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Measures of carotid atherosclerosis and fall-related hospitalization risk: The Perth Longitudinal Study of Ageing Women.
Gebre, AK, Sim, M, Via, JD, Rodríguez, AJ, Hodgson, JM, Bondonno, CP, Thompson, PL, Prince, RL, Lewis, JR
Nutrition, metabolism, and cardiovascular diseases : NMCD. 2023;(1):95-104
Abstract
BACKGROUND AND AIMS We and others have identified links between cardiovascular conditions and poor musculoskeletal health. However, the relationship between measures of carotid atherosclerosis such as focal carotid plaque and common carotid intima media thickness (CCA-IMT) and falls remains understudied. This study examined the association between measures of carotid atherosclerosis and fall-related hospitalization over 11.5 years in community dwelling older women. METHODS AND RESULTS 1116 older women recruited in 1998 to a five-year randomized controlled trial to examine the effect of calcium supplementation in preventing fracture and who had undertaken B-mode ultrasound in 2001 (three years after the baseline clinical visit) were included in this study. The participants were followed for over 11.5 years as Perth Longitudinal Study of Ageing Women (PLSAW). Over the follow up period, 428 (38.4%) women experienced a fall-related hospitalization. Older women with carotid plaque had 44% a higher relative hazard for fall-related hospitalization (HR 1.44; 95%CI, 1.18 to 1.76) compared to those without carotid plaque. The association persisted after adjustment for established falls risk factors such as measures of muscle strength and physical function.Each SD increase in the mean and maximum CCA-IMT was also associated with a higher risk of fall-related hospitalizations (HR 1.10; 95%CI, 1.00 to 1.21 and HR 1.11; 95%CI, 1.01 to 1.22, respectively). CONCLUSIONS Measures of carotid atherosclerosis are associated with a higher risk of fall-related hospitalization independent of established falls risk factors. These findings suggest the importance of vascular health when considering falls risk.
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Abdominal Aortic Calcification, Bone Mineral Density, and Fractures: A Systematic Review and Meta-analysis of Observational Studies.
Gebre, AK, Lewis, JR, Leow, K, Szulc, P, Scott, D, Ebeling, PR, Sim, M, Wong, G, Lim, WH, Schousboe, JT, et al
The journals of gerontology. Series A, Biological sciences and medical sciences. 2023;(7):1147-1154
Abstract
BACKGROUND Abdominal aortic calcification (AAC) has been inconsistently associated with skeletal health. We aimed to investigate the association of AAC with bone mineral density (BMD) and fracture risk by pooling the findings of observational studies. METHODS MEDLINE, EMBASE, Web of Science, and Google Scholar were searched (August 2021). All clinical studies that assessed the association between AAC and BMD or fracture were included. AAC was categorized into any/advanced (all higher reported groups) versus no/less advanced (lowest reported group). Pooled standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (CI) were determined for BMD and fracture, respectively, using random-effects models. RESULTS Of 2 192 articles screened, 86 (61 553 participants) were included in the review, while 42 provided data for meta-analysis. AAC was associated with lower BMD at the total hip (SMD = -1.05 [95%CI: -1.47 to -0.63]; 16 studies), femoral neck (-0.25 [-0.46 to-0.04]; 10), and lumbar spine (-0.67 [-1.21 to -0.12]; 20). AAC was associated with a greater risk of any fracture (RR = 1.73 [95%CI: 1.48-2.02]; 27). AAC was also associated with vertebral, non-vertebral, and hip fractures. In dose-response analysis, the highest AAC group had greater risks of any, vertebral and non-vertebral fractures. CONCLUSIONS AAC is associated with lower BMD and increased fracture risk at multiple sites, underscoring the potential importance of vascular disease on skeletal health. Detection of AAC at the time of BMD testing may provide clinicians with prognostic information about bone health to enhance osteoporosis screening programs and fracture risk prediction.
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Prognostic Value of Abdominal Aortic Calcification: A Systematic Review and Meta-Analysis of Observational Studies.
