Fruit and Vegetable Consumption and Mortality

European Prospective Investigation Into Cancer and Nutrition

Max Leenders, Ivonne Sluijs, Martine M. Ros, Hendriek C. Boshuizen, Peter D. Siersema, Pietro Ferrari, Cornelia Weikert, Anne Tjønneland, Anja Olsen, Marie-Christine Boutron-Ruault, Françoise Clavel-Chapelon, Laura Nailler, Birgit Teucher, Kuanrong Li, Heiner Boeing, Manuela M. Bergmann, Antonia Trichopoulou, Pagona Lagiou, Dimitrios Trichopoulos, Domenico Palli, Valeria Pala, Salvatore Panico, Rosario Tumino, Carlotta Sacerdote, Petra H. M. Peeters, Carla H. van Gils, Eiliv Lund, Dagrun Engeset, Maria Luisa Redondo, Antonio Agudo, Maria José Sánchez, Carmen Navarro, Eva Ardanaz, Emily Sonestedt, Ulrika Ericson, Lena Maria Nilsson, Kay-Tee Khaw, Nicholas J.Wareham, Timothy J. Key, Francesca L. Crowe, Isabelle Romieu, Marc J. Gunter, Valentina Gallo, Kim Overvad, Elio Riboli, and H. Bas Bueno-de-Mesquita


Am J Epidemiol. 2013;178(4):590-602. 

In This Article

Abstract and Introduction


In this study, the relation between fruit and vegetable consumption and mortality was investigated within the European Prospective Investigation Into Cancer and Nutrition. Survival analyses were performed, including 451,151 participants from 10 European countries, recruited between 1992 and 2000 and followed until 2010. Hazard ratios, rate advancement periods, and preventable proportions to respectively compare risk of death between quartiles of consumption, to estimate the period by which the risk of death was postponed among high consumers, and to estimate proportions of deaths that could be prevented if all participants would shift their consumption 1 quartile upward. Consumption of fruits and vegetables was inversely associated with all-cause mortality (for the highest quartile, hazard ratio = 0.90, 95% confidence interval (CI): 0.86, 0.94), with a rate advancement period of 1.12 years (95% CI: 0.70, 1.54), and with a preventable proportion of 2.95%. This association was driven mainly by cardiovascular disease mortality (for the highest quartile, hazard ratio = 0.85, 95% CI: 0.77, 0.93). Stronger inverse associations were observed for participants with high alcohol consumption or high body mass index and suggested in smokers. Inverse associations were stronger for raw than for cooked vegetable consumption. These results support the evidence that fruit and vegetable consumption is associated with a lower risk of death.


A healthy diet, including a daily consumption of 400–500 g of fruits and vegetables, is known to play an important role in prevention of chronic diseases.[1] Most prospective studies have consistently shown an approximately 10%–25% lower all-cause mortality when comparing people with high and low fruit and vegetable consumption.[2–9] When separating mortality Into cancer and cardiovascular disease mortality, evidence is more convincing that fruit and vegetable consumption protects against cardiovascular disease[10,11] than against cancer.[12] However, according to the 2007 expert report of the World Cancer Research Fund and the American Institute for Cancer Research,[13] some types of vegetables and fruits possibly protect against certain types of cancer.

Only a few studies examined whether the effect of fruit and vegetable consumption on all-cause mortality varied by smoking status, body size/adiposity, or gender, and these did not observe significant differences.[7–9] In addition, very few studies have quantified the number of years of life that can be gained by increasing fruit and vegetable consumption. Gundgaard et al.[14] estimated an increase in cancer-free life expectancy by 1 year or more for those consuming 400 g/day or more when compared with 250 g/day, but this was based solely on cancer mortality reductions taken mainly from case-control studies.[15]

This study aimed to investigate the association of fruit and vegetable consumption with mortality of all causes, cancer, and cardiovascular disease within the European Prospective Investigation Into Cancer and Nutrition (EPIC) and to estimate the time period by which the risk of death was postponed among participants with a high consumption of fruits and vegetables. Additionally, associations with mortality for vegetables will be compared according to preparation (i.e., cooked vs. raw). Preparation of vegetables is known to affect availability of nutrients, but its association with mortality has been rarely studied. The large size of this cohort combined with its long follow-up, the large number of deaths, and wide range of fruit and vegetable consumption provides an ideal setting to study these associations and allows identification of subgroups of the population that may benefit more from consumption of fruits and vegetables.