Cited by 538Nutritional Studies and DietFood composition and propertiesCardiovascular Health and Risk Factors

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Associations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) Study

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Steffen, Lyn M, Jacobs, David R, Stevens, June, Shahar, Eyal, Carithers, Teresa, Folsom, Aaron R·2003·The American Journal of Clinical Nutrition

DOI 10.1093/ajcn/78.3.383

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Abstract

Background Recent epidemiologic study results showed that subjects who had high intakes of whole-grain foods had lower risks of death and heart disease than did subjects who had low intakes. However, the findings were inconsistent for fruit and vegetable intake. Objective The relations of whole-grain, refined-grain, and fruit and vegetable intakes with the risk of total mortality and the incidence of coronary artery disease (CAD) and ischemic stroke were studied in the Atherosclerosis Risk in Communities (ARIC) cohort (baseline: age 45-64 y, n = 15,792). Design Proportional hazards regression analyses were used to assess the relations of whole-grain, refined-grain, and fruit and vegetable intakes with the risk of death and the incidence of CAD and ischemic stroke, with adjustment for age, sex, ethnicity, energy intake, and cardiovascular disease risk factors. Dietary intakes were assessed by using a food-frequency questionnaire. Results Over an 11-y follow-up period, whole-grain intake was inversely associated with total mortality and incident CAD. The relative hazards of death for quintiles 2-5 of fruit and vegetable intake were 1.08 (95% CI: 0.88, 1.33), 0.94 (0.75, 1.17), 0.87 (0.68, 1.10), and 0.78 (0.61, 1.01), respectively; P for trend = 0.02. An inverse association between fruit and vegetable intake and CAD was observed among African Americans but not among whites (P for interaction = 0.01). The risk of ischemic stroke was not significantly related to whole-grain, refined-grain, or fruit and vegetable consumption. Conclusion These observational findings suggest a beneficial effect of whole-grain and fruit and vegetable consumption on the risks of total mortality and incident CAD but not on the risk of ischemic stroke.

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“…is much stronger and consistent for antioxidant-rich fruits and vegetables than for single compounds (Willett, 1994; Gaziano et al. 1995; Joshipura et al. 1999, 2001; Liu et al. 2000, 2001; Bazzano et al. 2002; John et al. 2002; Mozaffarian et al. 2003; Steffen et al. 2003; Yusuf et al. 2004).”
Background
Alteration of phenolic profiles and antioxidant capacities of common buckwheat and tartary buckwheat produced in China upon thermal processing
Liu, Y., Cai, C., Yao, Y., & Xu, B. (2019) · Journal of the Science of Food and Agriculture · doi:10.1002/jsfa.9825 · Cited by 74
Glycemic Index, Retinal Vascular Caliber, and Stroke Mortality
Kaushik, S., Wang, J. J., Wong, T. Y., Flood, V. M., Barclay, A. W., Brand-Miller, J. C., & Mitchell, P. (2008) · Stroke · doi:10.1161/strokeaha.108.513812 · Cited by 74
Consumption of whole grains is associated with improved diet quality and nutrient intake in children and adolescents: the National Health and Nutrition Examination Survey 1999–2004
O’Neil, C. E., Nicklas, T. A., Zanovec, M. T., Cho, S. S., & Kleinman, R. E. (2010) · Public Health Nutrition · doi:10.1017/s1368980010002466 · Cited by 73
“Consumption of WG, unlike that of reﬁned grains, is associated with a lower risk of CVD and stroke (7,8) , hypertension (8,9) , type 2 diabetes (10) metabolic syndrome (11) , obesity (12) and some cancers (13,14) .”
