The low-carbohydrate diet and cardiovascular risk factors: evidence from epidemiologic studies

Dietary Approaches to Stop Hypertension (DASH) for the primary and secondary prevention of cardiovascular diseases

BACKGROUND

The Dietary Approaches to Stop Hypertension (DASH) diet is designed to lower blood pressure and improve cardiovascular health by reducing sodium and unhealthy fats while increasing nutrients, including potassium, calcium, magnesium, and fibre. While evidence supports its benefits for managing cardiovascular risk factors, gaps remain in understanding its long-term impact on preventing cardiovascular disease (CVD), particularly in terms of hard clinical outcomes such as myocardial infarction and stroke.

OBJECTIVES

To assess the effects of the DASH diet for the primary and secondary prevention of cardiovascular diseases.

SEARCH METHODS

We used standard extensive Cochrane search methods. The latest search date was in May 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing a DASH diet intervention to no intervention (including usual care), minimal intervention, or other dietary interventions. In the context of this review, 'minimal intervention' includes brief dietary advice or informational leaflets provided during a medical consultation, without a structured dietary intervention. 'Other dietary interventions' include any other dietary programme besides the DASH diet. Participants were adults with or without CVD. The minimum duration of eligible interventions was eight weeks and the minimum follow-up was three months.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were myocardial infarction, heart failure, and stroke. Secondary outcomes were the need for coronary revascularisation, carotid revascularisation, peripheral revascularisation, all-cause mortality, cardiovascular mortality, changes in blood pressure, blood lipids, the occurrence of type 2 diabetes, health-related quality of life, and adverse effects. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Five RCTs involving 1397 participants met our inclusion criteria and were included in this review. All five trials contributed at least one intervention arm to one or more of the three prespecified comparisons. In total, 1075 participants across eligible arms were included in the meta-analyses. The difference reflects trial arms that did not meet our prespecified intervention and comparison definitions, and were therefore not analysed, though all participants were randomised within eligible trials and are accounted for in the review total. The trials assessed the DASH diet in a primary prevention setting; none evaluated its effects in secondary prevention. Participants were generally healthy adults aged 18 years or older, without diagnosed cardiovascular disease. The intervention duration ranged from 16 weeks to 12 months, with follow-up periods between 16 weeks and 18 months (medium- and long-term). The trials were conducted in the USA and Poland, with funding from public institutions, including the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the Institute of Cardiology in Poland. DASH diet versus no intervention (including usual care) Myocardial infarction: one trial (144 participants) reported no myocardial infarctions in either group over a one-year follow-up. The GRADE certainty rating was low due to the high risk of performance bias and imprecision. Stroke: one trial (144 participants) reported no strokes in either group over the same follow-up period. The GRADE rating was low for similar reasons. All-cause mortality: one trial (90 participants) reported no deaths over a six-month follow-up. The GRADE rating was very low due to unclear risk of selection bias, high risk of performance bias, and imprecision. No data were available for heart failure or revascularisation needs (coronary, carotid, or peripheral) in this comparison. DASH diet versus minimal intervention Myocardial infarction: two trials (902 participants in total; 629 participants were in trial arms eligible for this comparison, based on our prespecified intervention and comparison definitions) reported limited events, with no clear differences between groups over one year (risk ratio (RR) 2.99, 95% confidence interval (CI) 0.12 to 73.04). The GRADE rating was low due to high risk of performance bias and imprecision. Stroke: two trials (reporting on the same 629 participants) reported no strokes in either group over follow-up periods ranging from six months to one year. The GRADE rating was low due to similar concerns. No data were available for heart failure, revascularisation needs (coronary, carotid, or peripheral), or all-cause mortality in this comparison. DASH diet versus another dietary intervention All-cause mortality: one trial (261 participants) reported no clear difference between the groups over one year (RR 2.98, 95% CI 0.12 to 72.42). The GRADE rating was very low due to multiple risks of bias and imprecision. No data were available for myocardial infarction, stroke, heart failure, or revascularisation needs in this comparison.

AUTHORS' CONCLUSIONS

The effect of the DASH diet on major cardiovascular outcomes - including myocardial infarction, stroke, cardiovascular mortality, and all-cause mortality - remains inconclusive due to a lack of robust long-term evidence. Additionally, no trials have assessed its impact on heart failure or the need for revascularisation procedures, such as coronary, carotid, or peripheral interventions. While the DASH diet may reduce blood pressure, total cholesterol, and triglyceride levels while increasing high-density lipoprotein (HDL) cholesterol compared to no intervention or usual care, it appears to have little to no effect on low-density lipoprotein (LDL) cholesterol. Evidence comparing the DASH diet to a minimal intervention or alternative dietary approaches remains limited. Although the DASH diet has minimal reported adverse effects, the absence of long-term safety data prevents definitive conclusions on its use in individuals with or without cardiovascular disease. The certainty of evidence is low to very low, primarily due to design limitations such as high risk of bias, small sample sizes, and short follow-up periods in the included trials. Most studies focused on cardiovascular risk factors rather than long-term clinical outcomes, and all eligible trials assessed primary prevention, with no data on secondary prevention. Given these uncertainties, well-designed, long-term randomised controlled trials are needed to evaluate the DASH diet's impact on major cardiovascular events, its effectiveness in secondary prevention, and its long-term safety.

Anthropometric Trajectories and Dietary Compliance During a Personalized Ketogenic Program

BACKGROUND/OBJECTIVES

Ketogenic diets (KDs) have gained attention for their potential to promote weight loss and metabolic improvements. However, data on long-term body composition changes and adherence rates in real-world settings remain limited.

OBJECTIVE

This study aimed to assess the effects of a personalized ketogenic dietary program on anthropometric parameters over a 9-month period and to evaluate adherence across time.

METHODS

A total of 491 adults participated in a longitudinal intervention involving a structured ketogenic nutrition plan with follow-up at 3, 6, and 9 months. Body weight, fat mass (FM), skeletal muscle mass (SMM), and other composition metrics were measured at each visit.

RESULTS

Significant reductions in body weight (-12.6 kg) and fat mass (-10.3 kg) were observed after 3 months (p < 0.001), with minimal changes at 6 months and partial regain by Month 9. SMM remained relatively stable throughout the study. Retention dropped substantially after 3 months, dropping from 487 to 115 participants at Month 6 and 41 at Month 9. Despite this, participants who completed the program maintained significant anthropometric improvements.

CONCLUSIONS

A well-formulated ketogenic diet may promote rapid fat loss while preserving lean mass in the short term. However, long-term adherence poses significant challenges. Strategies to enhance dietary sustainability and retention are essential for maximizing the benefits of KDs in clinical practice.

Effect of very low-carbohydrate high-fat diet and high-intensity interval training on mental health-related indicators in individuals with excessive weight or obesity

Very low carbohydrate high fat (VLCHF) diet and high-intensity interval training (HIIT) are widely utilized for weight reduction and cardiorespiratory fitness improvement, respectively. To assess the acceptability of these approaches, it is essential to examine mental health-related indicators. This secondary analysis of a randomized controlled trial investigated the isolated and synergistic effects of VLCHF and HIIT on mental health-related indicators in individuals with excessive weight or obesity. Sixty-eight participants (age = 42 ± 10.2; 20-60 years; BMI = 29.8 ± 3.7) were analysed across four groups: HIIT (n = 15, 4 males, 11 females), VLCHF (n = 19, 4 males, 15 females), VLCHF + HIIT (n = 19, 4 males, 15 females), and control (n = 15, 4 males, 11 females). The 12-week intervention, involved VLCHF diet or HIIT sessions, depending on group affiliation and completing online questionnaires via Qualtrics software before and after the intervention. The questionnaires included the 12-item Short Form Survey (SF-12) for mental (MHS) and physical health scores (PHS), the Satisfaction with Life Scale (SWLS), and the Perceived Stress Scale (PSS). Using the Kruskal-Wallis test, we found no significant differences in mental health-related indicators between groups after 12 weeks, except for SWLS (p = 0.031; ES = 0.133; medium), which improved significantly in the VLCHF + HIIT group compared to the HIIT group. Our findings indicate that HIIT and VLCHF, alone or combined, do not significantly affect mental health-related indicators.

The association between low carbohydrate dietary score (LCDS) and cardiovascular risk factors: results from the Shiraz Heart Study (SHS)

BACKGROUND

Cardiovascular disease (CVD) is a major cause of death and recent studies have highlighted the potential role of dietary carbohydrate indices in cardiovascular health. Given the controversial results in this field, the aim of this study was to investigate the association between low carbohydrate dietary score (LCDS) and CVD risk factors in a population of Iranian adults.

METHODS

This cross-sectional study was conducted within the framework of the Shiraz Heart Study (SHS) including 1982 adults. The validated 168 items food frequency questionnaire (FFQ) was used to assess participants' dietary intakes. To investigate the association between LCDS and cardiometabolic risk factors, logistic regression, was conducted.