Leow, K, Szulc, P, Schousboe, JT, Kiel, DP, Teixeira-Pinto, A, Shaikh, H, Sawang, M, Sim, M, Bondonno, N, Hodgson, JM, et al
Journal of the American Heart Association. 2021;(2):e017205
Abstract
Background The prognostic importance of abdominal aortic calcification (AAC) viewed on noninvasive imaging modalities remains uncertain. Methods and Results We searched electronic databases (MEDLINE and Embase) until March 2018. Multiple reviewers identified prospective studies reporting AAC and incident cardiovascular events or all-cause mortality. Two independent reviewers assessed eligibility and risk of bias and extracted data. Summary risk ratios (RRs) were estimated using random-effects models comparing the higher AAC groups combined (any or more advanced AAC) to the lowest reported AAC group. We identified 52 studies (46 cohorts, 36 092 participants); only studies of patients with chronic kidney disease (57%) and the general older-elderly (median, 68 years; range, 60-80 years) populations (26%) had sufficient data to meta-analyze. People with any or more advanced AAC had higher risk of cardiovascular events (RR, 1.83; 95% CI, 1.40-2.39), fatal cardiovascular events (RR, 1.85; 95% CI, 1.44-2.39), and all-cause mortality (RR, 1.98; 95% CI, 1.55-2.53). Patients with chronic kidney disease with any or more advanced AAC had a higher risk of cardiovascular events (RR, 3.47; 95% CI, 2.21-5.45), fatal cardiovascular events (RR, 3.68; 95% CI, 2.32-5.84), and all-cause mortality (RR, 2.40; 95% CI, 1.95-2.97). Conclusions Higher-risk populations, such as the elderly and those with chronic kidney disease with AAC have substantially greater risk of future cardiovascular events and poorer prognosis. Providing information on AAC may help clinicians understand and manage patients' cardiovascular risk better.
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The effects of vitamin K-rich green leafy vegetables on bone metabolism: A 4-week randomised controlled trial in middle-aged and older individuals.
Sim, M, Lewis, JR, Prince, RL, Levinger, I, Brennan-Speranza, TC, Palmer, C, Bondonno, CP, Bondonno, NP, Devine, A, Ward, NC, et al
Bone reports. 2020;:100274
Abstract
BACKGROUND High vegetable intake is associated with beneficial effects on bone. However, the mechanisms remain uncertain. Green leafy vegetables are a rich source of vitamin K1, which is known to have large effects on osteoblasts and osteocalcin (OC) metabolism. OBJECTIVE To examine the effects of consumption of two to three extra serves of green leafy vegetables daily on bone metabolism. METHODS Thirty individuals (mean age 61.8 ± 9.9 years, 67% male) completed three experimental phases in a randomised controlled crossover design, each lasting four weeks, with a washout period of four weeks between phases (clinical trial registration: ACTRN12615000194561). The three experimental phases were: (i) increased dietary vitamin K1 by consuming green leafy vegetables (H-K; ~200 g/d containing 164.3 [99.5-384.7] μg/d of vitamin K1); (ii) low vitamin K1 by consuming vitamin K1-poor vegetables (L-K; ~200 g/d containing 9.4 [7.7-11.6] μg/d of vitamin K1); and (iii) control (CON) where participants consumed an energy-matched non-vegetable control. OC forms, total OC (tOC), carboxylated OC (cOC) and undercarboxylated OC (ucOC), were measured in serum pre- and post-intervention for each experimental phase using a sandwich-electrochemiluminescence immunoassay. RESULTS Pre-intervention tOC, ucOC and ucOC:tOC levels were similar between phases (P > .05). Following H-K, but not L-K, tOC, ucOC and ucOC:tOC levels were significantly lower compared to pre-intervention levels (P ≤ .001) and compared to CON (~14%, 31% and 19%, respectively, all P < .05), while cOC remained unchanged. CONCLUSIONS In middle-aged healthy men and women, an easily achieved increase in dietary intake of vitamin K1-rich green leafy vegetables substantially reduces serum tOC and ucOC suggesting increased entry of OC into bone matrix, where it may improve the material property of bone. In conjunction with previous epidemiological and randomised controlled trial data, these findings suggest that interventions to increase vegetable intake over extended periods should include bone end points including fracture risk.