Serum lycopene decreases the risk of stroke in men
Karppi, J., Laukkanen, J. A., Sivenius, J., Ronkainen, K., & Kurl, S. (2012) · Neurology · doi:10.1212/wnl.0b013e31826e26a6 · Cited by 73
Bioactive substance contents and antioxidant capacity of raw and blanched vegetables
Wen, T. N., Prasad, K. N., Yang, B. J., & Ismail, A. (2010) · Innovative Food Science & Emerging Technologies · doi:10.1016/j.ifset.2010.02.001 · Cited by 72
A prospective study of healthful and unhealthful plant-based diet and risk of overall and cause-specific mortality
Li, H., Zeng, X., Wang, Y., Zhang, Z., Zhu, Y., Li, X., Hu, A., Zhao, Q., & Yang, W. (2021) · European Journal of Nutrition · doi:10.1007/s00394-021-02660-7 · Cited by 74
A Review of Healthy Dietary Choices for Cardiovascular Disease: From Individual Nutrients and Foods to Dietary Patterns
Chen, W., Zhang, S., Hu, X., Chen, F., & Li, D. (2023) · Nutrients · doi:10.3390/nu15234898 · Cited by 80
Carotenoids as Protection Against Disability in Older Persons
Lauretani, F., Semba, R. D., Bandinelli, S., Dayhoff-Brannigan, M., Lauretani, F., Corsi, A. M., Guralnik, J. M., & Ferrucci, L. (2008) · Rejuvenation Research · doi:10.1089/rej.2007.0581 · Cited by 70
Raw and processed fruit and vegetable consumption and 10-year stroke incidence in a population-based cohort study in the Netherlands
Griep, L. M. O., Verschuren, W. M. M., Kromhout, D., Ocké, M. C., & Geleijnse, J. M. (2011) · European Journal of Clinical Nutrition · doi:10.1038/ejcn.2011.36 · Cited by 70
“…was made between raw and processed (Gillman et al., 1995; Keli et al., 1996; Joshipura et al., 1999; Bazzano et al., 2002; Johnsen et al., 2003; Steffen et al., 2003) or this was not reported Received 1 October 2010; revised 9 February 2011; accepted 16 February 2011; published online 23 March…”
Background
Metabolic Risk Factors for Stroke and Transient Ischemic Attacks in Middle-Aged Men
Wiberg, B., Sundström, J., Ärnlöv, J., Terént, A., Vessby, B. O., Zethelius, B., & Lind, L. (2006) · Stroke · doi:10.1161/01.str.0000249056.24657.8b · Cited by 70
“Antidiabetic Rx use 92 (5) 20 (5) 18 (6) 3 (4)”
Amount, type, and sources of carbohydrates in relation to ischemic heart disease mortality in a Chinese population: a prospective cohort study
Rebello, S. A., Koh, H. W. L., Chen, C., Naidoo, N., Odegaard, A., Koh, W., Butler, L. M., Yuan, J., & van Dam, R. M. (2014) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.113.076273 · Cited by 71
“Ex-smoker 854 (18) 933 (20) 1091 (22) 125 (2) 118 (2) 131 (2) Current smoker (1–12 cigarettes/d) 571 (12) 599 (13) 685 (14) 234 (4) 225 (4) 283 (5)”
BackgroundInfluential
Risk Factor Management to Prevent First Stroke
Rundek, T., & Sacco, R. L. (2008) · Neurologic Clinics · doi:10.1016/j.ncl.2008.09.001 · Cited by 68
“Increased fruit and vegetable consumption is associated with a reduced risk of stroke in a dose-response manner [144].”
Associations between HDL-cholesterol and polymorphisms in hepatic lipase and lipoprotein lipase genes are modified by dietary fat intake in African American and White adults
Nettleton, J. A., Steffen, L. M., Ballantyne, C. M., Boerwinkle, E., & Folsom, A. R. (2006) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2006.11.025 · Cited by 69
Self-citation
Multiple Tailored Messages are Effective in Increasing Fruit and Vegetable Consumption Among Callers to the Cancer Information Service
Heimendinger, J., O'Neill, C., Marcus, A. C., Wolfe, P., Julesburg, K., Morra, M. E., Allen, A. R., Davis, S., Mowad, L. Z., Perocchia, R. S., et al. (2005) · Journal of Health Communication · doi:10.1080/10810730500263646 · Cited by 70
“Diets high in FV have been associated with a reduced risk of chronic diseases, such as heart disease and a variety of cancers (Steinmetz & Potter, 1996; Block, Patterson, & Subar, 1992; Key et al., 2004; Bazzano, Serdula, & Liu, 2003; Steffen et al., 2003).”
