort studies were eligible in this meta-analysis.

During follow-up periods ranging from 4.6 to 26 years there were 56,423 deaths

(11,512 from cardiovascular disease and 16,817 from cancer) among 833,234

participants. Higher consumption of fruit and vegetables was significantly

associated with a lower risk of all cause mortality. Pooled hazard ratios of all

cause mortality were 0.95 (95% confidence interval 0.92 to 0.98) for an increment

of one serving a day of fruit and vegetables (P=0.001), 0.94 (0.90 to 0.98) for

fruit (P=0.002), and 0.95 (0.92 to 0.99) for vegetables (P=0.006). There was a

threshold around five servings of fruit and vegetables a day, after which the

risk of all cause mortality did not reduce further. A significant inverse

association was observed for cardiovascular mortality (hazard ratio for each

additional serving a day of fruit and vegetables 0.96, 95% confidence interval

0.92 to 0.99), while higher consumption of fruit and vegetables was not

appreciably associated with risk of cancer mortality.

CONCLUSIONS: This meta-analysis provides further evidence that a higher

consumption of fruit and vegetables is associated with a lower risk of all cause

mortality, particularly cardiovascular mortality.

 

PMID: 25073782

 

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[2] J Nutr. 2006 Oct;136(10):2588-93.

Fruit and vegetable consumption and risk of coronary heart disease: a

meta-analysis of cohort studies.

 

Dauchet L(1), Amouyel P, Hercberg S, Dallongeville J.

 

Author information:

(1)INSERM U557, INRA U1125, CNAM, University Paris 13, Centre de Recherche en

Nutrition Humaine, 93017 Bobigny, France.

 

The consumption of fruit and vegetables is associated with a reduced rate of

coronary heart disease (CHD) in observational cohorts. The purpose of this study

was to assess the strength of this association in a meta-analysis. Cohort studies

were selected if they reported relative risks (RRs) and 95% CI for coronary heart

disease or mortality and if they presented a quantitative assessment of fruit and

vegetable intake. The pooled RRs were calculated for each additional portion of

fruit and/or vegetables consumed per day, and the linearity of the associations

were examined. Nine studies were eligible for inclusion in the meta-analysis that

consisted of 91,379 men, 129,701 women, and 5,007 CHD events. The risk of CHD was

decreased by 4% [RR (95% CI): 0.96 (0.93-0.99), P = 0.0027] for each additional

portion per day of fruit and vegetable intake and by 7% [0.93 (0.89-0.96), P <

0.0001] for fruit intake. The association between vegetable intake and CHD risk

was heterogeneous (P = 0.0043), more marked for cardiovascular mortality [0.74

(0.75-0.84), P < 0.0001] than for fatal and nonfatal myocardial infarction [0.95

(0.92-0.99), P = 0.0058]. Visual inspection of the funnel plot suggested a

publication bias, although not statistically significant. Therefore, the reported

RRs are probably overestimated. This meta-analysis of cohort studies shows that

fruit and vegetable consumption is inversely associated with the risk of CHD. The

causal mechanism of this association, however, remains to be demonstrated.

 

PMID: 16988131

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In further defense of fruit, and even other high GI carbs, I forgot to mention the pioneering work of Dr. Kempner and his Rice Diet.

Using a diet composed of virtually all (white) rice and fruit (including fruit juice), Kempner documented the curing of thousands of people of various illnesses, ranging from pathological hypertension to diabetes. See this post for more discussion.

--Dean

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More evidence on the non-badness of naturally occurring sugar, as opposed to added sugar, is this new study [1], by none other than saturated fat apologist Rajiv Chowdhury in the inaugural issue of the new journal "Obesity Science & Practice". The researchers followed 2000 teenage girls for 10 years to see how their intake of both added sugar  and naturally-occurring sugar was associated with BMI and abdominal obesity, as measured by waist circumference.

 

They found that added sugar, especially in liquid form, was associated with an increase in BMI, and especially in waist circumference. They found no such association with naturally occurring sugar in foods, including fruit.

 

--Dean

 

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[1] Obesity Science & Practice Volume 1, Issue 1, pages 41–49, October 2015 DOI: 10.1002/osp4.7

 

Sugars and adiposity: the long-term effects of consuming added and naturally occurring sugars in foods and in beverages 

 

A. K. Lee, R. Chowdhury and J. A. Welsh

 
 
Abstract
 
Objective
The aim of this study was to determine if the association with adiposity varies by the type (added vs. naturally occurring) and form (liquid vs. solid) of dietary sugars consumed.
 
Methods
Data from the 10-year National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study (n = 2,021 girls aged 9–10 years at baseline; n = 5,156 paired observations) were used. Using mixed linear models, 1-year changes in sugar intake, body mass index z-score (BMIz) and waist circumference (WC) were assessed.
 
Results
The results showed mean daily added sugar (AS) intake: 10.3 tsp (41 g) liquid; 11.6 tsp (46 g) solid and naturally occurring sugar intake: 2.6 tsp (10 g) liquid; 2.2 tsp (9 g) solid. Before total energy adjustment, each additional teaspoon of liquid AS was associated with a 0.222-mm increase in WC (p = 0.0003) and a 0.002 increase in BMIz (p = 0.003). Each teaspoon of solid AS was associated with a 0.126-mm increase in WC (p = 0.03) and a 0.001 increase in BMIz (p = 0.03). Adjusting for total energy, this association was maintained only between liquid AS and WC among all and between solid AS and WC among those overweight/obese only. There was no significant association with naturally occurring sugar.
 
Conclusions
These findings demonstrate to suggest a positive association between AS intake (liquid and solid) and BMI that is mediated by total energy intake and an association with WC that is independent of it.

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