Relationship Between a Plant-Based Dietary Portfolio and Risk of Cardiovascular Disease: Findings From the Women's Health Initiative Prospective Cohort Study

The portfolio dietary pattern and risk of cardiovascular disease mortality during 1988-2019 in US adults: a prospective cohort study

BACKGROUND

The Portfolio Diet, a dietary pattern of cholesterol-lowering foods, has been shown to reduce cardiovascular disease (CVD) risk factors in clinical trials and lower CVD risk in observational cohorts of mainly white men and women. However, evidence on mortality outcomes in diverse populations is limited.

OBJECTIVE

To examine the association of the Portfolio dietary pattern with CVD mortality in a racially diverse cohort.

METHODS

A total of 14,835 US adults from the National Health and Nutrition Examination Survey, NHANES (1988-1994), were included. Diet was assessed by a 24-h dietary recall which was supplemented with a food frequency questionnaire at baseline using the Portfolio Diet Score (PDS), with positive points for nuts, plant protein, viscous fiber, phytosterols, and plant monounsaturated fatty acid sources, and negative points for foods high in saturated fat and cholesterol (range, 6-30 points). The primary outcome was CVD mortality. Other mortality outcomes included coronary heart disease (CHD), stroke, and all-cause mortality.

RESULTS

During 22 years of follow-up, 2300 CVD deaths, including 1887 CHD deaths, 413 stroke deaths, and 6238 all-cause deaths were documented. Greater adherence was inversely associated with risk factors including blood lipids, glycemia, and inflammation. Treated as a continuous variable, an increase in PDS by 8 points was associated with a 12% (hazard ratio 0.88 [95% confidence intervals:0.78, 0.99]), 14% (0.86 [0.78, 0.96]), and 12% (0.88 [0.82, 0.95]) lower risk of CVD, CHD, and all-cause mortality after adjustments for known CVD risk factors. Comparing the highest to lowest tertiles of the PDS, higher PDS was associated with 16% (0.84 [0.73, 0.98]), 18% (0.82 [0.72, 0.95]) and 14% (0.86 [0.78, 0.96]) lower risk of CVD, CHD, and all-cause mortality, respectively. As part of exploratory analyses, an interaction between PDS and race/ethnicity was observed, emphasizing the necessity of future research involving underserved groups.

CONCLUSIONS

Among a national cohort of racially diverse adults in the US, greater adherence to the Portfolio dietary pattern was inversely and prospectively associated with CVD, CHD, and all-cause mortality.

Portfolio diet and LDL-C in a young, multiethnic cohort: cross-sectional analyses with cumulative exposure modeling

BACKGROUND

The Portfolio Diet is a plant-based dietary pattern of cholesterol-lowering foods that has demonstrated clinically meaningful reductions in low-density lipoprotein cholesterol (LDL-C) and other cardiovascular risk factors. However, the Portfolio Diet has not been assessed in an ethnoculturally diverse population of young adults.

OBJECTIVE

To examine the association of the Portfolio Diet Score (PDS) with LDL-C and other established cardiovascular risk factors in a young adult population.

METHODS

This cross-sectional analysis included 1,507 men and women (mean age, 23 ± 3 years) of diverse ethnocultural backgrounds from the Toronto Nutrigenomics and Health Study. Diet was assessed by a validated Toronto-modified Harvard 196-item food frequency questionnaire with adherence to the Portfolio Diet measured using the Portfolio Diet Score. Data were analyzed using multiple linear regressions with adjustment for potential confounders. Modeling analyses related LDL-C levels according to absolute adherence to the Portfolio Diet with cumulative LDL-C and onset of rising cardiovascular risk by age.

RESULTS

Participants were Caucasian (49%), East Asian (34%), South Asian (11%), or other (7%) with a mean LDL-C of 2.3 ± 0.7mmol/L. A 1-point higher PDS and higher PDS tertiles were associated with lower LDL-C (ß [95% CI] per 1-point: -0.009mmol/L [-0.016, -0.002], P = 0.013; Ptrend across tertiles =0.040), non-HDL-C (-0.010mmol/L [-0.018, -0.002], P = 0.014; Ptrend=0.028), total cholesterol (-0.011mmol/L [-0.019, -0.003], P = 0.011; Ptrend=0.038), systolic blood pressure (-0.150mmHg [-0.250, -0.050], P = 0.003; Ptrend<0.001) and diastolic blood pressure (-0.133mmHg [-0.219, -0.046], P = 0.003; Ptrend<0.001). Higher PDS tertiles were associated with lower triglycerides (Ptrend=0.039). A 1-point higher PDS was also associated with lower BMI (-0.038 kg/m2 [-0.071, -0.004], P = 0.026), waist circumference (-0.092cm [-0.171, -0.013], P = 0.022), body weight (-0.124 kg [-0.229, -0.019], P = 0.021) and FMI (-0.019 kg/m2 [-0.037, -0.001], P =0.039). There was no association with HDL-C, CRP, or fasting glucose. Modeling analyses suggest that compared to low adherence, 50% and 100% adherence to the Portfolio Diet may delay the onset of rising cardiovascular risk by an estimated 6 and 13 years, respectively.

CONCLUSIONS

Among young adults, the PDS was inversely associated with LDL-C and several other established cardiovascular risk factors. Early adherence to the Portfolio Diet may limit lifetime exposure to LDL-C and could delay the age at which cardiovascular events begin.

Dietary patterns and their associations with body composition, cardiometabolic and bone health in postmenopausal women

Background: Menopause, occurring typically between ages 45 and 55, is associated with various physical and psychological symptoms and an increased risk of cardiometabolic diseases, osteoporosis and obesity. Purpose and Research Design: This review examines the impact of healthy dietary patterns in postmenopausal women, focussing on recent literature on the Mediterranean Diet, Dietary Approaches to Stop Hypertension (DASH), the Portfolio diet and other national healthy eating guidelines.Results: Evidence suggests that adhering to one of these healthy dietary patterns can reduce the risk of cardiometabolic diseases and may benefit body composition and bone health.Conclusions: Although promising, the current evidence, primarily from observational studies, requires more extensive and long-term intervention trials to establish definite conclusions. This review underscores the importance of dietary choices in supporting postmenopausal health and highlights the need for comprehensive dietary strategies tailored to regional eating habits.

Metabolomic profiling of a cholesterol lowering plant-based diet from two randomized controlled feeding trials

BACKGROUND

Objective biomarkers of diet, such as metabolomics, may improve dietary assessment and provide additional insight into how diet influences disease risk. The portfolio diet, a cholesterol-lowering plant-based diet, is recommended for lowering low-density lipoprotein cholesterol (LDL-C). This diet is low in saturated fat and includes nuts, plant protein (legumes), viscous fiber, and phytosterols.

OBJECTIVE

We examined metabolomic profiles in response to the portfolio diet in two randomized controlled trials (RCTs), where all foods were provided to the participants, compared to a control vegetarian diet and the same control diet with a statin.

