Eating More Fruits and Vegetables May Sharply Cut Risk of Early Heart Disease

A massive new study spanning hospitals across Iran has found that people who eat the most fruits and vegetables may have dramatically lower odds of developing premature coronary artery disease, a form of heart disease that strikes adults in midlife and is rising alarmingly among younger populations worldwide. The research, published in the journal Food Science & Nutrition, analyzed data from 3,249 adults who underwent coronary angiography and found that those in the highest quartile of combined fruit and vegetable consumption had roughly 95 percent lower odds of premature coronary artery disease compared with those eating the least, even after extensive statistical adjustment for age, sex, smoking, physical activity, clinical risk factors, and the rest of the diet.

Premature coronary artery disease, often abbreviated PCAD, refers to significant narrowing of the coronary arteries occurring before age 60 in men and before age 70 in women. It is a growing public health concern because it robs people of decades of productive life and imposes heavy costs on health systems. More than 80 percent of people with PCAD have at least one modifiable risk factor, such as hypertension, diabetes, obesity, dyslipidemia, smoking, psychosocial stress, physical inactivity, or an unhealthy diet. Ischemic heart disease remains a leading cause of death and disability-adjusted life years both in Iran and globally, and its prevalence among younger adults is climbing, making the search for modifiable protective factors increasingly urgent.

The study was conducted within the framework of the IPAD project, which began in 2018 and recruited participants from cardiac catheterization and angiography units in roughly 14 cities across Iran. Uniquely, the study captured remarkable ethnic diversity, enrolling participants from Fars, Azari/Turk, Kurd, Arab, Lor, Gilak, Qashqai, and Bakhtiari backgrounds, with ethnicity determined by the birthplace of individuals and their parents. Cases were defined as adults with at least 75 percent stenosis in one coronary artery or at least 50 percent stenosis in the left main coronary artery, while controls had angiographically normal coronary arteries. Participants with prior confirmed coronary disease, prior interventions such as bypass surgery or angioplasty, implausible energy intakes below 800 or above 4,200 kilocalories per day, or recent herbal supplement use were excluded to improve data quality.

Dietary intake was assessed using a validated semi-quantitative food frequency questionnaire administered by trained interviewers, with participants reporting how often they consumed each of a long list of foods over the preceding year. The questionnaire showed acceptable validity and reproducibility for fruits and vegetables, with a de-attenuated Pearson correlation of 0.49 and an intraclass correlation of 0.57 for this food group. Blood samples were analyzed for fasting glucose and a full lipid profile, and dyslipidemia and diabetes were classified according to standard clinical guidelines. Severity of disease was quantified by the number of stenotic coronary arteries, and the researchers used both binary and ordinal logistic regression models to test whether fruit and vegetable intake related not only to the presence of PCAD but also to how severe it was.

The results were striking. In the fully adjusted model, participants in the highest quartile of fruit intake had 91 percent lower odds of PCAD than those in the lowest quartile, with an odds ratio of 0.09. For vegetables, the corresponding odds ratio was 0.04, a 97 percent reduction, and for total fruits and vegetables combined it was 0.05, a 95 percent reduction. The dose-response pattern was consistent, with each successive quartile of intake showing progressively lower risk and a highly significant trend across categories. Critically, the associations held within individual ethnic groups, including Azari, Fars, Gilak, Kurd, and a combined category of smaller groups, suggesting the protective pattern transcends cultural and culinary differences across the region.

The protective association extended to disease severity as well. Compared with the lowest intake quartile, the highest quartile of fruit consumption was associated with a 93 percent reduction in the odds of severe PCAD in the crude model, and this estimate barely changed after adjustment for confounders. For vegetables, the highest intake category was linked to a 97 percent reduction in severe disease, and combined fruit and vegetable intake showed a similarly powerful inverse relationship with severity. Sex-stratified analyses confirmed the pattern in both men and women, with top-quartile vegetable intake associated with odds ratios of 0.06 in males and 0.03 in females in the fully adjusted models.