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Low Vitamin D Status Is Associated With Impaired Bone Quality and Increased Risk of Fracture-Related Hospitalization in Older Australian Women.
Zhu, K, Lewis, JR, Sim, M, Prince, RL
Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2019;(11):2019-2027
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The vitamin D debate relates in part to ideal public health population levels of circulating 25-hydroxyvitamin D (25OHD) to maintain bone structure and reduce fracture. In a secondary analysis of 1348 women aged 70 to 85 years at baseline (1998) from the Perth Longitudinal Study of Aging in Women (a 5-year calcium supplementation trial followed by two 5-year extensions), we examined the dose-response relations of baseline plasma 25OHD with hip DXA BMD at year 1, lumbar spine BMD, and trabecular bone score (TBS) at year 5, and fracture-related hospitalizations over 14.5 years obtained by health record linkage. Mean baseline plasma 25OHD was 66.9 ± 28.2 nmol/L and 28.5%, 36.4%, and 35.1% of women had levels <50, 50 to 74.9, and ≥75 nmol/L, respectively. Generalized additive models showed that total hip and femoral neck BMD and TBS, but not spine BMD, were higher with increasing plasma 25OHD up to 100 nmol/L. Compared with those with 25OHD <50 nmol/L, women with 25OHD ≥75 nmol/L had significantly higher total hip and femoral neck BMD at year 1 (3.3% to 3.9%) and TBS at year 5 (2.0%), all P < 0.05. During the follow-up, 27.6% of women experienced any fracture-related hospitalization and 10.6% hip fracture-related hospitalization. Penalized spline regression models showed a decrease in risk with increased 25OHD levels up to 65 nmol/L and 75 nmol/L for hip fracture and any fracture-related hospitalization, respectively. Cox regression grouped analyses showed that compared with women with 25OHD <50 nmol/L, those with 25OHD levels 50 to 74.9 and ≥75 nmol/L had significantly lower risk for hip fracture [HR 0.60 (95% CI, 0.40 to 0.91) and 0.61 (95% CI, 0.40 to 0.92), respectively], and any fracture-related hospitalization [HR 0.77 (95% CI, 0.59 to 0.99) and 0.70 (95% CI, 0.54 to 0.91), respectively]. In older white women, 25OHD levels >50 nmol/L are a minimum public health target and 25OHD levels beyond 75 nmol/L may not have additional benefit to reduce fracture risk. © 2019 American Society for Bone and Mineral Research.
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Nitrate-rich vegetables do not lower blood pressure in individuals with mildly elevated blood pressure: a 4-wk randomized controlled crossover trial.
Blekkenhorst, LC, Lewis, JR, Prince, RL, Devine, A, Bondonno, NP, Bondonno, CP, Wood, LG, Puddey, IB, Ward, NC, Croft, KD, et al
The American journal of clinical nutrition. 2018;(6):894-908
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BACKGROUND Emerging evidence suggests that increasing intakes of nitrate-rich vegetables may be an effective approach to reduce blood pressure. OBJECTIVE Our primary aim was to determine whether daily consumption of nitrate-rich vegetables over 4 wk would result in lower blood pressure. DESIGN Thirty participants with prehypertension or untreated grade 1 hypertension were recruited to a randomized controlled crossover trial with 4-wk treatment periods separated by 4-wk washout periods. Participants completed 3 treatments in random order: 1) increased intake (∼200 g/d) of nitrate-rich vegetables [high-nitrate (HN); ∼150 mg nitrate/d], 2) increased intake (∼200 g/d) of nitrate-poor vegetables [low-nitrate (LN); ∼22 mg nitrate/d], and 3) no increase in vegetables (control; ∼6 mg nitrate/d). Compliance was assessed with the use of food diaries