High-quality fruit and vegetable characterized by cardiometabolic biomarkers and its relation to major chronic disease risk: results from 3 prospective United States cohort studies

Current guidelines recommend a specified total serving of fruits and vegetables (FV). However, how differences in their nutritional quality influence overall health remains unclear. To identify high-quality FV using 14 cardiometabolic biomarkers, and assess their consumption, alongside overall FV intake, with chronic disease risk. We used data from 3 prospective cohorts, Health Professionals Follow-up Study, Nurses' Health Study (NHS), and NHS-II. Diet was assessed at baseline and updated every 4 years. Biomarker analysis was conducted on 41,714 participants using generalized linear models. Metabolic quality was ascertained by each FV's association with biomarkers. Major chronic disease risk analysis involved 207,241 participants followed for 32 years with Cox proportional hazards models. We also analyzed atherosclerotic cardiovascular disease (ASCVD), type 2 diabetes (T2D), cancer, and chronic obstructive pulmonary disease (COPD) as secondary outcomes. Of 52 FV items, 19 were identified as high-metabolic quality (top five: apples/pears, iceberg/head lettuce, raw spinach, alfalfa sprouts, and eggplant/summer squash). In disease risk analysis, 60,712 major chronic disease events were recorded. A higher proportion of high-metabolic quality FV intake was associated with lower chronic disease risk across total FV quantity levels. In each quantity level stratum (quartiles Q1-Q4), comparing the highest to the lowest quality proportion quartiles, the HR (95% CI) were 0.85 (0.81-0.90), 0.86 (0.82-0.90), 0.84 (0.80-0.89), and 0.89 (0.84-0.94), all P-trend < 0.001. Patterns were similar for ASCVD, T2D, and COPD, but less consistent for cancer. High total FV intake, if consisting mostly of neutral or low-metabolic quality items, was not associated with lower chronic disease risk. For diabetes specifically, these were associated with significantly higher risk (quantity-Q3, HR=1.13 [1.05-1.22]; quantity-Q4, HR=1.17 [1.07-1.28]). Our findings stress the importance of considering both quality and quantity of FV for health, and support dietary guidelines to emphasize high-metabolic quality FV consumption alongside overall intake.