To test the robustness of the findings, the researchers performed sensitivity analyses excluding participants with major cardiovascular risk factors, including diabetes, hypertension, and smoking. The inverse associations persisted in these restricted samples, with the highest intake categories of fruits, vegetables, and combined fruits and vegetables all retaining statistically significant protective odds ratios. This suggests the observed relationship was not simply an artifact of the presence or absence of the most obvious clinical risk factors, although the authors themselves caution that the very large effect sizes should be interpreted carefully, since residual confounding by other lifestyle factors and measurement error in dietary assessment may partly contribute to the magnitude of the estimates.

The biological plausibility of these findings rests on well-characterized mechanisms. Fruits and vegetables are dense in soluble and insoluble dietary fiber, vitamins, carotenoids, flavonoids, minerals, and antioxidants. Soluble fiber slows gastric emptying and blunts postprandial rises in blood glucose and lipids, while viscous fibers can interfere with lipid and bile acid metabolism and lower serum LDL cholesterol. Both fiber types promote satiety through stomach distension and gut hormone signaling, supporting weight control and improved glucose metabolism over time. Antioxidants in plant foods help neutralize reactive oxygen species, which otherwise accelerate the oxidation of LDL cholesterol and the formation of foam cells and atherosclerotic plaques. Plant-rich diets also reduce inflammation, blood pressure, and platelet aggregation, and emerging evidence suggests they favorably shape the gut microbiota, whose fermentation products, the short-chain fatty acids, play roles in glucose, lipid, and cholesterol metabolism and immune regulation.

The study aligns with a substantial body of prior evidence. A 2017 dose-response meta-analysis of 66 studies found that each additional serving of fruits and vegetables per day was associated with roughly a 4 percent reduced risk of coronary heart disease, and that consuming 550 to 600 grams of vegetables daily was linked to a 30 percent lower risk of CHD. A 2020 meta-analysis reported that higher fruit consumption was associated with reductions of 9 to 18 percent in the incidence of cardiovascular disease, coronary heart disease, and stroke, while combined fruit and vegetable intake lowered disease incidence by 7 to 18 percent and related mortality by 11 to 27 percent. These estimates are far more modest than the odds ratios in the new study, a difference the authors attribute partly to the case-control design, the contrast between very low and very high intake levels, and the possibility of reverse causality, since subclinical disease may have influenced the dietary habits of cases before diagnosis.

Despite these limitations, which also include inevitable recall and selection bias and a marked imbalance between male and female participants, the study stands out as one of the largest investigations of diet and premature coronary disease in the Middle East, strengthened by angiography-confirmed diagnoses, standardized protocols across centers, and an ethnically diverse cohort. The authors conclude that promoting fruit and vegetable consumption is a simple and effective strategy for reducing PCAD risk, and they recommend that clinicians emphasize dietary interventions for at-risk individuals while public health initiatives improve access to fresh produce. They also call for well-designed randomized clinical trials to confirm the findings and clarify the mechanisms, noting that while the direction of the association is clear, the exact size of the protective effect remains to be pinned down with certainty.

Subject of Research: The association between fruit and vegetable consumption and the risk of premature coronary artery disease

Article Title: Association Between Fruits and Vegetables Consumption and Premature Coronary Artery Disease (PCAD): A Multi‐Center Case Control Study

Article References: Mohammadifard, N., Aghakhani, S., Zarepur, E., Khosravi Farsani, A., Azdaki, N., Salehi, N., Lotfizadeh, M., Ghaffari, S., Salari, A., Cheraghi, M., Assareh, A., Hassannejad, R., Soleimani, A., & Sarrafzadegan, N. (2026). Association Between Fruits and Vegetables Consumption and Premature Coronary Artery Disease ( PCAD ): A Multi‐Center Case Control Study. Food Science & Nutrition, 14(10), Article e72371. https://doi.org/10.1002/fsn3.72371

Image Credits: AI Generated

DOI: 10.1002/fsn3.72371

Keywords: premature coronary artery disease, fruits and vegetables, cardiovascular disease, case-control study, diet, Iran, coronary angiography, nutrition, dietary fiber, antioxidants, heart disease prevention, ethnicity