Whole fruit intake and 10-year ASCVD risk: mediation analysis in NHANES

Background Higher fruit intake is associated with better cardiovascular health, but mechanisms remain unclear and may differ for whole fruit versus fruit juice. We evaluated the association between usual whole-fruit intake and predicted 10-year ASCVD risk and explored potential dietary and biochemical mediators. Methods We analyzed 12,771 adults aged ≥40 years from NHANES 2007–2018 without prior cardiovascular disease. Usual whole-fruit intake (excluding juice) was estimated using the NCI multivariate method. The outcome was logit-transformed 10-year ASCVD risk based on the Pooled Cohort Equations. A high-dimensional mediation framework was applied to identify a latent mediator from multiple dietary and biomarker variables using machine learning (ridge regression, support vector regression, gradient boosting, and deep learning). Effects were estimated in a test set with bootstrapping and multiple imputations. Results Fruit consumers differed from non-consumers in socio-demographic and lifestyle characteristics, including lower smoking prevalence and obesity. Higher whole-fruit intake was associated with lower ASCVD risk. An increase of 80 g/day (one portion) corresponded to a total effect of − 0.037 (95% CI: −0.059, −0.015; p = 0.001), with consistent direct effects across models (−0.033 to − 0.037; p ≤ 0.002). Indirect effects were small and model-dependent; only gradient boosting detected a significant mediated effect (−0.003; p = 0.019), accounting for 8% of the total effect. Key contributors included eGFR, total energy intake, sodium, cured meat, and legumes/soy. Conclusions Higher whole-fruit intake was associated with lower predicted ASCVD risk, largely independent of the evaluated mediators. Findings suggest that whole-fruit intake reflects broader dietary and metabolic patterns rather than a single causal pathway. Key messages • Higher whole-fruit intake is associated with lower predicted 10-year cardiovascular risk in US adults, supporting current dietary recommendations. • The association is only weakly mediated, suggesting fruit intake reflects broader healthy dietary and metabolic patterns rather than a single pathway.