METHODS

The first RCT included 34 adults (age 58.4 ± 8.6 y) and the second RCT included 25 adults (age 61.0 ± 9.6 y), all with high LDL-C (>4.1 mmol/L). Plasma samples were obtained at baseline, week 2, and week 4 in both RCTs for metabolomics analysis using liquid chromatography-tandem mass spectrometry. Linear mixed models were used to examine effects of the interventions on the metabolites in each RCT, applying a Bonferroni correction.

RESULTS

Of 496 known metabolites, 145 and 63 metabolites significantly changed within the portfolio diet interventions in the first and second RCT, respectively. The majority were glycerophosphocholines (32%), triacylglycerols (20%), glycerophosphoethanolamines (14%), sphingomyelins (8%), and amino acids and peptides (8%) in the first RCT, and glycerophosphocholines (48%), glycerophosphoethanolamines (17%), and amino acids and peptides (8%) in the second RCT. Fifty-two metabolites were consistently changed in the same direction with the portfolio diet intervention across both RCTs, after Bonferroni correction.

CONCLUSIONS

Many of these metabolites likely reflect the plant-based nature, low saturated fat content, and cholesterol-lowering effects of the diet, such as increased N2-acetylornithine, L-pipecolic acid, lenticin, and decreased C18:0 lipids and cholesteryl esters. Further research is needed to validate these metabolites as biomarkers of a plant-based dietary pattern.

Protective association between dietary phytosterol intake and cardiovascular health: an analysis of the UK Biobank cohort

Background: Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality worldwide, with dietary interventions showing promise in reducing CVD risk factors. Phytosterols (PSs) in plant-based foods may reduce CVD risk by lowering low-density lipoprotein cholesterol. However, the relationship between dietary PS intake and CVD outcomes remains inconclusive. Methods: This study investigated the association between dietary PS intake and CVD outcomes, including coronary heart disease (CHD) and cardiovascular mortality, using a large cohort of 167 209 UK Biobank participants. PS intake was assessed through repeated 24 hour dietary recall data, with participants stratified into quintiles. The Cox proportional-hazards model was used to estimate hazard ratios (HRs) for CVD risk across quintiles of PS intake, adjusting for potential confounders. Restricted cubic splines were used to examine the nonlinear relationship between phytosterol intake and cardiovascular disease risk. Sensitivity and subgroup analyses explored interactions with demographic and lifestyle factors. Results: Higher dietary PS intake was significantly associated with a reduced risk of CVD events, including CHD and cardiovascular mortality. Each 100 mg increase in PS intake was linked to an 8% reduction in CVD risk (HR = 0.92, 95% CI: 0.87, 0.97). Multivariable-adjusted analyses revealed that participants in the highest quintile of PS intake had significantly lower CVD hazard ratios (HR = 0.81, 95% CI: 0.77, 0.84) compared to those in the lowest quintile. Significant inverse associations were also observed for cardiovascular mortality (HR: 0.86, 95% CI: 0.80, 0.94) and CHD (HR: 0.91, 95% CI: 0.84, 0.98). Subgroup analysis highlighted stronger inverse associations in current smokers, individuals with lower body mass index (BMI), and those with moderate to high physical activity levels, with variations observed based on dyslipidemia status. Sensitivity analyses, excluding early events and adjusting for energy intake, confirmed the robustness of the findings. Conclusions: This large cohort study provides evidence supporting the cardioprotective effects of dietary PS intake, particularly for CHD and cardiovascular mortality. Dietary PS may be considered an integral component of heart-healthy diets.

Combined effects of genetic background and diet on mouse metabolism and gene expression

In humans, dietary patterns impact weight and metabolism differentially across individuals. To uncover genetic determinants for differential dietary effects, we subjected four genetically diverse mouse strains to humanized diets (American, Mediterranean, vegetarian, and vegan) with similar macronutrient composition, and performed body weight, metabolic parameter, and RNA-seq analysis. We observed pronounced diet- and strain-dependent effects on weight, and triglyceride and insulin levels. Differences in fat mass, adipose tissue, and skeletal muscle glucose uptake, and gene expression changes in most tissues were strain-dependent. In visceral adipose tissue, ∼400 genes responded to diet in a strain-dependent manner, many of them in metabolite transport and lipid metabolism pathways and several previously identified to modify diet effects in humans. Thus, genetic background profoundly impacts metabolism, though chosen dietary patterns modify the strong genetic effects. This study paves the way for future mechanistic investigations into strain-diet interactions in mice and translation to precision nutrition in humans.

The effects of portfolio moderate-carbohydrate and ketogenic diets on anthropometric indices, metabolic status, and hormonal levels in overweight or obese women with polycystic ovary syndrome: a randomized controlled trial

BACKGROUND

Polycystic Ovary Syndrome (PCOS) is one of the most common hormonal disorders in reproductive-age women caused by hyperinsulinemia. The portfolio Moderate-carbohydrate diet (PMCD) is a plant-based diet with a carbohydrate content of 40% and incorporates five cholesterol-lowering foods. While, the ketogenic diet is a high-fat diet with 70% fat, promoting a ketosis state. To the best of our knowledge, no study compared the therapeutic effects of these two diets in PCOS patients. Thus, this study aimed to compare the impact of PLCD and KD on anthropometric indices, metabolic status, and hormonal levels in overweight or obese women with PCOS.

METHODS

This open-label, randomized clinical trial was conducted on forty-six PCOS women. 21 women in PMCD and 19 in the KD group completed the study. The anthropometric indices including body mass index (BMI) and fat body mass (FBM), metabolic markers (fasting blood glucose (FBG)) and plasma lipid profiles including low-density lipoprotein (LDL), triglycerides, and high-density lipoproteins (HDL) were measured. Reproductive hormones such as luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEA-s) and free testosterone were assessed at the baseline and after the intervention.

RESULTS

However, after 8 weeks both diets demonstrated enhancement in anthropometric indices (BMI, FBM, lean body mass), metabolic status (FBG, insulin serum levels), and reproductive hormones such as LH, free testosterone, and DHEA-s. The mean difference in the KD improved more than the PMCD in the field of BMI reduction (MD (SD) 2.73 (0.351) vs. MD (SD) 1.71 (0.775)) and LH (MD 4.13 (1.375) vs.MD 2.46 (1.105)). Nevertheless, the lipid profile including LDL-C and triglycerides improved more in the PMCD compared to the KD (MD 33.95 (7.345) vs. MD 23.34 (14.136)) and (MD 38.20 (10.757) vs. MD 57.62 (21.688)) respectively. There were no significant changes in the Ferriman-Gallwey score within or between the two groups.