Background
Wholegrain oat-based cereals have prebiotic potential and low glycaemic index
Connolly, M. L., Tuohy, K. M., & Lovegrove, J. A. (2012) · British Journal Of Nutrition · doi:10.1017/s0007114512000281 · Cited by 67
Salad and Raw Vegetable Consumption and Nutritional Status in the Adult US Population: Results from the Third National Health and Nutrition Examination Survey
Su, L. J., & Arab, L. (2006) · Journal of the American Dietetic Association · doi:10.1016/j.jada.2006.06.004 · Cited by 67
Vascular Aging: Assessment and Intervention
Li, A., Yan, J., Ya, Z., Yu, Z., Tian, S., Khan, A. H., Zhu, Y., Wu, A., Zhang, C., & Tian, X. (2023) · Clinical Interventions in Aging · doi:10.2147/cia.s423373 · Cited by 70
Evaluation of the evidence between consumption of refined grains and health outcomes
Williams, P. (2012) · Nutrition Reviews · doi:10.1111/j.1753-4887.2011.00452.x · Cited by 66
“Author Quality rating Subjects and study design Foods defined as refined grain Outcomes measured Key results Steffen et al (2003) 126 Positive quality 11,940 men and women aged 45- 64y in 1987-9 in the ARIC study, USA.”
Method
Comparison of Total Phenolic Content and Total Antioxidant Activity in Local Red Wines Determined by Spectrophotometric Methods
Büyüktuncel, E., Porgalı, E., & Çolak, C. (2014) · Food and Nutrition Sciences · doi:10.4236/fns.2014.517179 · Cited by 65
“Epidemiological studies indicated that a higher level of natural antioxidants (vitamins, carotenoids, phenolics) in human everyday diet can protect against cardiovascular diseases, cataract, cancer and aging-related disorders [4].”
Background
Effect of whole grains on markers of subclinical inflammation
Lefevre, M., & Jonnalagadda, S. S. (2012) · Nutrition Reviews · doi:10.1111/j.1753-4887.2012.00487.x · Cited by 64
Relationship between Whole-Grain Intake, Chronic Disease Risk Indicators, and Weight Status among Adolescents in the National Health and Nutrition Examination Survey, 1999-2004
Hur, I., & Reicks, M. M. (2011) · Journal of the Academy of Nutrition and Dietetics · doi:10.1016/j.jada.2011.08.028 · Cited by 64
Mass spectrometry-based analysis of whole-grain phytochemicals
Koistinen, V., & Hanhineva, K. (2015) · Critical Reviews in Food Science and Nutrition · doi:10.1080/10408398.2015.1016477 · Cited by 65
“…disease (Anderson, 2003; Jensen et al., 2004, 2006; Mellen et al., 2008), type 2 diabetes (de Munter et al., 2007; Aune et al., 2013), certain cancers (Jacobs Jr et al., 1998; Aune et al., 2011), as well as all-cause mortality (Jacobs Jr et al., 2000; Steffen et al., 2003; Olsen et al., 2011).”