and by measuring plasma nitrate and carotenoids. Nitrate metabolism was assessed with the use of plasma, salivary, and urinary nitrate and nitrite concentrations. The primary outcome was blood pressure assessed by using 24-h ambulatory, home, and clinic measurements. Secondary outcomes included measures of arterial stiffness. RESULTS Plasma nitrate and nitrite concentrations increased with the HN treatment in comparison to the LN and control treatments (P < 0.001). Plasma carotenoids increased with the HN and LN treatments compared with the control (P < 0.01). HN treatment did not reduce systolic blood pressure [24-h ambulatory-HN: 127.4 ± 1.1 mm Hg; LN: 128.6 ± 1.1 mm Hg; control: 126.2 ± 1.1 mm Hg (P = 0.20); home-HN: 127.4 ± 0.7 mm Hg; LN: 128.7 ± 0.7 mm Hg; control: 128.3 ± 0.7 mm Hg (P = 0.36); clinic-HN: 128.4 ± 1.3 mm Hg; LN: 130.3 ± 1.3 mm Hg; control: 129.8 ± 1.3 mm Hg (P = 0.49)] or diastolic blood pressure compared with LN and control treatments (P > 0.05) after adjustment for pretreatment values, treatment period, and treatment order. Similarly, no differences were observed between treatments for arterial stiffness measures (P > 0.05). CONCLUSION Increased intake of nitrate-rich vegetables did not lower blood pressure in prehypertensive or untreated grade 1 hypertensive individuals when compared with increased intake of nitrate-poor vegetables and no increase in vegetables. This trial was registered at www.anzctr.org.au as ACTRN12615000194561.
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Aortic Calcification is Associated with Five-Year Decline in Handgrip Strength in Older Women.
Rodríguez, AJ, Lewis, JR, Scott, DS, Kiel, DP, Schousboe, JT, Ebeling, PR, Prince, RL
Calcified tissue international. 2018;(6):589-598
Abstract
The objective of the study was to determine the association between AAC and neuromuscular function over 5 years. Participants in this study were ambulant women over 70 years old residing in Perth, Western Australia who participated in the Calcium Intake Fracture Outcomes Study, a randomised controlled trial of calcium supplementation. 1046 women (mean age = 74.9 ± 2.6 years; BMI = 27.1 ± 4.4 kg/m2) were included. Lateral spine images captured during bone density testing were scored for AAC (AAC24; 0-24) at baseline. Severe AAC (AACsev) was defined using established cut points (AAC24 ≥ 6). At baseline and follow-up, isometric grip strength was assessed using a dynamometer. Mobility was assessed by the Timed-Up-and-Go (TUG) test. Using pre-defined criteria, muscle weakness was considered as grip strength < 22 kg and poor mobility defined as TUG > 10.2 s. A subset of women had appendicular lean mass (ALM) determined by dual-energy X-ray absorptiometry at baseline and follow-up (n = 261). AACsev was evident in 193 (18.5%) women. Average decline in grip strength after 5 years was greater in those with AACsev than those without (3.6 ± 3.7 vs. 2.9 ± 4.2 kg; p = 0.034). This remained significant after adjustment for age, treatment allocation, diabetes, smoking history, renal function, medical record-derived prevalent vascular disease, BMI and physical activity (β = - 0.184; 95% confidence interval: - 0.361, - 0.008; p = 0.040). AACsev was not associated with 5-year changes in TUG or ALM in univariable or multivariable analyses (all p > 0.05). In older women, severe aortic calcification was associated with greater 5-year decline in muscle strength, but not TUG or ALM. These findings support the concept that vascular disease may have an effect on the loss of muscular strength.
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Cardiovascular Health Benefits of Specific Vegetable Types: A Narrative Review.