CONCLUSION

The findings revealed that both diets were effective in improving PCOS manifestations. However, the KD exhibited greater effectiveness in enhancing body measurements, metabolic factors, and reproductive hormone levels compared to the PMCD in obese PCOS women. Furthermore, PMCD could be more beneficial for PCOS women with lipide disorders.

REGISTRATION NUMBER OF CLINICAL TRIAL

IRCT20200912048693N3, Trial registered 2022-12-14. https://www.irct.ir/trial/67548.

Diet and risk of atrial fibrillation: a systematic review

Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia. Comprehensive modification of established AF risk factors combined with dietary interventions and breaking deleterious habits has been shown to reduce AF burden and recurrence. Numerous AF risk factors, such as diabetes, obesity or hypertension can be partially related to dietary and lifestyle choices. Therefore, dietary interventions may have potential as a therapeutic approach in AF. Based on available data, current guidelines recommend alcohol abstinence or reduction to decrease AF symptoms, burden, and progression, and do not indicate the need for caffeine abstention to prevent AF episodes (unless it is a trigger for AF symptoms). Uncertainty persists regarding harms or benefits of other dietary factors including chocolate, fish, salt, polyunsaturated and monounsaturated fatty acids, vitamins, and micronutrients. This article provides a systematic review of the association between AF and both dietary patterns and components. Additionally, it discusses potentially related mechanisms and introduces different strategies to assess patients' nutrition patterns, including mobile health solutions and diet indices. Finally, it highlights the gaps in knowledge requiring future investigation.

A systematic review and meta-analysis of randomized trials of substituting soymilk for cow's milk and intermediate cardiometabolic outcomes: understanding the impact of dairy alternatives in the transition to plant-based diets on cardiometabolic health

BACKGROUND

Dietary guidelines recommend a shift to plant-based diets. Fortified soymilk, a prototypical plant protein food used in the transition to plant-based diets, usually contains added sugars to match the sweetness of cow's milk and is classified as an ultra-processed food. Whether soymilk can replace minimally processed cow's milk without the adverse cardiometabolic effects attributed to added sugars and ultra-processed foods remains unclear. We conducted a systematic review and meta-analysis of randomized controlled trials, to assess the effect of substituting soymilk for cow's milk and its modification by added sugars (sweetened versus unsweetened) on intermediate cardiometabolic outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched (through June 2024) for randomized controlled trials of ≥ 3 weeks in adults. Outcomes included established markers of blood lipids, glycemic control, blood pressure, inflammation, adiposity, renal disease, uric acid, and non-alcoholic fatty liver disease. Two independent reviewers extracted data and assessed risk of bias. The certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). A sub-study of lactose versus sucrose outside of a dairy-like matrix was conducted to explore the role of sweetened soymilk which followed the same methodology.

RESULTS

Eligibility criteria were met by 17 trials (n = 504 adults with a range of health statuses), assessing the effect of a median daily dose of 500 mL of soymilk (22 g soy protein and 17.2 g or 6.9 g/250 mL added sugars) in substitution for 500 mL of cow's milk (24 g milk protein and 24 g or 12 g/250 mL total sugars as lactose) on 19 intermediate outcomes. The substitution of soymilk for cow's milk resulted in moderate reductions in non-HDL-C (mean difference, - 0.26 mmol/L [95% confidence interval, - 0.43 to - 0.10]), systolic blood pressure (- 8.00 mmHg [- 14.89 to - 1.11]), and diastolic blood pressure (- 4.74 mmHg [- 9.17 to - 0.31]); small important reductions in LDL-C (- 0.19 mmol/L [- 0.29 to - 0.09]) and c-reactive protein (CRP) (- 0.82 mg/L [- 1.26 to - 0.37]); and trivial increases in HDL-C (0.05 mmol/L [0.00 to 0.09]). No other outcomes showed differences. There was no meaningful effect modification by added sugars across outcomes. The certainty of evidence was high for LDL-C and non-HDL-C; moderate for systolic blood pressure, diastolic blood pressure, CRP, and HDL-C; and generally moderate-to-low for all other outcomes. We could not conduct the sub-study of the effect of lactose versus added sugars, as no eligible trials could be identified.

CONCLUSIONS

Current evidence provides a good indication that replacing cow's milk with soymilk (including sweetened soymilk) does not adversely affect established cardiometabolic risk factors and may result in advantages for blood lipids, blood pressure, and inflammation in adults with a mix of health statuses. The classification of plant-based dairy alternatives such as soymilk as ultra-processed may be misleading as it relates to their cardiometabolic effects and may need to be reconsidered in the transition to plant-based diets.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT05637866.

Simulation model to assess the validity of the clinical portfolio diet score used in the PortfolioDiet.app for dietary self-tracking: a secondary analysis of a randomized controlled trial in hyperlipidemic adults

Introduction

The Portfolio Diet combines cholesterol-lowering plant foods for the management of cardiovascular disease risk. However, the translation of this dietary approach into clinical practice necessitates a user-friendly method for patients to autonomously monitor their adherence.

Objective

This study aimed to develop and validate the clinical-Portfolio Diet Score (c-PDS) as a food-based metric to facilitate self-tracking of the Portfolio Diet.

Methods

Using a simulation model to estimate the c-PDS, the validity was assessed in a secondary analysis of a completed trial of the Portfolio Diet in 98 participants with hyperlipidemia over 6 months. Concurrent and predictive validity of the estimated c-PDS were assessed against the reference measure (weighed 7-day diet records) and concomitant changes in LDL-C from baseline to 6 months. Bland-Altman analysis was used to assess the limits of agreement between the two methods.

Results

The c-PDS was positively correlated with dietary adherence as measured using the 7-day diet records (r = 0.94, p < 0.001). The c-PDS was negatively correlated with change in LDL-C (r = -0.43, p < 0.001) with a 1-point increase in the c-PDS being associated with a - 0.04 mmol/L (CI:-0.06,-0.03; p < 0.001) or a 1.09% reduction in LDL-C. Visual evaluation of the Bland-Altman plots showed reasonable agreement.

Conclusion

These findings indicate good validity of the c-PDS for primary prevention in adults with hyperlipidemia. The predictive validity findings have informed the goals and messaging within the PortfolioDiet.app, a digital health application for delivering the Portfolio Diet. Future research will assess the effectiveness of the intended combination of the c-PDS and the PortfolioDiet.app in supporting behavior change.

Adherence to a Cholesterol-Lowering Diet and the Risk of Pancreatic Cancer: A Case-Control Study

BACKGROUND

Pancreatic cancer risk has been associated with increased serum cholesterol level, which is in turn partially influenced by diet. This study aimed at evaluating the association between pancreatic cancer risk and the adherence to a plant-based cholesterol-lowering diet.