RESULTS

During 5 years of follow-up, a total of 1982 adults, with a mean age of 53.07 ± 8.38 years, were included to the analysis. The adjusted model based on known confounding factors (age, sex, smoking, physical activity, energy intake and body mass index) revealed a significant decrease in a body shape index (ABSI) (OR = 0.70, 95% CI= (0.50 to 0.98), P = 0.038) comparing highest LCDS tertile vs. the reference. In contrast, risk of hypertension (HTN), body mass index (BMI), waist-hip ratio (WHR), triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), atherogenic index of plasma (AIP), and fasting blood sugar (FBS) were not significantly associated with LCDS.

CONCLUSION

Current findings suggest that adherence to a low carbohydrate diet reduces ABSI, a main indicator of central obesity.

The effect of a nurse-led low carbohydrate regimen on anthropometric and laboratory parameters of patients with metabolic syndrome: a quasi-experimental study

Introduction

Metabolic syndrome is a global health concern. It is a condition that includes a cluster of various risk factors for type 2 diabetes and cardiovascular disease. This quasi-experimental study investigates the effect of a nurse-led low-carbohydrate regimen on anthropometric and laboratory parameters in metabolic syndrome patients.

Methods

The study used a quasi-experimental design conducted at the University of Mosul; 128 participants meeting the metabolic syndrome criteria were recruited and divided into the intervention and control groups. The intervention group received personalized counseling and support in implementing a low-carb regime, while the control group received standard advice. The study participants were assessed by anthropometry, and laboratory parameters were evaluated pre- and post-intervention. Statistical data analysis was conducted using IBM-SPSS 27, including chi-square, Fisher's exact test, t-tests, and the Mcnemar test, which were performed to compare the changes within and between groups.

Results

The mean age of the participants in the intervention and control groups was 50.72 ± 6.43 years and 49.14 ± 6.89 years, respectively. Compared to the control group, the intervention group experienced a significant positive reduction in anthropometric measures and laboratory parameters, including weight, body mass index (BMI), waist circumference, lipid profiles, and HbA1c.

Conclusion

A tangible effect of nurse-led interventions based on low-carbohydrate regimens in managing metabolic syndrome was empirically authenticated. Positive changes were observed in the intervention group regarding anthropometric measures and laboratory parameters. However, future research may require a larger sample size and a longer follow-up to confirm these effects and evaluate long-term metabolic impacts.

Associations of Lower-Carbohydrate and Lower-Fat Diets with Mortality among People with Cardiovascular Disease

BACKGROUND

Although low-carbohydrate and low-fat diets have been shown to have short-term metabolic benefits, the associations of these dietary patterns, particularly different food sources and macronutrient quality, with mortality in people with cardiovascular disease (CVD) remain unclear.

OBJECTIVES

To examine the associations of different types of lower-carbohydrate diets (LCDs) and lower-fat diets (LFDs) with mortality in individuals with CVD.

METHODS

This study included 3971 adults with CVD from the NHANES 1999-2014. Mortality status was linked to National Death Index mortality data through 31 December 2019. Overall, unhealthy and healthy LCD and LFD scores were determined based on the percentages of energy from total and subtypes of carbohydrate, fat, and protein. Cox proportional hazards regression models were applied to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Higher healthy LCD score was associated with favorable blood lipids and higher homeostasis model assessment of insulin resistance, whereas higher unhealthy LFD score was associated with lower high-density lipoprotein and higher C-reactive protein at baseline (all P-trend < 0.05). During 35,150 person-years of follow-up, 2163 deaths occurred. For per 20-percentile increment in dietary scores, the multivariate-adjusted HRs of all-cause mortality were 0.91 (95% CI: 0.86, 0.96) for healthy LCD score (P < 0.001), 0.94 (95% CI: 0.89, 1.00) for healthy LFD score (P = 0.04), and 1.07 (95% CI: 1.00, 1.14) for unhealthy LFD score (P = 0.04).

CONCLUSIONS

Overall LCD and LFD scores are not associated with total mortality. Unhealthy LFD scores are associated with higher total mortality, whereas healthy LCD and LFD scores are associated with lower mortality in people with CVD.

A very-low carbohydrate content in a high-fat diet modifies the plasma metabolome and impacts systemic inflammation and experimental atherosclerosis

Ketogenic diets (KDs) are very high-fat low-carbohydrate diets that promote nutritional ketosis and are widely used for weight loss, although concerns about potential adverse cardiovascular effects remain. We investigated a very high-fat KD's vascular impact and plasma metabolic signature compared to a non-ketogenic high-fat diet (HFD). Apolipoprotein E deficient (ApoE -/-) mice were fed a KD (%kcal:81:1:18, fat/carbohydrate/protein), a non-ketogenic high-fat diet with half of the fat content (HFD) (%kcal:40:42:18, fat/carbohydrate/protein) for 12 weeks. Plasma samples were used to quantify the major ketone body beta-hydroxybutyrate (BHB) and several pro-inflammatory cytokines (IL-6, MCP-1, MIP-1alpha, and TNF alpha), and to targeted metabolomic profiling by mass spectrometry. In addition, aortic atherosclerotic lesions were quantified ex-vivo by magnetic resonance imaging (MRI) on a 14-tesla system. KD was atherogenic when compared to the control diet, but KD mice, when compared to the HFD group (1) had markedly higher levels of BHB and lower levels of cytokines, confirming the presence of ketosis that alleviated the well-established fat-induced systemic inflammation; (2) displayed significant changes in the plasma metabolome that included a decrease in lipophilic metabolites and an increase in hydrophilic metabolites; (3) had significantly lower levels of several atherogenic lipid metabolites, including phosphatidylcholines, cholesterol esters, sphingomyelins, and ceramides; and (4) presented significantly lower aortic plaque burden. KD was atherogenic and was associated with specific metabolic changes but alleviated the fat-induced inflammation and lessened the progression of atherosclerosis when compared to the HFD.

Habitual low carbohydrate high fat diet compared with omnivorous, vegan, and vegetarian diets

Background

Dietary patterns which exclude whole food groups, such as vegetarian, vegan and low carbohydrate high fat diet (LCHF), are increasingly popular in general public. When carefully planned, all these diets have some known benefits for health, but concerns are also raised in particular for LCHF. The quality of LCHF diet which individuals follow in real life without supervision is not known.

Methods

One hundred thirty healthy individuals with stable body mass following LCHF, vegan, vegetarian and omnivorous diet for at least six months, were compared in a cross-sectional study. Diet was analyzed through 3-day food records and FFQ, anthropometric measurements were performed and serum metabolic biomarkers determined from fasting blood.

Results

Participants on LCHF diet had the intakes of micronutrients comparable to other groups, while the intakes of macronutrients differed in line with the definition of each diet. The intakes of saturated fats, cholesterol and animal proteins were significantly higher and the intakes of sugars and dietary fibers were lower compared to other groups. Healthy eating index 2015 in this group was the lowest. There were no differences in the levels of glucose, triacylglycerols and CRP among groups. Total and LDL cholesterol levels were significantly higher in LCHF group, in particular in participants with higher ketogenic ratio. Fatty acids intakes and intakes of cholesterol, dietary fibers and animal proteins explained 40% of variance in total cholesterol level, with saturated fatty acids being the strongest positive predictor and monounsaturated fatty acids a negative predictor.

Conclusion

None of the self-advised diets provided all the necessary nutrients in optimal levels. Due to the detected increased levels of serum cholesterols, selection of healthy fat sources, higher intake of dietary fibers and partial replacing of animal sources with plant sources of foods should be recommended to the individuals selecting LCFH dietary pattern.Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04347213.

The association between low carbohydrate diet scores and cardiometabolic risk factors in Chinese adults

Epidemiological studies on the association between the low carbohydrate diet (LCD) score and CVD risk factors have limited and inconsistent results. Data are from the baseline survey of Community-based Cohort Study on Nervous System Diseases. A total of 4609 adults aged ≥ 18 years were included in the study. Dietary data were assessed using a validated semi-quantitative FFQ. Multivariable logistic regression analyses were used to estimate relationships of three LCD scores with low HDL-cholesterol, high LDL-cholesterol, hypercholesterolaemia, hypertriacylglycerolaemia, impaired fasting glucose (IFG), high blood pressure and hyperuricaemia after adjusting for potential confounders. A higher LCD score was negatively associated with low HDL-cholesterol (OR: 0·65 (95 % CI 0·50, 0·83), P = 0·0001) and IFG (OR: 0·65 (95 % CI 0·51, 0·81), P = 0·001) after the final adjustment. However, there are sex differences in this result. Males in the highest quintile of the animal-based or plant-based LCD scores showed a decreased risk of low HDL-cholesterol, and females in the highest quintile of the animal-based or plant-based LCD scores showed a decreased risk of IFG than those in the lowest quintile of the LCD scores. These results suggest that sex differences should be considered when using LCD to treat dyslipidaemia and reduce fasting blood glucose.