Blekkenhorst, LC, Sim, M, Bondonno, CP, Bondonno, NP, Ward, NC, Prince, RL, Devine, A, Lewis, JR, Hodgson, JM
Nutrients. 2018;10(5)
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Diets high in vegetables are linked with a lower incidence of chronic disease. Some vegetables may have much larger health benefits in comparison to others, and therefore dietary guidelines could be developed to include targeted advice on consuming specific types of vegetables with the greatest health benefits. This review of observational studies focused on the cardiovascular health benefits of specific vegetable types. Vegetables discussed in this review were grouped into the following types: leafy green, cruciferous, alliums, yellow-orange-red and legumes. These vegetables contain many nutrients and phytochemicals that have been proposed to have benefits for cardiovascular health. The authors looked at the results from nearly 100 observational studies. Most of the studies were carried out on older adults; some were focussed on a single gender (male or female), and some were mixed. Follow up periods in the studies ranged from 3 years to 28 years. Most of the studies relied on food frequency questionnaires (FFQs) to estimate vegetable consumption, and many did not define the size of a vegetable portion in grams. The percentage of studies demonstrating significant benefits of vegetable consumption on CVD ranged from 25% for legumes to 43% for leafy greens. The strongest beneficial effects on CVD risk were seen for leafy green and cruciferous vegetables. The authors concluded that the evidence in this review suggests intake of leafy green and cruciferous vegetables may confer strong cardiovascular health benefits. Increasing vegetable intake, with a focus on leafy green and cruciferous vegetables may provide the greatest benefits.
Expert Review
Conflicts of interest:
Educator for various organizations, such as Institute for Functional Medicine, American Academy for Anti-Aging Medicine
Take Home Message:
- Green leafy vegetables and cruciferous vegetables were found to most impactful for cardiovascular health.
Evidence Category:
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A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
This review highlights the role of specific types of vegetables based on color and nutrients for cardiovascular health benefit.
Clinical practice applications:
The authors investigated whether some vegetable types were more relevant for cardiovascular-related issues than others. Based on their review of the scientific literature, green, leafy vegetables and cruciferous vegetables were found to be most impactful.
Considerations for future research:
This review suggests that more research is needed to understand how certain plant foods, vegetables, and phytochemicals may be functionally important for certain organ systems.
Abstract
Adequate vegetable consumption is one of the cornerstones of a healthy diet. The recommendation to increase vegetable intake is part of most dietary guidelines. Despite widespread and long-running public health messages to increase vegetable intake, similar to other countries worldwide, less than 1 in 10 adult Australians manage to meet target advice. Dietary guidelines are predominantly based on studies linking diets high in vegetables with lower risk of chronic diseases. Identifying vegetables with the strongest health benefits and incorporating these into dietary recommendations may enhance public health initiatives around vegetable intake. These enhanced public health initiatives would be targeted at reducing the risk of chronic diseases, such as cardiovascular diseases (CVD). Specific vegetable types contain high levels of particular nutrients and phytochemicals linked with cardiovascular health benefits. However, it is not clear if increasing intake of these specific vegetable types will result in larger benefits on risk of chronic diseases. This review presents an overview of the evidence for the relationships of specific types of vegetables, including leafy green, cruciferous, allium, yellow-orange-red and legumes, with subclinical and clinical CVD outcomes in observational epidemiological studies.
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Vegetable Diversity, Injurious Falls, and Fracture Risk in Older Women: A Prospective Cohort Study.
Sim, M, Blekkenhorst, LC, Lewis, JR, Bondonno, CP, Devine, A, Zhu, K, Woodman, RJ, Prince, RL, Hodgson, JM
Nutrients. 2018;10(8)
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Plain language summary
Vegetables contain a variety of nutrients and phytochemicals, with a range of health benefits. Previous research has linked higher vegetable consumption in older populations with a lower risk of falls. The importance of vegetable diversity (number of different vegetables consumed) for the risk of falling and fractures is unclear. The objective of this study was to examine the relationship between vegetable diversity with falls and fractures leading to hospitalisation in a prospective cohort of Australian women aged 70 years or over. Vegetable diversity was quantified by assessing the number of different vegetables consumed daily. Vegetable intake was estimated using a food frequency questionnaire at baseline in 1998. Over 14.5 years, injurious falls and fractures were captured using health records. Over 14.5 years of follow-up 39.7% of participants experienced an injurious fall. The percentage of women who experienced an injurious fall in the low (≤3/day), moderate (4/day) and high (≥5/day) vegetable diversity groups were 42.6%, 40.2%, and 36.6%, respectively. For each additional vegetable consumed, there was an 8% reduction in the risk of falls and a 9% reduction in the risk of fractures. The largest benefit of higher vegetable diversity were observed in the one third of women with the lowest vegetable intake (<2.2 servings/day). The authors concluded that increasing vegetable diversity, especially in older women with low vegetable intake, may be an effective way to reduce injurious fall and fracture risk.