METHODS

Data were derived from an Italian case-control study including 258 pancreatic cancer patients and 551 controls. The cholesterol-lowering diet score was based on seven components: high intakes of (i) non-cellulosic polysaccharides (a proxy of viscous fibers), (ii) monounsaturated fatty acids, (iii) legumes, and (iv) seeds/corn oils (a proxy of phytosterols); and low intakes of (v) saturated fatty acids, (vi) dietary cholesterol, and (vii) food with a high glycemic index. The score was calculated adding one point for each fulfilled component, thus ranging from zero (no adherence) to seven (complete adherence). The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated through the logistic regression model.

RESULTS

Scores 5-7 were associated with reduced cancer risk (OR = 0.30; 95% CI: 0.18-0.52) compared to scores 0-2.

CONCLUSIONS

Adherence to a plant-based cholesterol-lowering diet was associated with a reduced risk of pancreatic cancer.

Increasing the frequency of plant-based food intake in daily diets reduces the risk of cardiovascular disease among elderly Chinese: a cohort study

Objective

There is limited research on the relationship between the frequency of plant-based food intake and the risk of cardiovascular disease (CVD) among elderly Chinese. This study aims to evaluate the association between plant-based dietary index (PDI) and CVD risks, providing evidence for elderly Chinese to reduce CVD risks by increasing the frequency of plant-based food consumption.

Methods

This study analyzed data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 2011-2018, employing a multivariate modified Poisson regression model, trend tests, and restricted cubic spline (RCS) analysis to assess the linear and non-linear relationship between the PDI and CVD risks. Subgroup analyses and interaction tests were conducted to evaluate the robustness and population-specificity of the results.

Results

This study included a total of 1,414 elderly Chinese, and at the end of follow-up, 487 participants had developed CVD. The multivariate modified Poisson regression model revealed a negative association between PDI and CVD risks [RR = 0.983, 95%CI = (0.970, 0.997)]. Similarly, the multivariate trend test (p = 0.031) and RCS analysis (P for nonlinear = 0.600) indicated a linear relationship between PDI and CVD risks. Subgroup analyses showed that the relationship between PDI and CVD risk was not influenced by gender, BMI, smoking, alcohol use, or exercise.

Conclusion

The PDI was negatively correlated with CVD risks, indicating that increasing the frequency of plant-based food intake in the diet may reduce CVD risks among elderly Chinese.

From Palm to Plate: Unveiling the Potential of Coconut as a Plant-Based Food Alternative

This review investigates coconut as a sustainable and nutrient-rich plant-based alternative to traditional animal-based food sources. We have explored the nutritional profile, culinary versatility, particularly focusing on the use of coconut meat, milk, cream, and oil in diverse dietary contexts when consumed in balance. Comparative analysis with animal-derived products reveals the high content of medium-chain triglycerides (MCTs), essential vitamins, and minerals in coconut, contrasted with its lower protein content. Researchers have underscored the environmental sustainability of coconut, advocating for its role in eco-friendly food production chains. We have also addressed challenges like potential allergies, nutritional balance, sensory attributes, and consumer motivations for coconut-based products, in terms of understanding the market dynamics. In conclusion, this review positions coconut as a promising candidate within sustainable diet frameworks, advocating for further research to augment its nutritional value, sensory characteristics, and product stability, thereby facilitating its integration into health-conscious and eco-centric dietary practices.

Disease burden of stroke and its subtypes attributable to low dietary fiber in China, 1990-2019

This study aimed to assess the current status and changing trends of the disease burden of stroke and its subtypes due to low dietary fiber intake in China from 1990 to 2019. In cases of stroke and its subtypes attributable to low dietary fiber, deaths, disability-adjusted life-years (DALYs), age-standardized mortality rates (ASMR), age-standardized DALYs rates (ASDR), and percentage change were used to assess disease burden. Data were obtained from the 2019 global burden of disease study. Trends were assessed using Joinpoint regression and age-period-cohort analysis. Between 1990 and 2019, there was a declining trend in stroke and its subtypes, ASDR and ASMR, as well as the corresponding number of deaths and DALYs, due to low dietary fiber intake in China. Subarachnoid hemorrhage (SH) showed the greatest decrease, followed by intracerebral hemorrhage (IH) and ischemic stroke (IS). Local drift curves showed a U-shaped distribution of stroke, IS, and IH DALYs across the whole group and sex-based groups. For mortality, the overall and male trends were similar to those for DALYs, whereas female stroke, IH, and IS showed an upward trend. The DALYs for stroke and IH showed a clear bimodal distribution, IS showed an increasing risk with age. For mortality, the SH subtype showed a decreasing trend, whereas other subtypes showed an increasing risk with age. Both the period and cohort rates of stroke DALYs and motality due to low dietary fiber have declined. Males had a higher risk of DALYs and mortality associated with low fiber levels. The burden of stroke and its subtypes associated with a low-fiber diet in China has been declining over the past 30 years, with different patterns of change for different stroke subtypes and a higher burden for males, highlighting the differential impact of fiber intake on stroke and its subtypes.

Diet strategies for promoting healthy aging and longevity: An epidemiological perspective

In recent decades, global life expectancies have risen significantly, accompanied by a marked increase in chronic diseases and population aging. This narrative review aims to summarize recent findings on the dietary factors influencing chronic diseases and longevity, primarily from large cohort studies. First, maintaining a healthy weight throughout life is pivotal for healthy aging and longevity, mirroring the benefits of lifelong, moderate calorie restriction in today's obesogenic food environment. Second, the specific types or food sources of dietary fat, protein, and carbohydrates are more important in influencing chronic disease risk and mortality than their quantity. Third, some traditional diets (e.g., the Mediterranean, Nordic, and Okinawa) and contemporary dietary patterns, such as healthy plant-based diet index, the DASH (dietary approaches to stop hypertension) diet, and alternate healthy eating index, have been associated with lower mortality and healthy longevity. These patterns share many common components (e.g., a predominance of nutrient-rich plant foods; limited red and processed meats; culinary herbs and spices prevalent in global cuisines) while embracing distinct elements from different cultures. Fourth, combining a healthy diet with other lifestyle factors could extend disease-free life expectancies by 8-10 years. While adhering to core principles of healthy diets, it is crucial to adapt dietary recommendations to individual preferences and cultures as well as nutritional needs of aging populations. Public health strategies should aim to create a healthier food environment where nutritious options are readily accessible, especially in public institutions and care facilities for the elderly. Although further mechanistic studies and human trials are needed to better understand molecular effects of diet on aging, there is a pressing need to establish and maintain long-term cohorts studying diet and aging in culturally diverse populations.

Phytosterol intake and risk of coronary artery disease: Results from 3 prospective cohort studies

BACKGROUND

Phytosterols are structurally similar to cholesterol and partially inhibit intestinal absorption of cholesterol, although their impact on coronary artery disease (CAD) risk remains to be elucidated.

OBJECTIVES

This study aimed to prospectively assess the associations between total and individual phytosterol intake and CAD risk in United States health professionals.