A bibliometric and visual analysis of low carbohydrate diet

Introduction

Numerous studies have confirmed the effects of low carbohydrate diet (LChD) on metabolism and chronic diseases. However, there were no bibliometric studies on LChD. This study was conducted through a bibliometric analysis to investigate the current status, hotspots and frontiers trends.

Methods

We searched all research publications related to LChD from 2002 to 2021 on the Web of Scientific Core Collection (WoSCC). CiteSpace and VOSviewer software was used to analyze countries/regions, institutions, journals, authors, references, and keywords.

Results

A total of 6938 papers were included, with an increasing trend of annual publication. LChD categories mainly included nutrition, endocrinology, and neurosciences which reflected the interdisciplinary characteristics. USA was with the largest number and the world science center in LChD field. Universities were main research institutions and five of the top 10 institutions were from USA. Eric Heath Kossoff had 101 publications and ranked first. Nutrients was the leading journal. "A randomized trial of a low-carbohydrate diet for obesity" and "Obesity" were considered to be the most co-cited and cited reference respectively. The hotspots of LChD are four aspects, "ketogenic diet", "metabolism disease", "cardiovascular disease" and "cancer". We summarized that "oxidative stress", "gut microbiota", and "inflammation factors" are becoming frontiers trends of LChD research in the future and deserve further study.

Discussion

Over the past 20 years research on LChD has gained great attention. To better explore LChD field, multilevel mechanism studies will be required in the future.

High-Fat or High-Carbohydrate Meal-Does It Affect the Metabolism of Men with Excess Body Weight?

Excessive adipose tissue in the body may lead to adverse health effects, carbohydrate and lipid metabolism disorders, and cardiovascular diseases. The aim of this study was to analyze the effect of a standardized high-fat meal (HF) on changes in energy expenditure and changes in the oxidation of energy substrates as well as the concentration of glucose, insulin, triglycerides and homocysteine in blood serum in relation to a standardized high-carbohydrate (non-fat, HC) meal in men with different nutritional status. In this study, 26 men (aged 19-60) without carbohydrate disorders (study group GS = 13 overweight/obese; control group GC = 13 normal body weight) were examined. It was observed that following a high-fat or high-carbohydrate meal, men with excessive body weight metabolized the main nutrients differently than men with normal body weight, and postprandial insulin secretion was also different (even without any significant differences in glucose concentrations). Overweight/obesity, which is in itself a risk factor for cardiovascular disease, contributes to an increase in the concentration of other risk factors, such as the concentration of homocysteine and triglycerides, which is referred to as cardiometabolic risk. Consumption of a high-fat meal increased the number of potential risk factors for cardiovascular disease (homocysteine and triglycerides) compared to a high-carbohydrate meal.

Associations of lower-carbohydrate and lower-fat diets with mortality among people with prediabetes

BACKGROUND

Although low-carbohydrate and low-fat diets are beneficial in short-term metabolic improvement, the associations of these dietary patterns, particularly with different food sources and quality of macronutrients, with mortality remain unclear among people with prediabetes.

OBJECTIVES

We aimed to examine the associations of different types of lower-carbohydrate diets (LCDs) and lower-fat diets (LFDs) with mortality among individuals with prediabetes.

METHODS

This study included 9793 adults with prediabetes from the NHANES 1999-2014. Mortality status was linked to National Death Index mortality data through 31 December, 2015. Overall, unhealthy, and healthy LCD and LFD scores were determined based on the percentages of energy from total and subtypes of carbohydrate, fat, and protein. Cox proportional hazards regression models were applied to calculate HRs and 95% CIs.

RESULTS

Higher healthy LCD score was associated with favorable blood glucose, insulin, HOMA-IR, C-reactive protein (CRP), and blood lipids, whereas higher healthy LFD score was associated with lower blood glucose and CRP at baseline (all P-trend < 0.05). During 72,054 person-years of follow-up, 1352 deaths occurred. The multivariate-adjusted HRs (95% CIs) of all-cause mortality per 20-percentile increment in dietary scores were 0.88 (0.80, 0.96) for healthy LCD score (P = 0.003), 0.85 (0.78, 0.93) for healthy LFD score (P < 0.001), 1.09 (0.99, 1.21) for unhealthy LCD score (P = 0.08), and 1.11 (1.00, 1.22) for unhealthy LFD score (P = 0.05). Isocalorically replacing 3%-5% energy of low-quality carbohydrate or saturated fat with high-quality carbohydrate, plant-based protein, or unsaturated fat was associated with a 14%-37% reduced all-cause mortality.

CONCLUSIONS

Healthy LCD and LFD scores were significantly associated with lower all-cause mortality, whereas unhealthy LCD and LFD scores tended to be associated with higher all-cause mortality, among people with prediabetes.

The Effect of Nutritional Ketosis on Aquaporin Expression in Apolipoprotein E-Deficient Mice: Potential Implications for Energy Homeostasis

Ketogenic diets (KDs) are very low-carbohydrate, very high-fat diets which promote nutritional ketosis and impact energetic metabolism. Aquaporins (AQPs) are transmembrane channels that facilitate water and glycerol transport across cell membranes and are critical players in energy homeostasis. Altered AQP expression or function impacts fat accumulation and related comorbidities, such as the metabolic syndrome. Here, we sought to determine whether nutritional ketosis impacts AQPs expression in the context of an atherogenic model. To do this, we fed ApoE^−/− (apolipoprotein E-deficient) mice, a model of human atherosclerosis, a KD (Kcal%: 1/81/18, carbohydrate/fat/protein) or a control diet (Kcal%: 70/11/18, carbohydrate/fat/protein) for 12 weeks. Plasma was collected for biochemical analysis. Upon euthanasia, livers, white adipose tissue (WAT), and brown adipose tissue (BAT) were used for gene expression studies. Mice fed the KD and control diets exhibited similar body weights, despite the profoundly different fat contents in the two diets. Moreover, KD-fed mice developed nutritional ketosis and showed increased expression of thermogenic genes in BAT. Additionally, these mice presented an increase in Aqp9 transcripts in BAT, but not in WAT, which suggests the participation of Aqp9 in the influx of excess plasma glycerol to fuel thermogenesis, while the up-regulation of Aqp7 in the liver suggests the involvement of this aquaporin in glycerol influx into hepatocytes. The relationship between nutritional ketosis, energy homeostasis, and the AQP network demands further investigation.

Short-term Effects of Eating Behavior Modification on Metabolic Syndrome-Related Risks in Overweight and Obese Korean Adults

Background

We investigated whether eating behavior modification improves metabolic syndrome (MetS)-related risks in overweight/obese Korean adults, and identified dietary factors that improve metabolic status.

Methods

Among 159 volunteers, 71 with a body mass index ≥23 kg/m² and without other chronic diseases participated in the 8-week intervention, among which 54 participants who completed the intervention were included in the analyses. At baseline, patients were categorized either metabolically healthy obese (MHO; <3 MetS risk factors, n=42) or metabolically unhealthy obese (MUHO; ≥3 MetS risk factors, n=12), and then educated regarding how to choose healthy foods and meals.

Results

Lipid profiles and anthropometric and glycemic parameters were significantly improved among all participants after the intervention. Changes in waist circumference (P=0.025), and glycemic parameters (glucose, P=0.046, insulin, P=0.005, C-peptide, P=0.041) were positively correlated with changes in calorie intake from snacks. Changes in visceral fat area were negatively correlated with changes in total calorie intake (P=0.046), and positively correlated with those in calorie intake from dietary fats (P=0.039). In addition, changes in insulin (P=0.013) and C-peptide (P=0.008) concentrations were negatively correlated with changes in dietary fiber intake at dinner. After the intervention, 83.3% of initially MUHO participants became MHO and 16.7% of MHO participants became MUHO.

Conclusion

Eating behavior modification may be an important strategy to improve metabolic factors in overweight/obese people.

The association between low-carbohydrate diet score and metabolic syndrome among Iranian adults

OBJECTIVE

Assessing the relationship between low-carbohydrate diet (LCD) score and metabolic syndrome (Mets) in Iranian adults.

DESIGN

Cross-sectional study.

SETTING

Yazd Health Study and Taghzieh Mardom-e-Yazd study.

PARTICIPANTS

Data of 2074 participants were used. Dietary intakes were assessed by a validated semi-quantitative FFQ. LCD score was calculated for each person by summing up the assigned scores to deciles of energy percentages from macronutrients. Mets was evaluated using National Cholesterol Education Program Adult Treatment Panel III. Eventually, association between LCD score and Mets was examined using logistic regression.