Background
Applying the FDA Definition of Whole Grains to the Evidence for Cardiovascular Disease Health Claims ,
de Moura, F. F., Lewis, K. D., & Falk, M. C. (2009) · Journal of Nutrition · doi:10.3945/jn.109.112383 · Cited by 60
Low serum carotenoids and development of severe walking disability among older women living in the community: the Women's Health and Aging Study I
Semba, R. D., Varadhan, R., Bartali, B., Ferrucci, L., Ricks, M. O., Blaum, C. S., & Fried, L. P. (2006) · Age and Ageing · doi:10.1093/ageing/afl122 · Cited by 59
Kale Juice Improves Coronary Artery Disease Risk Factors in Hypercholesterolemic Men
Kim, S. Y., Yoon, S. A., Soo Mi, K. W. O. N., Park, K. S., & Lee‐Kim, Y. C. (2008) · Biomedical and Environmental Sciences · doi:10.1016/s0895-3988(08)60012-4 · Cited by 61
Health effects associated with foods characteristic of the Nordic diet: a systematic literature review
Åkesson, A., Andersen, L. F., Kristjansdottir, Á. G., Roos, E., Trolle, E., Voutilainen, E., & Wirfält, E. (2013) · Food & Nutrition Research · doi:10.3402/fnr.v57i0.22790 · Cited by 63
“Therefore, no conclusion could be drawn regarding the associations between potato consumption and CVD/CHD, type 2 diabetes, or inflammatory markers.”
Background
Fruit and vegetable intake in the Mexican population: results from the Mexican National Health and Nutrition Survey 2006.
Ramírez‐Silva, C. I., Rivera, J. Á., Ponce-Martínez, X., & Hernández‐Ávila, M. (2009) · PubMed · Cited by 58
Linking vegetable preferences, health and local food systems through community-supported agriculture
Wilkins, J. L., Farrell, T. J., & Rangarajan, A. (2015) · Public Health Nutrition · doi:10.1017/s1368980015000713 · Cited by 58
“Inverse associations have been shown between fruit and vegetable intake and incidence of both coronary artery disease (10,11) and diabetes (particularly among women) (12) .”
Perspective: Refined Grains and Health: Genuine Risk, or Guilt by Association?
Gaesser, G. A. (2018) · Advances in Nutrition · doi:10.1093/advances/nmy104 · Cited by 62
“In addition to staple grain foods such as bread, cereals and pasta, most of the studies that have examined refined grain intake separate from a Western dietary pattern have defined refined grains to include such foods as cookies (29, 38, 55, 65, 83), cakes (25, 29, 31, 38, 44, 47, 52, 53, 55, 65, 86), donuts (29, 83),…”
Whole-grain consumption and the risk of all-cause, CVD and cancer mortality: a meta-analysis of prospective cohort studies
Wei, H., Gao, Z., Liang, R., Li, Z., Hao, H., & Liu, X. (2016) · British Journal Of Nutrition · doi:10.1017/s0007114516001975 · Cited by 58
“For example, individuals who eat a lot of whole grains will probably also have lower rates of smoking, alcohol use and obesity and higher levels of physical exercise than those who do not eat much whole grains (12,52) .”
Association between Dietary Patterns and Cardiovascular Risk Factors among Middle-Aged and Elderly Adults in Taiwan: A Population-Based Study from 2003 to 2012
Muga, M. A., Owili, P. O., Hsu, C., Rau, H.-H., & Chao, J. C.-J. (2016) · PLoS ONE · doi:10.1371/journal.pone.0157745 · Cited by 57
Peroxisome proliferator–activated receptor α genetic variation interacts with n−6 and long-chain n−3 fatty acid intake to affect total cholesterol and LDL-cholesterol concentrations in the Atherosclerosis Risk in Communities Study
Volcik, K. A., Nettleton, J. A., Ballantyne, C. M., & Boerwinkle, E. (2008) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/87.6.1926 · Cited by 56
Food and vessels: the importance of a healthy diet to prevent cardiovascular disease
Engelfriet, P. M., Hoekstra, J., Hoogenveen, R. T., Büchner, F. L., van Rossum, C. T. M., & Verschuren, W. M. M. (2010) · European Journal of Cardiovascular Prevention & Rehabilitation · doi:10.1097/hjr.0b013e32832f3a76 · Cited by 55
Randomized Trial on the5 a Day, the Rio Grande WayWebsite, A Web-based Program to Improve Fruit and Vegetable Consumption in Rural Communities
Buller, D. B., Woodall, W. G., Zimmerman, D. E., Slater, M. D., Heimendinger, J., Waters, E., Hines, J. M., Starling, R., Hau, B., Burris-Woodall, P., et al. (2008) · Journal of Health Communication · doi:10.1080/10810730801985285 · Cited by 57
“…a diet high in fruits and vegetables (FV) is associated with reduced risk of chronic diseases (Bazzano, Serdula, & Liu, 2003; Key et al., 2004; Knowler et al., 2002; Pietinen, Lahti-Koski, Vartiainen, & Puska, 2001; Rylander & Axelsson, 2006; Steffen et al., 2003; Zyriax, Boeing, & Windler, 2005).”