METHODS

The analysis included 213,992 participants from 3 prospective cohorts-the Nurses' Health Study (NHS), NHSII, and Health Professionals Follow-Up Study-without cardiovascular disease or cancer at baseline. Diet was assessed using a validated food frequency questionnaire every 2-4 y since baseline. Associations between phytosterol intake and the risk of CAD, such as nonfatal myocardial infarction and fatal CAD, were evaluated using Cox proportional hazards regression models.

RESULTS

More than 5,517,993 person-years, 8725 cases with CAD were documented. Comparing extreme quintiles, pooled hazard ratios (95% CIs) of CAD were 0.93 (0.86, 1.01; P-trend = 0.16) for total phytosterols, 0.89 (0.82, 0.96; P-trend = 0.05) for campesterol, 0.95 (0.88, 1.02; P-trend = 0.10) for stigmasterol, and 0.92 (0.85, 1.00; P-trend = 0.09) for β-sitosterol. Nonlinear associations were observed for total phytosterols, campesterol, and β-sitosterol: the risk reduction plateaued at intakes above ∼180, 30, and 130 mg/d, respectively (P-nonlinearity < 0.001). In a subset of participants (N range between 11,983 and 22,039), phytosterol intake was inversely associated with plasma concentrations of total cholesterol, triglycerides, high-density lipoprotein cholesterol, and IL-6 and positively associated with adiponectin, whereas no significant associations were observed for low-density lipoprotein cholesterol or C-reactive protein concentrations.

CONCLUSIONS

Higher long-term intake of total and major subtypes of phytosterols may be associated with a modest reduction in CAD risk, displaying a nonlinear relationship that plateau at moderate intake levels. The role of phytosterols in preventing CAD warrants further investigation.

Portfolio Diet Score and Risk of Cardiovascular Disease: Findings From 3 Prospective Cohort Studies

BACKGROUND

The plant-based Portfolio dietary pattern includes recognized cholesterol-lowering foods (ie, plant protein, nuts, viscous fiber, phytosterols, and plant monounsaturated fats) shown to improve several cardiovascular disease (CVD) risk factors in randomized controlled trials. However, there is limited evidence on the role of long-term adherence to the diet and CVD risk. The primary objective was to examine the relationship between the Portfolio Diet Score (PDS) and the risk of total CVD, coronary heart disease (CHD), and stroke.

METHODS

We prospectively followed 73 924 women in the Nurses' Health Study (1984-2016), 92 346 women in the Nurses' Health Study II (1991-2017), and 43 970 men in the Health Professionals Follow-up Study (1986-2016) without CVD or cancer at baseline. Diet was assessed using validated food frequency questionnaires at baseline and every 4 years using a PDS that positively ranks plant protein (legumes), nuts and seeds, viscous fiber sources, phytosterols (mg/day), and plant monounsaturated fat sources, and negatively ranks foods high in saturated fat and cholesterol.

RESULTS

During up to 30 years of follow-up, 16 917 incident CVD cases, including 10 666 CHD cases and 6473 strokes, were documented. After multivariable adjustment for lifestyle factors and a modified Alternate Healthy Eating Index (excluding overlapping components), comparing the highest with the lowest quintile, participants with a higher PDS had a lower risk of total CVD (pooled hazard ratio [HR], 0.86 [95% CI, 0.81-0.92]; Ptrend<0.001), CHD (pooled HR, 0.86 [95% CI, 0.80-0.93]; Ptrend=0.0001), and stroke (pooled HR, 0.86 [95% CI, 0.78-0.95]; Ptrend=0.0003). In addition, a 25-percentile higher PDS was associated with a lower risk of total CVD (pooled HR, 0.92 [95% CI, 0.89-0.95]), CHD (pooled HR, 0.92 [95% CI, 0.88-0.95]), and stroke (pooled HR, 0.92 [95% CI, 0.87-0.96]). Results remained consistent across sensitivity and most subgroup analyses, and there was no evidence of departure from linearity for CVD, CHD, or stroke. In a subset of participants, a higher PDS was associated with a more favorable blood lipid and inflammatory profile.

CONCLUSIONS

The PDS was associated with a lower risk of CVD, including CHD and stroke, and a more favorable blood lipid and inflammatory profile, in 3 large prospective cohorts.

Associations between plant-based dietary patterns and risks of type 2 diabetes, cardiovascular disease, cancer, and mortality - a systematic review and meta-analysis

BACKGROUND

Plant-based dietary patterns are gaining more attention due to their potential in reducing the risk of developing major chronic diseases, including type 2 diabetes (T2D), cardiovascular disease (CVD), cancer, and mortality, while an up-to-date comprehensive quantitative review is lacking. This study aimed to summarize the existing prospective observational evidence on associations between adherence to plant-based dietary patterns and chronic disease outcomes.

METHODS

We conducted a systematic review and meta-analysis of evidence across prospective observational studies. The data sources used were PubMed and MEDLINE, Embase, Web of Science, and screening of references. We included all prospective observational studies that evaluated the association between adherence to plant-based dietary patterns and incidence of T2D, CVD, cancer, and mortality among adults (≥ 18 years).

RESULTS

A total of 76 publications were identified, including 2,230,443 participants with 60,718 cases of incident T2D, 157,335 CVD cases, 57,759 cancer cases, and 174,435 deaths. An inverse association was observed between higher adherence to a plant-based dietary pattern and risks of T2D (RR, 0.82 [95% CI: 0.77-0.86]), CVD (0.90 [0.85-0.94]), cancer (0.91 [0.87-0.96]), and all-cause mortality (0.84 [0.78-0.92]) with moderate to high heterogeneity across studies (I2 ranged: 47.8-95.4%). The inverse associations with T2D, CVD and cancer were strengthened when healthy plant-based foods, such as vegetables, fruits, whole grains, and legumes, were emphasized in the definition of plant-based dietary patterns (T2D: 0.79 [0.72-0.87]; CVD: 0.85 [0.80-0.92]; cancer: 0.86 [0.80-0.92]; I2 ranged: 53.1-84.1%). Association for mortality was largely similar when the analyses were restricted to healthy plant-based diets (0.86 [0.80-0.92], I2 = 91.9%). In contrast, unhealthy plant-based diets were positively associated with these disease outcomes. Among four studies that examined changes in dietary patterns, increased adherence to plant-based dietary patterns was associated with a significantly reduced risk of T2D (0.83 [0.71-0.96]; I2 = 71.5%) and a marginally lower risk of mortality (0.95 [0.91-1.00]; I2 = 0%).

CONCLUSIONS

Better adherence to plant-based dietary patterns, especially those emphasizing healthy plant-based foods, is beneficial for lowering the risks of major chronic conditions, including T2D, CVD, cancer, as well as premature deaths.

REGISTRATION OF REVIEW PROTOCOL

This review was registered at the PROSPERO International Prospective Register of Systematic Reviews ( https://www.crd.york.ac.uk/PROSPERO/ ) with the registration number CRD42022290202.