RESULTS

Total Mets prevalence was approximately 40·5 %. After adjustment for confounders, subjects in the higher quartile of LCD score had a significant lower chance of Mets than lower quartile among all participants (Q4 v. Q1: OR: 0·68, 95 % CI (0·50, 0·92)) and separately in men (Q4 v. Q1: OR: 0·54, 95 % CI (0·34, 0·86)) and women (Q2 v. Q1: OR: 0·53, 95 % CI (0·34, 0·82)). Furthermore, more LCD adherence in men reduced abdominal obesity by 47 % (Q3 v. Q1: OR: 0·53, 95 % CI (0·28, 0·99)). A significant inverse relation was also observed between low HDL cholesterol and LCD score in all participants (Q4 versus Q1 OR: 0·74, 95% CI: 0·56-0·99) and separately in men (Q4 versus Q1 OR: 0·63, 95% CI: 0·40-0·98).

CONCLUSIONS

More adherence to LCD might be related to lower chance of Mets and some of its components such as low HDL-cholesterol and abdominal obesity specially in men. Further studies are required to confirm the findings.

A Step Closer to the "Fourth 90": A Practical Narrative Review of Diagnosis and Management of Nutritional Issues of People Living with HIV

The quality of life of people living with HIV (PLWH) has remarkably increased thanks to the introduction of combined antiretroviral therapy. Still, PLWH are exposed to an increased risk of cardiovascular diseases, diabetes, chronic kidney disease, and liver disease. Hence, the purpose of this review is to summarize the current knowledge about diagnosis and nutritional management with specific indication of macro and micronutrients intake for the main comorbidities of PLWH. In fact, a prompt diagnosis and management of lifestyle behaviors are fundamental steps to reach the "fourth 90". To achieve an early diagnosis of these comorbidities, clinicians have at their disposal algorithms such as the Framingham Score to assess cardiovascular risk; transient elastography and liver biopsy to detect NAFLD and NASH; and markers such as the oral glucose tolerance test and GFR to identify glucose impairment and renal failure, respectively. Furthermore, maintenance of ideal body weight is the goal for reducing cardiovascular risk and to improve diabetes, steatosis and fibrosis; while Mediterranean and low-carbohydrate diets are the dietetic approaches proposed for cardioprotective effects and for glycemic control, respectively. Conversely, diet management of chronic kidney disease requires different nutritional assessment, especially regarding protein intake, according to disease stage and eventually concomitant diabetes.

Adherence to Low Carbohydrate Diet in Relation to Chronic Obstructive Pulmonary Disease

Purpose: Data on the link between adherence to low-carbohydrate diet (LCD) and odds of chronic obstructive pulmonary disease (COPD) are scarce. The current study aimed to investigate the relation between adherence to LCD and COPD in Iranian adults.

Methods: In this hospital-based case-control study, we enrolled 84 newly-diagnosed COPD patients and 252 age and sex matched healthy controls in Alzahra University Hospital, Isfahan, Iran. COPD was defined based on findings of spirometry test (forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) < 70% or FEV1 < 80%). Dietary intakes of study participants were assessed using the validated Block-format 168-item FFQ. Data on potential confounders were also collected through the use of a pre-tested questionnaire.

Results: Mean age of cases and controls were 57.7 and 55.07 years, respectively. Adherence to LCD was inversely associated with odds of COPD (0.35; 95% CI: 0.16-0.75). This inverse association did not alter after controlling for age, sex, and energy intake (0.42; 95% CI: 0.19-0.93). Adjustments for other potential confounders, including dietary intakes, smoking, and educational status, did not affect these findings; such that those in the highest quintile of LCD score were 64% less likely to have COPD than those in the lowest quintile (OR: 0.36; 95% CI: 0.13-0.99).

Conclusion: We found an inverse association between adherence to LCD and odds of COPD. The association remained statistically significant even after taking other potential confounders, including socioeconomic characteristic and dietary intakes into account.

The effects of low-fat, high-carbohydrate diets vs. low-carbohydrate, high-fat diets on weight, blood pressure, serum liquids and blood glucose: a systematic review and meta-analysis

Our aim was to determine the relative effectiveness of two dietary macronutrient patterns (LFHC (low-fat, high-carbohydrate) diets and LCHF (low-carbohydrate, high-fat) diets) on weight loss and cardiovascular risk factors. We searched four databases including MEDLINE, EMBASE, Cochrane Library, and Web of Science to identify the eligible studies on March 13, 2020. Randomized clinical trials (RCT) were included which compared the effect of two diets (LFHC and LCHF) on weight loss, blood pressure, serum liquids, and blood glucose in overweight or obesity adults. Standardized mean difference (SMD) and 95% confidence interval (CI) were used for the pooled results. This paper included eleven studies involving 739 participants. Compared with LFHC diets, LCHF diets had a greater effect on weight loss (SMD = -1.01 kg; 95% CI -1.99 to -0.04, p = 0.04) and HDL-cholesterol changes (SMD = 0.82 mmol/l; 95% CI 0.43 to 1.21, p < 0.0001), but a smaller effect on total cholesterol decrease (SMD = 0.63 mmol/l; 95% CI 0.18-1.08, p = 0.006) and LDL-cholesterol decrease (SMD = 0.59 mmol/l; 95% CI 0.11-1.18, p = 0.05). Between the two groups, changes in lean mass, fat mass, systolic blood pressure, diastolic blood pressure, triglycerides, and glucose were non-significant. To conclude, both diets are effective for weight control and reduction of cardiovascular risk factors. And further studies with long-term follow-up are needed to confirm our results.

The Potential Health Benefits of the Ketogenic Diet: A Narrative Review

Considering the lack of a comprehensive, multi-faceted overview of the ketogenic diet (KD) in relation to health issues, we compiled the evidence related to the use of the ketogenic diet in relation to its impact on the microbiome, the epigenome, diabetes, weight loss, cardiovascular health, and cancer. The KD diet could potentially increase genetic diversity of the microbiome and increase the ratio of Bacteroidetes to Firmicutes. The epigenome might be positively affected by the KD since it creates a signaling molecule known as β-hydroxybutyrate (BHB). KD has helped patients with diabetes reduce their HbA1c and reduce the need for insulin. There is evidence to suggest that a KD can help with weight loss, visceral adiposity, and appetite control. The evidence also suggests that eating a high-fat diet improves lipid profiles by lowering low-density lipoprotein (LDL), increasing high-density lipoprotein (HDL), and lowering triglycerides (TG). Due to the Warburg effect, the KD is used as an adjuvant treatment to starve cancer cells, making them more vulnerable to chemotherapy and radiation. The potential positive impacts of a KD on each of these areas warrant further analysis, improved studies, and well-designed randomized controlled trials to further illuminate the therapeutic possibilities provided by this dietary intervention.

Longitudinal association of dietary carbohydrate and the risk cardiovascular disease: a dose-response meta-analysis

Previous findings on the association of dietary carbohydrate with cardiovascular disease (CVD) events and mortality are inconsistent. We aimed to assess the relationship between dietary carbohydrate and the incidence of cardiovascular events and mortality. A comprehensive literature search of MEDLINE (PubMed), Scopus, ISI Web of Science, and EMBASE, was performed up to June 2019. Prospective cohort studies which examined dietary carbohydrate in relation to fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, heart failure, and sudden cardiac death were included in our study. Summary HRs and 95% CIs were estimated using a random-effects model. A total of 19 cohort studies including 15,663,111 participants were identified. Combining 27 effect sizes with 1,577,225 CVD cases led to a significant association between dietary carbohydrate and total CVD events (HR= 1.05, 95% CI: 1.00, 1.10; I² = 38.5%), but no association was observed between dietary carbohydrate and CVD mortality (HR = 1.02; 95% CI: 0.91, 1.14; I²=27.1%, derived from 8 effect sizes with 106,412 events), and CHD events (HR = 1.03, 95% CI: 0.98, 1.09; I² = 46.6%, derived from 18 effect sizes with 1,549,281 events). Moreover, using 8 effect sizes with 6,829 cases, higher carbohydrate intake was associated with increased risk of stroke (HR = 1.13; 95% CI: 1.01, 1.27; I²= 0.0%). In subgroup analysis by sex, higher carbohydrate intake increased the risk of total CVD events (HR: 1.10; 95% CI: 1.03, 1.17; I² = 0.0%), and CHD (HR: 1.10; 95% CI: 1.01, 1.20; I²= 15.0%), but not stroke and CVD mortality in women. No significant association was found in men. Low- to very-low-certainty evidence suggests that higher carbohydrate intake is directly but slightly associated with CVD and stroke risk, while no association was found for CHD and CVD mortality. We also found sex-specific associations.

Fat, Sugar or Gut Microbiota in Reducing Cardiometabolic Risk: Does Diet Type Really Matter?

