부산대학교 도서관

To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1016/S0140-6736(17)32253-5 Byline: Victoria Miller, BSc [victoria.miller@phri.ca] (a,*), Andrew Mente, PhD (a), Mahshid Dehghan, PhD (a), Sumathy Rangarajan, MSc (a), Xiaohe Zhang, MSc (a), Sumathi Swaminathan, PhD (b), Gilles Dagenais, MD (c), Prof Rajeev Gupta, PhD (d), Prof Viswanathan Mohan, MD (e), Prof Scott Lear, PhD (f), Shrikant I Bangdiwala, PhD (a), Aletta E Schutte, PhD (g), Edelweiss Wentzel-Viljoen, PhD (g), Prof Alvaro Avezum, MD (h), Yuksel Altuntas, PhD (i), Khalid Yusoff, MBBS (j,k), Noorhassim Ismail, MD (l), Nasheeta Peer, PhD (m), Jephat Chifamba, DPhil (n), Rafael Diaz, MD (o), Omar Rahman, MD (p), Noushin Mohammadifard, PhD (q), Fernando Lana, MD (r), Katarzyna Zatonska, MD (s), Prof Andreas Wielgosz, MD (t), Afzalhussein Yusufali, MD (u), Romaina Iqbal, PhD (v), Prof Patricio Lopez-Jaramillo, MD (w), Rasha Khatib, PhD (x), Prof Annika Rosengren, MD (y), Prof V Raman Kutty, MD (z), Prof Wei Li, PhD (aa), Jiankang Liu, MSc (ab), Xiaoyun Liu, PhD (aa), Lu Yin, PhD (aa), Prof Koon Teo, MD (a), Prof Sonia Anand, MD (a), Prof Salim Yusuf, DPhil (a), R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, S Yusuf, J Dejesus, D Agapay, T Tongana, R Solano, I Kay, S Trottier, J Rimac, W Elsheikh, L Heldman, E Ramezani, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, Jia Xuan, Hu Bo, Sun Yi, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Chang Xiaohong, Deng Qing, Cheng Xiaoru, Deng Qing, He Xinye, Hu Bo, Jia Xuan, Li Jian, Li Juan, Liu Xu, Ren Bing, Sun Yi, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhang Hongye, Zhao Xiuwen, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, Bian Rongwen, Tian Xiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gomez-Arbelaez, JF Arguello, R Duenas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, W Zatonski, A Szuba, K Zatonska, R Ilow, M Ferus, B Regulska-Ilow, D Rozanska, M Wolyniec, Alkamel, M Ali, M A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Bostrom, A Gustavsson, M Andreasson, M Snallman, L Wirdemann, A Oguz, N Imeryuz, Y Altuntas, S Gulec, A Temizhan, K Karsidag, KBT Calik, AAK Akalin, OT Caklili, MV Keskinler, AN Erbakan, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, F Hussain, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, R Mapanga Summary Background The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. Methods We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135,335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. Findings Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3*91 (SD 2*77) servings per day. During a median 7*4 years (5*5--9*3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0*90, 95% CI 0*74--1*10, p.sub.trend=0*1301), myocardial infarction (0*99, 0*74--1*31; p.sub.trend=0*2033), stroke (0*92, 0*67--1*25; p.sub.trend=0*7092), cardiovascular mortality (0*73, 0*53--1*02; p.sub.trend=0*0568), non-cardiovascular mortality (0*84, 0*68--1*04; p.sub.trend =0*0038), and total mortality (0*81, 0*68--0*96; p.sub.trend Interpretation Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375--500 g/day). Funding Full funding sources listed at the end of the paper (see Acknowledgments). Author Affiliation: (a) Population Health Research Institute, McMaster University, Hamilton, ON, Canada (b) St John's Research Institute, Bangalore, India (c) Institut universitaire de cardiologie et pneumologie de Quebec, Universite Laval, QC, Canada (d) Eternal Heart Care Centre and Research Institute, Jaipur, India (e) Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialties Centre, Chennai, India (f) Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada (g) South African Medical Research Council/North-West University, Potchefstroom, South Africa (h) Dante Pazzanese Institute of Cardiology, University Santo Amaro, Sao Paulo, Brazil (i) Istanbul Sisli Hamidiye Etfal Health Training and Research Center, Istanbul, Turkey (j) Universiti Teknologi MARA, Selayang, Selangor, Malaysia (k) UCSI University, Cheras, Kuala Lumpur, Malaysia (l) Department of Community Health, Faculty of Medicine, University of Kebangsaan Malaysia, Kuala Lumpur, Malaysia (m) Non-Communicable Diseases Research Unit, South African Medical Research Council, Durban, South Africa (n) Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe (o) Estudios Clinicos Latinoamerica ECLA, Rosaria, Argentina (p) Independent University, Dhaka, Bangladesh (q) Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (r) Universidad de La Frontera, Temuco, Chile (s) Department of Social Medicine, Medical University of Wroclaw, Wroclaw, Poland (t) University of Ottawa Department of Medicine, Ottawa, ON, Canada (u) Hatta Hospital, Dubai Health Authority and Dubai Medical College, Dubai, United Arab Emirates (v) Aga Khan University, Karachi, Pakistan (w) Research Institute, FOSCAL and MASIRA Institute, Medical Studies, UDES, Bucaramanga, Colombia (x) Public Health Sciences, Stritch School of Medicine, IL, USA (y) Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital/Astra, Goteborg, Sweden (z) Health Action by People, Trivandrum, India (aa) State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China (ab) Jianshe Road Community Health Center, Chengdu, Sichuan Province, China * Correspondence to: Ms Victoria Miller, Population Health Research Institute, DBCVS Research Institute, McMaster University, Hamilton, ON, L8L 2X2, Canada (footnote)[Dagger] Investigators listed in the