Background
Dietary fiber and digestive health in children
Korczak, R., Kamil, A., Fleige, L. E., Donovan, S. M., & Slavin, J. L. (2016) · Nutrition Reviews · doi:10.1093/nutrit/nuw068 · Cited by 58
Whole- and Refined-Grain Consumption and Longitudinal Changes in Cardiometabolic Risk Factors in the Framingham Offspring Cohort
Sawicki, C. M., Jacques, P. F., Lichtenstein, A. H., Rogers, G. T., Ma, J., Saltzman, E. J., & McKeown, N. M. (2021) · Journal of Nutrition · doi:10.1093/jn/nxab177 · Cited by 55
Whole Grain Wheat Consumption Affects Postprandial Inflammatory Response in a Randomized Controlled Trial in Overweight and Obese Adults with Mild Hypercholesterolemia in the Graandioos Study
Hoevenaars, F. P. M., Esser, D., Schutte, S., Priebe, M. G., Vonk, R. J., van den Brink, W. J., van der Kamp, J. W., Stroeve, J. H. M., Afman, L. A., & Wopereis, S. (2019) · Journal of Nutrition · doi:10.1093/jn/nxz177 · Cited by 54
Bioactive components in Bambara groundnut (Vigna subterraenea (L.) Verdc) as a potential source of nutraceutical ingredients
Okafor, J. N. C., Jideani, V. A., Meyer, M., & Roes‐Hill, M. L. (2022) · Heliyon · doi:10.1016/j.heliyon.2022.e09024 · Cited by 53
“…been demonstrated that individuals who consume abundant quantities of dietary fiber have less danger of hypertension (Whelto et al., 2005), stroke (Steffen et al., 2003), cardiovascular disease (Lui et al., 1999), gastrointestinal disorder (Petruzziello et al., 2006), obesity (Lairon et al.,…”
Background
Food Pyramid of the Swiss Society for Nutrition
Walter, P., Infanger, E., & Mühlemann, P. (2007) · Annals of Nutrition and Metabolism · doi:10.1159/000103562 · Cited by 53
Effects of NUTRIOSE ® dietary fiber supplementation on body weight, body composition, energy intake, and hunger in overweight men
Guérin‐Deremaux, L., Li, S., Pochat, M., Wils, D., Mubasher, M., Reifer, C. J., & Miller, L. E. (2011) · International Journal of Food Sciences and Nutrition · doi:10.3109/09637486.2011.569492 · Cited by 55
“…diet lowers the risk for a number of chronic diseases including heart disease, stroke, and diabetes (Liu et al. 1999, Montonen et al. 2003, Steffen et al. 2003) and decreases risk factors such as glucose levels, lipid profiles and blood pressure (Brown et al. 1999, Keenan et al. 2002,…”
Background
Association between inflammatory potential of diet and mortality among women in the Swedish Mammography Cohort
Shivappa, N., Harris, H. R., Wolk, A., & Hébert, J. R. (2015) · European Journal of Nutrition · doi:10.1007/s00394-015-1005-z · Cited by 51
“In support of our findings, previous work in the SMC examining diet and mortality, have shown significant inverse associations between anti-inflammatory food parameters such as fruits and vegetables [72], which is consistent with results from other studies such as ARIC [73], 2001–2008 Health Surveys for England [74],…”
Result
Higher Diet Quality Is Inversely Associated with Mortality in African-American Women1–4