Academy of Plant-based Physical Therapy: overdue to address a nutrition crisis with a transformative population approach

This timely evidence synthesis supports the need for an Academy of Plant-based Physical Therapy. Given epidemiological and empirical evidence and the profession's values and practice scope, the time has come for a specialty of plant-based physical therapy based on population health principles. This review connects these factors. Non-communicable diseases (NCDs) are largely nutrition-related resulting from unnatural elements of our diet (i.e., heart disease, several cancers, hypertension, stroke, diabetes, obesity, gastrointestinal diseases, autoimmune diseases, renal disease, and Alzheimer's disease). Most adults, even children, have NCD risk factors or manifestations. Alternatively, plant-based nutrition can prevent, manage, as well as potentially reverse these diseases, as well as augment conventional physical therapy outcomes by reducing inflammation and pain. Proposed competencies for plant-based physical therapists include high-level competency in health and NCD risk assessments/evaluations, to establish population health-informed nutrition needs for maximal health, healing and repair, in turn, function and wellbeing; and assessment of patients' nutrition-related knowledge, beliefs/attitudes, self-efficacy, and readiness-to-change. Population-informed nutritional counseling is initiated as indicated. An Academy of Plant-based Physical Therapy could advance the profession globally at this point in history and also serve as a role model to other health professions through practicing evidence-based, plant-based nutrition built upon population health principles.

An Update on Nutrition Guidance for Cardiovascular Health

PURPOSE OF REVIEW

The goal of this article is to summarize recent guidance on diet and cardiovascular health.

RECENT FINDINGS

Cardiovascular diseases are the leading cause of death in the USA, and diet significantly impacts cardiovascular disease risk. The focus of contemporary dietary recommendations has shifted from single nutrient replacements to dietary patterns such as the Mediterranean, healthy USA, Dietary Approaches to Stop Hypertension, and healthy plant-based patterns. Recommended dietary patterns emphasize whole grains, fruits, vegetables, nuts, seeds, legumes/pulses, seafood, lean meats, and fish/seafood. They also limit intakes of ultra-processed foods, processed meats, and alcohol, as well as foods high in salt and added sugars, particularly sugar-sweetened beverages.

Association of Dietary Potassium Intake With Abdominal Aortic Calcification and Pulse Pressure in US Adults

OBJECTIVES

Arterial calcification contributes to cardiovascular mortality. Based on a recent animal study, we hypothesized that higher dietary potassium intake was associated with less abdominal aortic calcification (AAC) and lower arterial stiffness among adults in the United States.

METHODS

Cross-sectional analyses were performed on participants over 40 years old from the National Health and Nutrition Examination Survey 2013-2014. Dietary potassium intake was categorized into quartiles (Q1: <1911, Q2: 1911-2461, Q3: 2462-3119, and Q4: >3119 mg/d). Primary outcome AAC was quantified using the Kauppila scoring system. AAC scores were categorized into no AAC (AAC = 0, reference group), mild/moderate (AAC >0 to ≤ 6), and severe AAC (AAC >6). Pulse pressure was used as a surrogate for arterial stiffness and examined as a secondary outcome.

RESULTS

Among 2,418 participants, there was not a linear association between dietary potassium intake and AAC. Higher dietary potassium intake was associated with less severe AAC when comparing dietary potassium intake in Q2 with Q1 (odds ratio 0.55; 95% confidence interval: 0.34 to 0.92; P = .03). Higher dietary potassium intake was significantly associated with lower pulse pressure (P = .007): per 1000 mg/d higher dietary potassium intake, pulse pressure was 1.47 mmHg lower in the fully adjusted model. Compared to participants with dietary potassium intake in Q1, pulse pressure was 2.84 mmHg lower in Q4 (P = .04).

CONCLUSIONS

We did not find a linear association between dietary potassium intake and AAC. Dietary potassium intake was negatively associated with pulse pressure.

Nut and seed consumption is inversely associated with metabolic syndrome in females but not males: findings from the 2005-2018 NHANES data

PURPOSE

To assess the association between nut and seed consumption, both combined and separately, and metabolic syndrome and its components, including fasting glucose, triglycerides, high-density lipoprotein (HDL) cholesterol, central obesity, and blood pressure.

METHODS

This cross-sectional analysis used data from 22,687 adults (aged ≥ 18 years) involved in seven cycles (2005-2018) of the National Health and Nutrition Examination Survey (NHANES). Habitual nut and seed intakes were estimated by the Multiple Source Method using data from two 24-h dietary recalls. Metabolic syndrome was ascertained using biochemical data and self-reported medication use. Sex-specific effect estimates were obtained using logistic and linear regressions adjusting for lifestyle and socioeconomic confounders.

RESULTS

Compared to non-consumers, female, but not male, habitual consumers of either nuts or seeds had lower odds of having metabolic syndrome (OR: 0.83, 95% CI 0.71, 0.97). Both nut intake alone and seed intake alone were inversely associated with high fasting glucose and low HDL-cholesterol in females compared to non-consumers. When restricted to habitual consumers only, the combined intake of nuts and seeds at 6 g/day was associated with the lowest triglycerides and highest HDL-cholesterol in females. Combined consumption of nuts and seeds up to one ounce-equivalent (15 g) per day, but not in higher intake levels, was inversely associated with metabolic syndrome, high fasting glucose, central obesity, and low HDL-cholesterol in females.

CONCLUSIONS

Nut and seed consumption, both separately or combined, below 15 g/day was inversely associated with metabolic syndrome and its component conditions in females but not males.

Dietary intake, biomarkers and supplementation of fatty acids and risk of coronary events: a systematic review and dose-response meta-analysis of randomized controlled trials and prospective observational studies

We aimed to review the association of dietary fats and risk of coronary events in adults. We searched PubMed, Embase, CENTRAL, Scopus, and Web of Sciences to April 2022 for prospective cohorts and randomized trials investigating the association of dietary intake and biomarkers of fats and fatty acid interventions and the risk of coronary events. We performed random-effects meta-analyses to estimate relative risk (RR) for the top versus bottom tertiles of exposures. One-hundered sixty-five prospective cohorts and randomized trials were included. Dietary intake and biomarkers of total fat and saturated, monounsaturated, and polyunsaturated fatty acids were not associated with the risk of coronary events. Dietary intake of trans fatty acids, palmitic acid, stearic acid, and saturated fatty acids from meat and unprocessed meat was modestly associated with a higher risk and, in contrast, intake of alpha-linolenic acid, long-chain omega-3 fatty acids, and linoleic acid was modestly associated with a lower risk. Supplementation with long-chain omega-3 fatty acids and increasing the consumption of alpha-linolenic and linoleic acids in place of saturated fats reduced the risk of coronary events. Existing evidence, in its totality, provides a modest support in favor of current recommendations suggesting replacement of saturated fats with polyunsaturated fats.