The incidence of cardiometabolic diseases, such as obesity, diabetes, and cardiovascular diseases, is constantly rising. Successful lifestyle changes may limit their incidence, which is why researchers focus on the role of nutrition in this context. The outcomes of studies carried out in past decades have influenced dietary guidelines, which primarily recommend reducing saturated fat as a therapeutic approach for cardiovascular disease prevention, while limiting the role of sugar due to its harmful effects. On the other hand, a low-carbohydrate diet (LCD) as a method of treatment remains controversial. A number of studies on the effect of LCDs on patients with type 2 diabetes mellitus proved that it is a safe and effective method of dietary management. As for the risk of cardiovascular diseases, the source of carbohydrates and fats corresponds with the mortality rate and protective effect of plant-derived components. Additionally, some recent studies have focused on the gut microbiota in relation to cardiometabolic diseases and diet as one of the leading factors affecting microbiota composition. Unfortunately, there is still no precise answer to the question of which a single nutrient plays the most important role in reducing cardiometabolic risk, and this review article presents the current state of the knowledge in this field.

C. S, Basnet R, Neupane B. Dietary nutrients of relative importance associated with coronary artery disease: Public health implication from random forest analysis

Dietary nutrients have significant effects on the risk of cardiovascular diseases. However, the results were not uniform across different countries. The study aims to determine the relative importance of dietary nutrients associated with coronary artery disease (CAD) among the Nepalese population. A hospital-based matched case-control study was carried out at Shahid Gangalal National Heart Center in Nepal. In the present study, patients with more than seventy percent stenosis in any main coronary artery branch in angiography were defined as cases, while those presenting normal coronary angiography or negative for stressed exercise test were considered controls. Dietary intakes of 612 respondents over the past 12 months were evaluated using a semi-quantitative customized food frequency questionnaire. In conditional regression model, the daily average dietary intake of β-carotene (OR: 0.54; 95%CI: 0.34, 0.87), and vitamin C (OR: 0.96; 95%CI: 0.93, 0.99) were inversely, whereas dietary carbohydrate (OR: 1.16; 95%CI: 1.1, 1.24), total fat/oil (OR: 1.47; 95%CI: 1.27, 1.69), saturated fatty acid (SFA) (OR: 1.2; 95%CI: 1.11, 1.3), cholesterol (OR: 1.01; 95%CI: 1.001, 1.014), and iron intakes (OR: 1.11; 95%CI: 1.03, 1.19) were positively linked with CAD. Moreover, in random forest analysis, the daily average dietary intakes of SFA, vitamin A, total fat/oil, β-carotene, and cholesterol were among the top five nutrients (out of 12 nutrients variables) of relative importance associated with CAD. The nutrients of relative importance imply a reasonable preventive measure in public health nutrients specific intervention to prevent CAD in a resource-poor country like Nepal. The findings are at best suggestive of a possible relationship between these nutrients and the development of CAD, but prospective cohort studies and randomized control trials will need to be performed in the Nepalese population.

Low carbohydrate diet: are concerns with saturated fat, lipids, and cardiovascular disease risk justified?

PURPOSE OF REVIEW

There is an extensive literature on the efficacy of the low carbohydrate diet (LCD) for weight loss, and in the improvement of markers of the insulin-resistant phenotype, including a reduction in inflammation, atherogenic dyslipidemia, hypertension, and hyperglycemia. However, critics have expressed concerns that the LCD promotes unrestricted consumption of saturated fat, which may increase low-density lipoprotein (LDL-C) levels. In theory, the diet-induced increase in LDL-C increases the risk of cardiovascular disease (CVD). The present review provides an assessment of concerns with the LCD, which have focused almost entirely on LDL-C, a poor marker of CVD risk. We discuss how critics of the LCD have ignored the literature demonstrating that the LCD improves the most reliable CVD risk factors.

RECENT FINDINGS

Multiple longitudinal clinical trials in recent years have extended the duration of observations on the safety and effectiveness of the LCD to 2-3 years, and in one study on epileptics, for 10 years.

SUMMARY

The present review integrates a historical perspective on the LCD with a critical assessment of the persistent concerns that consumption of saturated fat, in the context of an LCD, will increase risk for CVD.

Ketone metabolism in the failing heart

The high energy demands of the heart are met primarily by the mitochondrial oxidation of fatty acids and glucose. However, in heart failure there is a decrease in cardiac mitochondrial oxidative metabolism and glucose oxidation that can lead to an energy starved heart. Ketone bodies are readily oxidized by the heart, and can provide an additional source of energy for the failing heart. Ketone oxidation is increased in the failing heart, which may be an adaptive response to lessen the severity of heart failure. While ketone have been widely touted as a "thrifty fuel", increasing ketone oxidation in the heart does not increase cardiac efficiency (cardiac work/oxygen consumed), but rather does provide an additional fuel source for the failing heart. Increasing ketone supply to the heart and increasing mitochondrial ketone oxidation increases mitochondrial tricarboxylic acid cycle activity. In support of this, increasing circulating ketone by iv infusion of ketone bodies acutely improves heart function in heart failure patients. Chronically, treatment with sodium glucose co-transporter 2 inhibitors, which decreases the severity of heart failure, also increases ketone body supply to the heart. While ketogenic diets increase circulating ketone levels, minimal benefit on cardiac function in heart failure has been observed, possibly due to the fact that these dietary regimens also markedly increase circulating fatty acids. Recent studies, however, have suggested that administration of ketone ester cocktails may improve cardiac function in heart failure. Combined, emerging data suggests that increasing cardiac ketone oxidation may be a therapeutic strategy to treat heart failure.

Glycemic index, glycemic load, and risk of coronary heart disease: a pan-European cohort study

BACKGROUND

High carbohydrate intake raises blood triglycerides, glucose, and insulin; reduces HDLs; and may increase risk of coronary heart disease (CHD). Epidemiological studies indicate that high dietary glycemic index (GI) and glycemic load (GL) are associated with increased CHD risk.

OBJECTIVES

The aim of this study was to determine whether dietary GI, GL, and available carbohydrates are associated with CHD risk in both sexes.

METHODS

This large prospective study-the European Prospective Investigation into Cancer and Nutrition-consisted of 338,325 participants who completed a dietary questionnaire. HRs with 95% CIs for a CHD event, in relation to intake of GI, GL, and carbohydrates, were estimated using covariate-adjusted Cox proportional hazard models.

RESULTS

After 12.8 y (median), 6378 participants had experienced a CHD event. High GL was associated with greater CHD risk [HR 1.16 (95% CI: 1.02, 1.31) highest vs. lowest quintile, p-trend 0.035; HR 1.18 (95% CI: 1.07, 1.29) per 50 g/day of GL intake]. The association between GL and CHD risk was evident in subjects with BMI (in kg/m2) ≥25 [HR: 1.22 (95% CI: 1.11, 1.35) per 50 g/d] but not in those with BMI <25 [HR: 1.09 (95% CI: 0.98, 1.22) per 50 g/d) (P-interaction = 0.022). The GL-CHD association did not differ between men [HR: 1.19 (95% CI: 1.08, 1.30) per 50 g/d] and women [HR: 1.22 (95% CI: 1.07, 1.40) per 50 g/d] (test for interaction not significant). GI was associated with CHD risk only in the continuous model [HR: 1.04 (95% CI: 1.00, 1.08) per 5 units/d]. High available carbohydrate was associated with greater CHD risk [HR: 1.11 (95% CI: 1.03, 1.18) per 50 g/d]. High sugar intake was associated with greater CHD risk [HR: 1.09 (95% CI: 1.02, 1.17) per 50 g/d].

CONCLUSIONS

This large pan-European study provides robust additional support for the hypothesis that a diet that induces a high glucose response is associated with greater CHD risk.

Nutrigenetics-personalized nutrition in obesity and cardiovascular diseases

Epidemiological data support the view that both obesity and cardiovascular diseases (CVD) account for a high proportion of total morbidity and mortality in adults throughout the world. Obesity and CVD have complex interplay mechanisms of genetic and environmental factors, including diet. Nutrition is an environmental factor and it has a predominant and recognizable role in health management and in the prevention of obesity and obesity-related diseases, including CVD. However, there is a marked variation in CVD in patients with obesity and the same dietary pattern. The different genetic polymorphisms could explain this variation, which leads to the emergence of the concept of nutrigenetics. Nutritional genomics or nutrigenetics is the science that studies and characterizes gene variants associated with differential response to specific nutrients and relating this variation to various diseases, such as CVD related to obesity. Thus, the personalized nutrition recommendations, based on the knowledge of an individual's genetic background, might improve the outcomes of a specific dietary intervention and represent a new dietary approach to improve health, reducing obesity and CVD. Given these premises, it is intuitive to suppose that the elucidation of diet and gene interactions could support more specific and effective dietary interventions in both obesity and CVD prevention through personalized nutrition based on nutrigenetics. This review aims to briefly summarize the role of the most important genes associated with obesity and CVD and to clarify the knowledge about the relation between nutrition and gene expression and the role of the main nutrition-related genes in obesity and CVD.