Abstract
The importance of vegetable diversity for the risk of falling and fractures is unclear. Our objective was to examine the relationship between vegetable diversity with injurious falling and fractures leading to hospitalization in a prospective cohort of older Australian women (n = 1429, ≥70 years). Vegetable diversity was quantified by assessing the number of different vegetables consumed daily. Vegetable intake (75 g servings/day) was estimated using a validated food frequency questionnaire at baseline (1998). Over 14.5 years, injurious falls (events = 568, 39.7%), and fractures (events = 404, 28.3%) were captured using linked health records. In multivariable-adjusted Cox regression models, women with greater vegetable diversity (per increase in one different vegetable/day) had lower relative hazards for falls (8%; p = 0.02) and fractures (9%; p = 0.03). A significant interaction between daily vegetable diversity (number/day) and total vegetable intake (75 g servings/day) was observed for falls (pinteraction = 0.03) and fractures (pinteraction < 0.001). The largest benefit of higher vegetable diversity were observed in the one third of women with the lowest vegetable intake (<2.2 servings/day; falls HR 0.83 95% CI (0.71⁻0.98); fractures HR 0.74 95% CI (0.62⁻0.89)). Increasing vegetable diversity especially in older women with low vegetable intake may be an effective way to reduce injurious fall and fracture risk.
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Cruciferous and Total Vegetable Intakes Are Inversely Associated With Subclinical Atherosclerosis in Older Adult Women.
Blekkenhorst, LC, Bondonno, CP, Lewis, JR, Woodman, RJ, Devine, A, Bondonno, NP, Lim, WH, Zhu, K, Beilin, LJ, Thompson, PL, et al
Journal of the American Heart Association. 2018;(8)
Abstract
BACKGROUND Dietary patterns rich in fruits and vegetables are considered to reduce atherosclerotic disease presentation and are reported to be inversely associated with subclinical measures of atherosclerosis, such as carotid artery intima-media thickness (IMT) and plaque. However, the effect of vegetable intake alone, and relationships to specific types of vegetables containing different phytochemical profiles, is important. The aim of this study was to investigate the associations of total vegetable intake and specific vegetables grouped according to phytochemical constituents with common carotid artery IMT (CCA-IMT) and carotid plaque severity in a cohort of older adult women (aged ≥70 years). METHODS AND RESULTS Total vegetable intake was calculated at baseline (1998) using a validated food frequency questionnaire. Vegetable types included cruciferous, allium, yellow/orange/red, leafy green, and legumes. In 2001, CCA-IMT (n=954) and carotid focal plaque (n=968) were assessed using high-resolution B-mode carotid ultrasonography. Mean (SD) total vegetable intake was 199.9 (78.0) g/d. Women consuming ≥3 servings of vegetables each day had ≈4.6% to 5.0% lower mean CCA-IMT (P=0.014) and maximum CCA-IMT (P=0.004) compared with participants consuming <2 servings of vegetables. For each 10 g/d higher in cruciferous vegetable intake, there was an associated 0.006 mm (0.8%) lower mean CCA-IMT (P<0.01) and 0.007 mm (0.8%) lower maximum CCA-IMT (P<0.01). Other vegetable types were not associated with CCA-IMT (P>0.05). No associations were observed between vegetables and plaque severity (P>0.05). CONCLUSIONS Increasing vegetables in the diet with a focus on consuming cruciferous vegetables may have benefits for the prevention of subclinical atherosclerosis in older adult women. CLINICAL TRIAL REGISTRATION URL: http://www.anzctr.org.au. Unique identifier: ACTRN12615000750583.