The EAT-Lancet diet, genetic susceptibility and risk of atrial fibrillation in a population-based cohort

BACKGROUND

The EAT-Lancet Commission proposed a global reference diet with both human health benefits and environmental sustainability in 2019. However, evidence regarding the association of such a diet with the risk of atrial fibrillation (AF) is lacking. In addition, whether the genetic risk of AF can modify the effect of diet on AF remains unclear. This study aimed to assess the association of the EAT-Lancet diet with the risk of incident AF and examine the interaction between the EAT-Lancet diet and genetic susceptibility of AF.

METHODS

This prospective study included 24,713 Swedish adults who were free of AF, coronary events, and stroke at baseline. Dietary habits were estimated with a modified diet history method, and an EAT-Lancet diet index was constructed to measure the EAT-Lancet reference diet. A weighted genetic risk score was constructed using 134 variants associated with AF. Cox proportional hazards regression models were applied to estimate the hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

During a median follow-up of 22.9 years, 4617 (18.7%) participants were diagnosed with AF. The multivariable HR (95% CI) of AF for the highest versus the lowest group for the EAT-Lancet diet index was 0.84 (0.73, 0.98) (P for trend < 0.01). The HR (95% CI) of AF per one SD increment of the EAT-Lancet diet index for high genetic risk was 0.92 (0.87, 0.98) (P for interaction = 0.15).

CONCLUSIONS

Greater adherence to the EAT-Lancet diet index was significantly associated with a lower risk of incident AF. Such association tended to be stronger in participants with higher genetic risk, though gene-diet interaction was not significant.

The Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD), Aas AM, Axelsen M, Churuangsuk C, Hermansen K, Kendall CWC, Kahleova H, Khan T, Lean MEJ, Mann JI, Pedersen E, Pfeiffer A, Rahelić D, Reynolds AN, Risérus U, Rivellese AA, Salas-Salvadó J, Schwab U, Sievenpiper JL, Thanopoulou A, Uusitupa EM. Evidence-based European recommendations for the dietary management of diabetes

Diabetes management relies on effective evidence-based advice that informs and empowers individuals to manage their health. Alongside other cornerstones of diabetes management, dietary advice has the potential to improve glycaemic levels, reduce risk of diabetes complications and improve health-related quality of life. We have updated the 2004 recommendations for the nutritional management of diabetes to provide health professionals with evidence-based guidelines to inform discussions with patients on diabetes management, including type 2 diabetes prevention and remission. To provide this update we commissioned new systematic reviews and meta-analyses on key topics, and drew on the broader evidence available. We have strengthened and expanded on the previous recommendations to include advice relating to dietary patterns, environmental sustainability, food processing, patient support and remission of type 2 diabetes. We have used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to determine the certainty of evidence for each recommendation based on findings from the commissioned and identified systematic reviews. Our findings indicate that a range of foods and dietary patterns are suitable for diabetes management, with key recommendations for people with diabetes being largely similar for those for the general population. Important messages are to consume minimally processed plant foods, such as whole grains, vegetables, whole fruit, legumes, nuts, seeds and non-hydrogenated non-tropical vegetable oils, while minimising the consumption of red and processed meats, sodium, sugar-sweetened beverages and refined grains. The updated recommendations reflect the current evidence base and, if adhered to, will improve patient outcomes.

Assessing the Quality of Simulated Food Patterns with Reduced Animal Protein Using Meal Data from NHANES 2017-2018

The nutritional consequences of progressively replacing meat products with plant-based foods need to be systematically evaluated. Modeling analyses provide insights into the predicted food consumption and nutritional adequacy of plant-based diets. We developed a novel methodology to simulate food patterns and evaluate diet quality. Meal data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 was used to create 100 7-day meal plans subject to various nutrient and food group optimization criteria. Omnivore (reference diet), flexitarian, pescatarian, and vegetarian food patterns were modeled using mixed integer linear programming. The modeled food patterns used the 25th and 75th percentiles of the US Usual Dietary Intakes to set the optimization constraints. The diet quality was determined using the Healthy Eating Index 2015 (HEI-2015). The modeled vegetarian, pescatarian, and flexitarian food patterns outperformed the omnivore diet on the HEI-2015, with the vegetarian pattern achieving the highest score (82 for females, 78 for males). Modeled flexitarian patterns, with a 25 to 75% reduction in animal protein, offer viable options for those seeking to reduce but not eliminate their animal protein intake while supporting the transition from omnivore to fully plant-based diets. This methodology could be applied to evaluate the nutrient and diet quality of different dietary patterns with various constraints.

Adherence to the EAT-Lancet diet and risk of coronary events in the Malmö Diet and Cancer cohort study

BACKGROUND

The EAT-Lancet Commission proposed a globally environmentally sustainable dietary pattern featuring mainly plant-based foods in 2019. However, evidence on this dietary pattern in preventing coronary events is minimal.

OBJECTIVES

We aimed to examine the association between the EAT-Lancet diet and risk of coronary events.

METHODS

The Malmö Diet and Cancer cohort study (recruited between 1991 and 1996) included 23,877 participants aged 44.5-73.6 y (62.5% women) without CVDs and diabetes at baseline. A modified diet history was used to collect the dietary data. An EAT-Lancet diet index (range, 0-42 points) was applied on the basis of 14 food components scored 0 (nonadherence) to 3 (adherence). Coronary events were extracted from the registers. Cox proportional hazards models were used to estimate the HRs and 95% confidential intervals (CIs).

RESULTS

Over a median of 24.9 y of follow-up, 3031 coronary events occurred (incidence rate: 5.89/1000 person-years). After adjusting for age, sex, dietary assessment methods, season, total energy intake, leisure-time physical activity, alcohol consumption, smoking status, educational level, and BMI, the multivariable HR (95% CI) for coronary events among participants who had the highest adherence to the EAT-Lancet diet index (≥23 points, 8.1%) was 0.80 (0.67, 0.96) compared with those who had the lowest adherence (≤13 points, 9.7%) (P-trend = 0.01 across 5 groups of the EAT-Lancet diet). The inverse association was consistent in men and women and was robust after excluding those with misreported energy and significant diet changes or excluding coronary events occurred within the first 2 y of follow-up.

CONCLUSIONS

Our data indicate that adherence to the EAT-Lancet diet was associated with a lower risk of coronary events.