Low-carbohydrate diet and cardiovascular diseases in Iranian population: Tehran Lipid and Glucose Study

BACKGROUND AND AIMS

Studies indicated that the risk of cardiovascular disease (CVD) in association to greater adherence to low-carbohydrate diet (LCD) differs in various populations. In this study, we aimed to assess the association of LCD score with the risk of CVD events in a prospective population-based study.

METHODS AND RESULTS

CVD-free participants (n = 2188) were recruited from the Tehran Lipid and Glucose Study (2006-2008) and followed for a mean of 6.7 years. Using a valid and reliable 168 item semi-quantitative food frequency questionnaire, the LCD score was determined based on the percentage of energy as carbohydrate, protein, and fat, which ranged from 0 to 12. Cox proportional hazard regression models, adjusted for potential confounders, were used to estimate the hazard ratios (HRs) and 95% confidence interval (CI) of CVD across tertiles of LCD score in women and men. Mean ± SD age of participants (44.8% male) was 38.8 ± 13.0 years, and median (25-75, interquartile range) of the LCD score was 6 (4-8) at baseline. During follow-up, 77 (3.5%) new cases of CVD were identified. After adjustment for sex, age, body mass index, physical activity, smoking, energy intake, diabetes, and hypertension, there was no association between the LCD score and risk of CVD outcomes in all participants (HR = 0.93; 95% CI: 0.86-1.02) and women (HR = 1.13; 95% CI: 0.94-1.36); however, the LCD score was associated with an 11% reduced incidence of CVD events in men (HR = 0.89; 95% CI: 0.80-0.98), (P for trend: 0.028).

CONCLUSION

Findings showed that higher adherence to LCD may be associated with a lower risk of CVD outcomes in men but not in women.

The Effects of Different Degrees of Carbohydrate Restriction and Carbohydrate Replacement on Cardiometabolic Risk Markers in Humans-A Systematic Review and Meta-Analysis

Low-carbohydrate diets (LCDs) often differ in their diet composition, which may lead to conflicting results between randomized controlled trials. Therefore, we aimed to compare the effects of different degrees of carbohydrate (CHO) restriction on cardiometabolic risk markers in humans. The experimental LCDs of 37 human trials were classified as (1) moderate-low CHO diets (<45–40 E%, n = 13), (2) low CHO diets (<40–30 E%, n = 16), and (3) very-low CHO diets (<30–3 E%; n = 8). Summary estimates of weighted mean differences (WMDs) in selected risk markers were calculated using random-effect meta-analyses. Differences between the LCD groups were assessed with univariate meta-regression analyses. Overall, the LCDs resulted in significant weight loss, reduced diastolic blood pressure BP, and increased total cholesterol and high-density lipoprotein cholesterol (HDL-C), without significant differences between the three LCD groups. Higher low-density lipoprotein cholesterol (LDL-C) concentrations were found with the very-low CHO diets compared to the moderate-low CHO diets. Decreases in triacylglycerol (TAG) concentrations were more pronounced with the low and very-low CHO diets, compared to the moderate-low CHO diets. Substitution of CHO by mainly saturated fatty acids (SFAs) increased total cholesterol, LDL-C, and HDL-C concentrations. Except for LDL-C and TAGs, effects were not related to the degree of CHO restriction. Potential effects of nutrient exchanges should be considered when following LCDs.

Non-Systematic Review of Diet and Nutritional Risk Factors of Cardiovascular Disease in Obesity

Although cardiovascular disease and its risk factors have been widely studied and new methods of diagnosis and treatment have been developed and implemented, the morbidity and mortality levels are still rising-cardiovascular disease is responsible for more than four million deaths each year in Europe alone. Even though nutrition is classified as one of the main and changeable risk factors, the quality of the diet in the majority of people does not follow the recommendations essential for prevention of obesity and cardiovascular disease. It demonstrates the need for better nutritional education in cardiovascular disease prevention and treatment, and the need to emphasize dietary components most relevant in cardiovascular disease. In our non-systematic review, we summarize the most recent knowledge about nutritional risk and prevention in cardiovascular disease and obesity.

Animal based low carbohydrate diet is associated with increased risk of type 2 diabetes in Tehranian adults

BACKGROUND

To investigate the association of low carbohydrate diet (LCD) score with the risk of type 2 diabetes among adults.

METHODS

This cohort study was conducted on 4356 healthy participants aged ≥ 19 years old, who were followed-up for a mean duration of 3 years within the framework of the Tehran Lipid and Glucose Study. LCD score was calculated using a food frequency questionnaire according to intake of carbohydrate, protein, and fat at baseline. Diabetes was defined according to the criteria of the American Diabetes Association. Multivariable logistic regression models, adjusted for potential confounders, were used to estimate risk of diabetes across quartiles of LCD score.

RESULTS

Mean ± SD age of the study participants (44.4% men) was 40.5 ± 13.0 years. The median (25-75 interquartile range) of LCD score was 17.0 (12.0-21.0) and after a 3 year follow-up period, 123 (2.8%) incident cases of diabetes were ascertained. After adjustment for confounding variables, including age, sex, smoking status, physical activity, total calorie intake, saturated fatty acid, waist circumference, educational level, and family history of diabetes, the multivariable-adjusted ORs (95% CIs) of type 2 diabetes, comparing the highest with the lowest quartiles, were 2.16 (1.16-4.04) for total LCD score (P-value = 0.015), 1.81 (1.06-3.11) for animal-based LCD score (P-value = 0.029), and 1.47 (0.85-2.52) for plant-based LCD score (P-value = 0.160).

CONCLUSION

Our findings suggest that a higher adherence to LCD, mostly with higher intakes of protein and fat from animal-source foods, can increase the incidence of diabetes; however, a plant-based low-carbohydrate dietary pattern is not significantly associated with risk of type 2 diabetes.

Racial differences of incident diabetes postpartum in women with a history of gestational diabetes

AIMS

The aim of the present study was to investigate the race-specific association between a history of gestational diabetes mellitus (GDM) and incidence of type 2 diabetes and evaluate how the risk changed over different years after delivery.

METHODS

We performed two large cohorts - the Coronary Artery Risk Development in Young Adults (CARDIA) cohort and the Tianjin GDM Observational Study. The multivariate cox regression model was used to assess the risk of incident postpartum diabetes between women with and without prior GDM.

RESULTS

During a mean follow-up of 13.8 years, 405 women developed type 2 diabetes. After adjustment for multiple confounding factors, Chinese women with GDM had a higher risk of incident diabetes within 5 years postpartum than African Americans with GDM compared with Chinese and African Americans without GDM (Hazard ratio 71.5 in Chinese vs. 9.29 in African Americans). When the risk of incident diabetes was analyzed within 10 years, white women with GDM seemed to have a higher hazard ratio than African American and Chinese women with GDM compared with non-GDM women of different races. In comparison to African American women without GDM, the highest risk of type 2 diabetes over 10 years postpartum appeared in Chinese women with GDM, followed by African American women with GDM, and the smallest risk was seen in white women with GDM.

CONCLUSIONS

Different genetic backgrounds and other risk factors among women of different races might contribute to the racial differences in the incidence of diabetes postpartum among women with GDM.

Overview of Meta-Analyses: The Impact of Dietary Lifestyle on Stroke Risk

A stroke is one of the most prevalent cardiovascular diseases worldwide, both in high-income countries and in medium and low-medium income countries. The World Health Organization's (WHO) report on non-communicable diseases (NCDs) indicates that the highest behavioral risk in NCDs is attributable to incorrect nutrition. The objective of our work is to present an overview of meta-analyses that have investigated the impact of different foods and/or drinks in relationship with the risk of stroke events (ischemic/hemorrhagic). The papers to be included in the overview were found in MEDLINE, EMBASE, Scopus, Clinicaltrials.gov, Web of Science, and Cochrane Library and were selected according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart. Quality assessment were made according to the AMSTAR 2 scale. This overview shows that all primary studies came from countries with high income levels. This evidence shows that many countries are not represented. Therefore, different lifestyles, ethnic groups, potentially harmful or virtuous eating habits are not reported. It is important to underline how the choose of foods may help reduce the risk of cardiovascular diseases and stroke in particular.

