Higher Consumption of Healthy Foods Lowers Cardiovascular Risk

Risk for cardiovascular disease can be decreased via higher consumption of healthy foods.

Globally, cardiovascular risk can be decreased with higher consumption of healthy foods (ie, fish, nuts, vegetables, fruits, legumes, dairy), especially in lower-income countries, according to findings published in the European Heart Journal.

Investigators sought to develop a globally applicable healthy diet score associated with health outcomes. The primary outcomes were all-cause mortality and major cardiovascular events (cardiovascular disease [CVD]).

They conducted an observational study and meta-analysis using a healthy diet score developed from almost 147,642 people in the general population in 21 countries (the PURE study) with the aim of replicating the results in 3 independent studies (n=43,834 in 50 countries) and in 2 case-control studies of myocardial infarction (n=26,191 in 52 countries) and stroke (n=26,930 in 33 countries). Overall, these 6 studies included patients (N=244,597) from 80 countries.

The PURE study developed a healthy diet score (range, 0-6) based on the following 6 foods:

  • Fish
  • Nuts
  • Vegetables
  • Fruits
  • Legumes
  • Dairy (primarily whole-fat)

In the PURE study, the median follow-up was 9.3 years (IQR, 7.5-10.8) and a diet score of at least 5 was associated with lower risk for CVD (hazard ratio [HR], 0.82; 95% CI, 0.75-0.91), mortality (HR, 0.70; 95% CI, 0.63-0.77), stroke (HR, 0.81; 95% CI, 0.71-0.93), and myocardial infarction (HR, 0.86; 95% CI, 0.75-0.99).

Lower consumption of healthy foods including fruits, vegetables, nuts, legumes, fish, and dairy…contributes to an increase in cardiovascular risk globally….

The mean PURE Healthy Diet Score was 2.95 (SD, 1.50), with the highest median diet scores by region found in Europe, North America, South America, and Middle East. South and Southeast Asia, Africa, and China had lower scores and lower intake of the 6 component foods (higher per capita gross national income associated with higher healthy diet scores [Ptrend <.0001]).

In the PURE study, the least healthy diet (scores ≤1) had lower amounts of each of the 6 healthy foods compared with the healthiest diet scores (≥5). The least healthy diet vs the healthiest diet corresponds to high carbohydrates, lower fat, lower protein, lower red meat, and lower poultry.

Among patients with vascular disease in 3 independent studies, the investigators found similar results, with higher diet scores associated with statistically significant lower CVD (HR, 0.79; 95% CI, 0.72-0.87), mortality (HR, 0.73; 95% CI, 0.66-0.81), and myocardial infarction (HR, 0.85; 95% CI, 0.71-0.99). There was also a nonstatistically significant lower risk for stroke (HR, 0.87; 95% CI, 0.73-1.03).

Among patients in 2 case-control studies, higher diet scores were associated with lower risk for stroke (odds ratio [OR], 0.57; 95% CI, 0.50-0.65) and first myocardial infarction (OR, 0.72; 95% CI, 0.65-0.80).

In regions with lower gross national incomes, a higher diet score was associated with significantly lower risk of CVD or death (Pheterogeneity <.0001). Slightly stronger associations with CVD or death were reported with the PURE score vs several other common diet scores (P <.001 for each comparison).

Study limitations include the observational design, self-reported diet data, and unexamined role of individual fruits and vegetables.

“Lower consumption of healthy foods including fruits, vegetables, nuts, legumes, fish, and dairy (i.e. a lower PURE diet score), contributes to an increase in cardiovascular risk globally, especially in countries with lower income,” the investigators wrote. “This was consistent in individuals with or without vascular disease, and in all world regions, especially in countries with lower income.”

Disclosure: This research was supported by major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithKline, and additional contributions from Novartis and King Pharma.


Mente A, Dehghan M, Rangarajan S, et al. Diet, cardiovascular disease, and mortality in 80 countries. Eur Heart J. Published online July 21, 2023. doi:10.1093/eurheartj/ehad269