Boggs, D. A., Ban, Y., Palmer, J. R., & Rosenberg, L. A. (2015) · Journal of Nutrition · doi:10.3945/jn.114.195735 · Cited by 57
Plasma Magnesium and Risk of Ischemic Stroke Among Women
Adebamowo, S. N., Jiménez, M. C., Chiuve, S. E., Spiegelman, D. L., Willett, W. C., & Rexrode, K. M. (2014) · Stroke · doi:10.1161/strokeaha.114.005917 · Cited by 51
Lifestyle Changes: Effect of Diet, Exercise, Functional Food, and Obesity Treatment on Lipids and Lipoproteins
Enkhmaa, B., Surampudi, P. N., Anuurad, E., & Berglund, L. (2015) · Europe PMC (PubMed Central) · Cited by 50
Consumption of whole grains in relation to mortality from all causes, cardiovascular disease, and diabetes
Li, B., Zhang, G., Tan, M., Zhao, L., Jin, L., Tang, X., Jiang, G., & Zhong, K. (2016) · Medicine · doi:10.1097/md.0000000000004229 · Cited by 51
“Conclusion: Evidence from observational cohort studies indicates inverse associations of intake of whole grains with risk of mortality from all-cause, CVD, and CHD.”
Background

Authors: Steffen, L. M., Jacobs, D. R., Stevens, J., Shahar, E., Carithers, T., & Folsom, A. R.
Affiliations: University of North Carolina at Chapel Hill (US)
Corresponding author: Steffen, Lyn M
ORCID: Steffen, Lyn M
Jacobs, David R
Shahar, Eyal
Carithers, Teresa
Folsom, Aaron R
Venue: The American Journal of Clinical Nutrition
Publisher: Elsevier BV
Published: 2003-09
Volume: 78
Issue: 3
Pages: 383-390
ISSN: 0002-9165 (ISSN-L)
DOI: 10.1093/ajcn/78.3.383
OpenAlex: W2100700568
Cited by: 538
References: 34
Citations by year: 2026: 3 · 2025: 6 · 2024: 11 · 2023: 13 · 2022: 24 · 2021: 25 · 2020: 19 · 2019: 14 · 2018: 12 · 2017: 22 · 2016: 30 · 2015: 29 · 2014: 33 · 2013: 36 · 2012: 35
FWCI: 22.77
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 7109 d)
Locations: American Journal of Clinical Nutrition (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (n01hc55021-47-0-1, n01hc55020-39-0-0, n01hc55016-37-0-0, n01hc055022-024, n01hc55019-35-0-1, n01hc55018-38-0-1, n01hc55015-48-0-1)
National Heart, Lung, and Blood Institute (N01-HC55022, N01-HC-55018, N01 HC 55020, N01 HC 55019, N01-HC55016, N01‐HC‐55015, N01-HC55021)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
Health Sciences › Nursing › Nutrition and Dietetics › Food composition and properties
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
Keywords: whole grain intake, fruit and vegetable intake, all-cause mortality, coronary artery disease, ischemic stroke, dietary intake, African Americans, cardiovascular risk
MeSH terms: Arteriosclerosis, Edible Grain, Coronary Artery Disease, Diet, Female, Follow-Up Studies, Fruit, Humans, Male, Surveys and Questionnaires, Risk, Vegetables, Cohort Studies, Incidence, Proportional Hazards Models, Stroke

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Associations of whole-grain, refined-grain, and fruit and vegetable consumption with risks of all-cause mortality and incident coronary artery disease and ischemic stroke: the Atherosclerosis Risk in Communities (ARIC) Study

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