Association of low-carbohydrate diet score with overweight, obesity and cardiovascular disease risk factors: a cross-sectional study in Iranian women

Introduction: This study aimed to determine the association of low-carbohydrate-diet score with overweight, obesity and cardiovascular risk factors among Iranian women. Methods: In healthy Iranian women 20-50 years, demographics, anthropometrics, physical activity, blood pressure, fasting blood glucose, blood lipids, and dietary intake (using a validated food frequency questionnaire) were assessed. Participants were divided into deciles of macronutrient intakes. Women in the lowest decile of carbohydrate intake received a score of 9 and women in the highest decile received a score of 0. For protein and fat intakes, women in the lowest decile received a score of 0 for that macronutrient and those in the highest decile received the score of 9. Macronutrient scores were summed to create the low-carbohydrate diet score and women were grouped into tertiles based on these scores. Continuous and qualitative variables were compared among the low-carbohydrate-diet score by one-way ANOVA and chi-square test, respectively. Logistic regression was used to determine the association of low-carbohydrate-diet score and cardiovascular risk factors. Results: A total of 209 women were included in the study. Socioeconomic status significantly increased from tertile 1 to 3 of the low-carbohydrate diet score (P = 0.02). Total dietary glycemic index (GI) significantly differed among tertiles (tertile 1 GI: 63.1 ±0.50, tertile 2 GI: 61.9 ± 0.5, tertile 3 GI: 59.5 ± 0.5; P < 0.001). The odds ratios for overweight, obesity and cardiovascular risk factors were not significantly different among the tertiles of low-carbohydrate diet score. Conclusion: In Iranian women, diets lower in carbohydrate and higher in protein and fat were not associated with overweight, obesity and cardiovascular risk factors.

The 'epileptic diet'- ketogenic and/or slow release of glucose intervention: A review

BACKGROUND & AIMS

The ketogenic diet is high in fat content, adequate with respect to protein but low in carbohydrate and designed to provide brain energy as ketone bodies rather than glucose. The consequence is that epilepsy can be managed and endurance (sport) related energy be derived from fat rather than ingested or stored (glycogen) carbohydrate. This review aims to set the diet in context for seizure related intervention, sport and potential modern variants with respect to glucose management - which have many medical (including epilepsy potentially) and activity related applications.

METHODS

The literature was reviewed using relevant data bases (e.g. Pubmed, Science Direct, Web of Science, Wiley on Line Library) and relevant articles were selected to provide historic and contemporary data for the text and associated Tables.

RESULTS

It is clear great health related benefits have been achieved by feeding the ketogenic to individuals subject to seizures where it helps manage the malaise. Sports applications are evident to. Glucose control diets provide health benefits of the ketogenic diet potentially and there is some evidence they are/can be very effective.

CONCLUSIONS

Key to epilepsy and sport performance is the control of blood glucose. The ketogenic diet has proven to be very effective in this regard but now other approaches to control blood glucose ae being evaluated which have advantages over the ketogenic diet. This therapeutic approach of clinical nutrition will undoubtedly move forwards over the next few years in view of the negative aspects of the ketogenic diet.

Association of habitual glucosamine use with risk of cardiovascular disease: prospective study in UK Biobank

OBJECTIVE

To prospectively assess the association of habitual glucosamine use with risk of cardiovascular disease (CVD) events.

DESIGN

Prospective cohort study.

SETTING

UK Biobank.

PARTICIPANTS

466 039 participants without CVD at baseline who completed a questionnaire on supplement use, which included glucosamine. These participants were enrolled from 2006 to 2010 and were followed up to 2016.

MAIN OUTCOME MEASURES

Incident CVD events, including CVD death, coronary heart disease, and stroke.

RESULTS

During a median follow-up of seven years, there were 10 204 incident CVD events, 3060 CVD deaths, 5745 coronary heart disease events, and 3263 stroke events. After adjustment for age, sex, body mass index, race, lifestyle factors, dietary intakes, drug use, and other supplement use, glucosamine use was associated with a significantly lower risk of total CVD events (hazard ratio 0.85, 95% confidence interval 0.80 to 0.90), CVD death (0.78, 0.70 to 0.87), coronary heart disease (0.82, 0.76 to 0.88), and stroke (0.91, 0.83 to 1.00).

CONCLUSION

Habitual use of glucosamine supplement to relieve osteoarthritis pain might also be related to lower risks of CVD events.

Lower carbohydrate diets and all-cause and cause-specific mortality: a population-based cohort study and pooling of prospective studies

Aims

Little is known about the long-term association between low-carbohydrate diets (LCDs) and mortality. We evaluated the link between LCD and overall or cause-specific mortality using both individual data and pooled prospective studies.

Methods and results

Data on diets from the National Health and Nutrition Examination Survey (NHANES; 1999–2010) were analysed. Multivariable Cox proportional hazards were applied to determine the hazard ratios and 95% confidence intervals (CIs) for mortality for each quartile of the LCD score, with the lowest quartile (Q1—with the highest carbohydrates intake) used as reference. We used adjusted Cox regression to determine the risk ratio (RR) and 95% CI, as well as random effects models and generic inverse variance methods to synthesize quantitative and pooled data, followed by a leave-one-out method for sensitivity analysis. Overall, 24 825 participants from NHANES study were included (mean follow-up 6.4 years). After adjustment, participants with the lowest carbohydrates intake (quartile 4 of LCD) had the highest risk of overall (32%), cardiovascular disease (CVD) (50%), cerebrovascular (51%), and cancer (36%) mortality. In the same model, the association between LCD and overall mortality was stronger in the non-obese (48%) than in the obese (19%) participants. Findings on pooled data of nine prospective cohort studies with 462 934 participants (mean follow-up 16.1 years) indicated a positive association between LCD and overall (RR 1.22, 95% CI 1.06–1.39, P < 0.001, I2 = 8.6), CVD (RR 1.13, 95% CI 1.02–1.24, P < 0.001, I2 = 11.2), and cancer mortality (RR 1.08, 95% CI 1.01–1.14, P = 0.02, I2 = 10.3). These findings were robust in sensitivity analyses.

Conclusion

Our study suggests a potentially unfavourable association of LCD with overall and cause-specific mortality, based on both new analyses of an established cohort and by pooling previous cohort studies. Given the nature of the study, causality cannot be proven; we cannot rule out residual bias. Nevertheless, further studies are needed to extend these important findings, which if confirmed, may suggest a need to rethink recommendations for LCD in clinical practice.

Effects of "plate model" as a part of dietary intervention for rehabilitation following myocardial infarction: a randomized controlled trial

Background

Reducing body weight by nutritional management is an integral element of cardiac rehabilitation and in secondary prevention of cardiovascular diseases. Administration of a "plate model" is one practical aspect to control calorie intake. The study aimed to evaluate the effectiveness of the plate model as a part of dietary modification in losing excess weight in post-myocardial infarction (MI) patients.

Methods

An interventional, randomized, single-blinded study with parallel subject allocation was conducted among patients with a history of troponin-positive acute coronary syndrome (ACS). A total of 120 patients were recruited to intervention and control groups. The Intervention cluster was provided with 'plate model' and both groups received standard cardiac rehabilitation care. Anthropometric, clinical and metabolic parameters were measured at recruitment and repeated during 4th and 12th week.

Results

A sample of 79 patients (the intervention group: 40, the control group: 39) completed the study. At the end of 12 weeks participants in the intervention group exhibited a significant weight loss (-1.27±3.58 vs. -0.26±2.42 kg; P=0.029) and a significant reduction in BMI (-0.48±1.31 vs. -0.10±0.89 kg/m²; P=0.023). Overweight and obese patients (BMI >23 kg/m²) displayed greater weight loss (-2.13±3.46 vs. 0.12±2.62 kg; P=0.013). Many of overweight and obese patients in the test group (35.7%) experienced a weight loss ≥5% compared to the control group (13.04%) which was a nearly significant result (P=0.065). No significant changes observed in other metabolic parameters.

Conclusions

Plate model is an effective dietary intervention in view of weight reduction in post-MI patients.

Low-carbohydrate diets and prevalence, incidence and progression of coronary artery calcium in the Multi-Ethnic Study of Atherosclerosis (MESA)

The evidence linking low-carbohydrate diets (LCD) to CVD is controversial, and results from epidemiological studies are inconsistent. We aimed to assess the relationship between LCD patterns and coronary artery Ca (CAC) scores from computed tomography in the Multi-Ethnic Study of Atherosclerosis cohort. Our sample included 5614 men and women free of clinical CVD at baseline (2000-2002), who had a FFQ, a baseline measure and ≥1 measure of CAC during follow-up. We excluded those with implausible energy intake or daily physical activity. The overall, animal-based and plant-based LCD scores were calculated based on intakes of macronutrients. Relative risk regression and robust regression models were used to examine the cross-sectional and longitudinal relationship between LCD score quintile and CAC outcomes, after adjustment for multiple cardiovascular risk factors. The mean age of participants was 63 years. The median intakes of total carbohydrate, fat and protein were 53·7, 30·5 and 15·6 % energy/d, respectively. Among 2892 participants with zero CAC scores at baseline, 264 developed positive scores during 2·4-year follow-up (11-59 months). Among those with positive scores at baseline, the median increase in CAC was 47 units over the course of follow-up. The overall, the animal-based and the plant-based LCD scores were not associated with CAC prevalence, incidence and progression. In conclusion, diets low in carbohydrate and high in fat and/or protein, regardless of the sources of protein and fat, were not associated with higher levels of CAC, a validated predictor of cardiovascular events, in this large multi-ethnic cohort.

The association between the DNAH11 rs10248618 SNP and serum lipid traits, the risk of coronary artery disease, and ischemic stroke

Previous genome-wide association studies have shown that the rs10248618 single nucleotide polymorphism (SNP) in the dynein axonemal heavy chain 11 gene (DNAH11) has been associated with serum high-density lipoprotein cholesterol (HDL-C) levels. However, little is known about such association in the Chinese population. The present study was performed to clarify the association between the DNAH11 rs10248618 SNP and serum lipid traits and the risk of coronary artery disease (CAD) and ischemic stroke (IS) in the Guangxi Han population. Genotypes of the DNAH11 rs10248618 SNP in 1,213 unrelated patients (CAD, 600 and IS, 613) and 631 healthy controls were determined by snapshot technology. The genotypic and allelic frequencies of the SNP were significantly different between the CAD/IS patients and the controls (P < 0.01 for all). The CT/TT genotypes and the T allele were associated with an increased risk of CAD and IS (CAD: P < 0.01 for CT/TT vs. CC and T vs. C; IS: P < 0.01 for CT/TT vs. CC and T vs. C). The CT/TT genotypes in the healthy controls, but not in CAD or IS patients, were associated with a decreased serum HDL-C and apolipoprotein (Apo) A1 concentration. These results suggest that the DNAH11 rs10248618 SNP is associated with the risk of CAD and IS in our study population. It is likely to increase the risk of CAD and IS by reducing serum HDL-C and ApoA1 levels.

A review and critique of published real-world weight management program studies

BACKGROUND

Beyond the essential but somewhat artificial conditions that typify formal clinical studies, real-world evidence (RWE) of weight loss program effectiveness is paramount for an accurate assessment of such programs and refinement of best practices.

OBJECTIVES

To evaluate the current state of RWE studies and publications on weight loss, identify the range of weight loss components being used in RWE programs, and to provide a general overview of the consistency or lack of consistency with regard to measuring and reporting outcomes.

METHODS

A structured search of PubMed was performed to identify relevant English-language publications from 2006 to December 2017 that reported real-world studies of weight loss among adults. Duplicates, non-relevant publications, articles on weight loss surgery, pediatric studies, randomized controlled trials, studies with self-reported weight loss, no objective weight measures, or that failed to include weight loss results were excluded.

RESULTS

This review included 62 RWE publications. Forty-nine studies included dietary intervention, 37 included exercise, 29 included motivational counseling, and 5 contained some patients who had pharmacologic treatment as part of their weight loss regimen. The numbers of participants per study ranged from 10 to more than 3 million. The interventions reported in the publications included diet, exercise, counseling to promote diet and/or exercise, motivational counseling, and pharmacotherapy, and various combinations of these.

CONCLUSIONS

Despite general acceptance that weight loss programs are capable of facilitating successful outcomes, this review revealed substantial inconsistency in the design and reporting of such programs, making it very difficult to draw conclusions about the comparative merits of different real-world weight loss strategies/components. In addition, there was a marked lack of congruence with current weight loss management guidelines, and notably few studies incorporating anti-obesity medications. There clearly is a need for greater rigor and standardization among designing and reporting RWE weight-loss studies.

Improved General and Oral Health in Diabetic Patients by an Okinawan-Based Nordic Diet: A Pilot Study

Periodontal disease, periodontitis as well as the preceding gingivitis, has been associated with both obesity and diabetes. Studies have shown that diet changes can lead to a lower incidence of such inflammation. The aim of the present case series over four weeks was to study the effects on medical and dental conditions in patients with type 2 diabetes of the consumption of the Okinawan-based Nordic Diet (OBND^®). Medical and dental examinations were performed to estimate the general health and gingivitis/periodontitis. Serum cytokine levels were assessed using Luminex technology. Eight of ten study participants completed the study. All participants lost weight (p = 0.012). Six out of seven that were treated with insulin could reduce their insulin intake after two weeks with OBND^®. The reduction was about 16 units which corresponds to a 34% relative reduction compared to the starting point (range 15–63%). Fasting blood glucose values fell (p = 0.035). Hemoglobin A1c (HbA1c) (p = 0.01), triglycerides (p = 0.05), and low-density lipoprotein (LDL) (p = 0.05) were also reduced. Bleeding on probing changed from ~28% before any dietary changes to ~13% after two weeks with OBND^® (p = 0.01). The reduction in gingival bleeding was as substantial as might be expected from one session of professional tooth cleaning. Markers of inflammation were also reduced. The OBND^® thus showed significant promise in alleviating the impact of diabetes on dental as well as general health.

Dietary Patterns in Secondary Prevention of Heart Failure: A Systematic Review

BACKGROUND

Diet is an important factor in secondary prevention of heart failure (HF) but there is still no consensus as to which dietary model should be adopted by this population. This systematic review aims to clarify the relationship between dietary patterns and secondary prevention in HF.

METHODS

We searched the Medline, Embase and Cochrane databases for studies with different dietary patterns and outcomes of secondary prevention in HF. No limitation was used in the search.

RESULTS

1119 articles were identified, 12 met the inclusion criteria. Studies with Dietary Approaches to Stop Hypertension (DASH), Mediterranean, Hyperproteic and Low-carb diets were found. The DASH pattern showed improvement in cardiac function, functional capacity, blood pressure, oxidative stress and mortality. The Mediterranean diet had a correlation with inflammation, quality of life and cardiac function but just on cross-sectional studies. Regarding the Hyperproteic and Low-carb diets only one study was found with each pattern and both were able to improve functional capacity in patients with HF.

CONCLUSIONS

DASH pattern may have benefits in the secondary prevention of HF. The Mediterranean diet demonstrated positive correlation with factors of secondary prevention of HF but need more RCTs and cohort studies to confirm these effects. In addition, the Hyperproteic and Low-carb diets, despite the lack of studies, also demonstrated positive effects on the functional capacity in patients with HF.

The Effect of Lean-Seafood and Non-Seafood Diets on Fasting and Postprandial Serum Metabolites and Lipid Species: Results from a Randomized Crossover Intervention Study in Healthy Adults

The metabolic effects associated with intake of different dietary protein sources are not well characterized. We aimed to elucidate how two diets that varied in main protein sources affected the fasting and postprandial serum metabolites and lipid species. In a randomized controlled trial with crossover design, healthy adults (n = 20) underwent a 4-week intervention with two balanced diets that varied mainly in protein source (lean-seafood versus non-seafood proteins). Nuclear magnetic resonance spectroscopy and liquid chromatography-mass spectrometry analyses were applied to examine the effects of the two diets on serum metabolites. In the fasting state, the lean-seafood diet period, as opposed to the non-seafood diet period, significantly decreased the serum levels of isoleucine and valine, and during the postprandial state, a decreased level of lactate and increased levels of citrate and trimethylamine N-oxide were observed. The non-seafood diet significantly increased the fasting level of 26 lipid species including ceramides 18:1/14:0 and 18:1/23:0 and lysophosphatidylcholines 20:4 and 22:5, as compared to the lean-seafood diet. Thus, the lean-seafood diet decreased circulating isoleucine and valine levels, whereas the non-seafood diet elevated the levels of certain ceramides, metabolites that are associated with insulin-resistance.

Diet and primary prevention of stroke: Systematic review and dietary recommendations by the ad hoc Working Group of the Italian Society of Human Nutrition

BACKGROUND AND AIMS

To systematically review the latest evidence on established and emerging nutrition-related risk factors for incidence of and mortality from total, ischemic and haemorrhagic strokes. The present review was conducted in the framework of the work carried out through 2015 and 2016 for the preparation of the Italian Guidelines for the Prevention and Treatment of Stroke, 8th Edition, by ISO-SPREAD (Italian Stroke Organization and the Stroke Prevention and Educational Awareness Diffusion).

METHODS AND RESULTS

Systematic review of articles focused on primary prevention of stroke published between January 2013 to May 2016 through an extensive search of the literature using MEDLINE/PUBMED, EMBASE and the Cochrane Library. Articles were ranked according to the SIGN methodology while the GRADE system was used to establish the strength of recommendations. As a result of our literature search, we examined 87 meta-analyses overall (mainly of prospective studies), a few isolated more recent prospective studies not included in the meta-analyses, and a smaller number of available randomized controlled trials and case-control studies. Based on the analysis of the above articles, 36 Syntheses of the available evidence and 36 Recommendations were eventually prepared. The present document was developed by organizing the available evidence into three individual areas (nutrients, food groups and dietary patterns) to provide a systematic and user-friendly overview of the available evidence on the relationship between nutrition and primary prevention of stroke. Yet analysis of foods and food patterns allowed translating the information about nutrients in a tool more amenable to use in daily life also in the light of the argument that people eat foods rather than nutrients.

CONCLUSIONS

The present literature review and dietary recommendations provide healthcare professionals and all interested readers with a useful overview for the reduction of the risk of total, ischemic and haemorrhagic stroke through dietary modifications.