Nuts and Cardiovascular Disease Outcomes: A Review of the Evidence and Future Directions

Nuts are nutrient-rich foods that contain many bioactive compounds that are beneficial for cardiovascular health. Higher consumption of nuts has been associated with a reduced risk of several cardiovascular diseases (CVD) in prospective cohort studies, including a 19% and 25% lower risk of CVD incidence and mortality, respectively, and a 24% and 27% lower risk of coronary heart disease incidence and mortality, respectively. An 18% lower risk of stroke mortality, a 15% lower risk of atrial fibrillation, and a 19% lower risk of total mortality have also been observed. The role of nuts in stroke incidence, stroke subtypes, peripheral arterial disease and heart failure has been less consistent. This narrative review summarizes recommendations for nuts by clinical practice guidelines and governmental organizations, epidemiological evidence for nuts and CVD outcomes, nut-containing dietary patterns, potential mechanisms of nuts and CVD risk reduction, and future research directions, such as the use of biomarkers to help better assess nut intake. Although there are still some uncertainties around nuts and CVD prevention which require further research, as summarized in this review, there is a substantial amount of evidence that supports that consuming nuts will have a positive impact on primary and secondary prevention of CVD.

The Portfolio Diet and Incident Type 2 Diabetes: Findings From the Women's Health Initiative Prospective Cohort Study

OBJECTIVE

A plant-based dietary pattern, the Portfolio Diet, has been shown to lower LDL cholesterol and other cardiovascular disease risk factors. However, no study has evaluated the association of this diet with incident type 2 diabetes.

RESEARCH DESIGN AND METHODS

This analysis included 145,299 postmenopausal women free of diabetes at baseline in the Women's Health Initiative (WHI) Clinical Trials and Observational Study from 1993 to 2021. Adherence to the diet was assessed with a score based on six components (high in plant protein [soy and pulses], nuts, viscous fiber, plant sterols, and monounsaturated fat and low in saturated fat and cholesterol) determined from a validated food-frequency questionnaire. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs of the association of the Portfolio Diet, alongside the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets, with incident type 2 diabetes, with adjustment for potential confounders.

RESULTS

Over a mean follow-up of 16.0 years, 13,943 cases of incident type 2 diabetes were identified. In comparisons of the highest with the lowest quintiles of adherence, the HRs for risk of incident type 2 diabetes were 0.77 (95% CI 0.72, 0.82) for the Portfolio Diet, 0.69 (0.64, 0.73) for the DASH diet, and 0.78 (0.74, 0.83) for the Mediterranean diet. These findings were attenuated by 10% after additional adjustment for BMI.

CONCLUSIONS

Greater adherence to the plant-predominant Portfolio, DASH, and Mediterranean diets was prospectively associated with lower risk of type 2 diabetes in postmenopausal women.

Nordic dietary patterns and cardiometabolic outcomes: a systematic review and meta-analysis of prospective cohort studies and randomised controlled trials

AIMS/HYPOTHESIS

Nordic dietary patterns that are high in healthy traditional Nordic foods may have a role in the prevention and management of diabetes. To inform the update of the EASD clinical practice guidelines for nutrition therapy, we conducted a systematic review and meta-analysis of Nordic dietary patterns and cardiometabolic outcomes.

METHODS

We searched MEDLINE, EMBASE and The Cochrane Library from inception to 9 March 2021. We included prospective cohort studies and RCTs with a follow-up of ≥1 year and ≥3 weeks, respectively. Two independent reviewers extracted relevant data and assessed the risk of bias (Newcastle-Ottawa Scale and Cochrane risk of bias tool). The primary outcome was total CVD incidence in the prospective cohort studies and LDL-cholesterol in the RCTs. Secondary outcomes in the prospective cohort studies were CVD mortality, CHD incidence and mortality, stroke incidence and mortality, and type 2 diabetes incidence; in the RCTs, secondary outcomes were other established lipid targets (non-HDL-cholesterol, apolipoprotein B, HDL-cholesterol, triglycerides), markers of glycaemic control (HbA1c, fasting glucose, fasting insulin), adiposity (body weight, BMI, waist circumference) and inflammation (C-reactive protein), and blood pressure (systolic and diastolic blood pressure). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of the evidence.

RESULTS

We included 15 unique prospective cohort studies (n=1,057,176, with 41,708 cardiovascular events and 13,121 diabetes cases) of people with diabetes for the assessment of cardiovascular outcomes or people without diabetes for the assessment of diabetes incidence, and six RCTs (n=717) in people with one or more risk factor for diabetes. In the prospective cohort studies, higher adherence to Nordic dietary patterns was associated with 'small important' reductions in the primary outcome, total CVD incidence (RR for highest vs lowest adherence: 0.93 [95% CI 0.88, 0.99], p=0.01; substantial heterogeneity: I2=88%, pQ<0.001), and similar or greater reductions in the secondary outcomes of CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). Inverse dose-response gradients were seen for total CVD incidence, CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). No studies assessed CHD or stroke mortality. In the RCTs, there were small important reductions in LDL-cholesterol (mean difference [MD] -0.26 mmol/l [95% CI -0.52, -0.00], pMD=0.05; substantial heterogeneity: I2=89%, pQ<0.01), and 'small important' or greater reductions in the secondary outcomes of non-HDL-cholesterol, apolipoprotein B, insulin, body weight, BMI and systolic blood pressure (p<0.05). For the other outcomes there were 'trivial' reductions or no effect. The certainty of the evidence was low for total CVD incidence and LDL-cholesterol; moderate to high for CVD mortality, established lipid targets, adiposity markers, glycaemic control, blood pressure and inflammation; and low for all other outcomes, with evidence being downgraded mainly because of imprecision and inconsistency.

CONCLUSIONS/INTERPRETATION

Adherence to Nordic dietary patterns is associated with generally small important reductions in the risk of major CVD outcomes and diabetes, which are supported by similar reductions in LDL-cholesterol and other intermediate cardiometabolic risk factors. The available evidence provides a generally good indication of the likely benefits of Nordic dietary patterns in people with or at risk for diabetes.

REGISTRATION

ClinicalTrials.gov NCT04094194.

FUNDING

Diabetes and Nutrition Study Group of the EASD Clinical Practice.

Heart Failure in Menopause: Treatment and New Approaches

Aging is an important risk factor for the development of heart failure (HF) and half of patients with HF have preserved ejection fraction (HFpEF) which is more common in elderly women. In general, sex differences that lead to discrepancies in risk factors and to the development of cardiovascular disease (CVD) have been attributed to the reduced level of circulating estrogen during menopause. Estrogen receptors adaptively modulate fibrotic, apoptotic, inflammatory processes and calcium homeostasis, factors that are directly involved in the HFpEF. Therefore, during menopause, estrogen depletion reduces the cardioprotection. Preclinical menopause models demonstrated that several signaling pathways and organ systems are closely involved in the development of HFpEF, including dysregulation of the renin-angiotensin system (RAS), chronic inflammatory process and alteration in the sympathetic nervous system. Thus, this review explores thealterations observed in the condition of HFpEF induced by menopause and the therapeutic targets with potential to interfere with the disease progress.

Role of dietary fiber in promoting immune health-An EAACI position paper

Microbial metabolism of specific dietary components, such as fiber, contributes to the sophisticated inter-kingdom dialogue in the gut that maintains a stable environment with important beneficial physiological, metabolic, and immunological effects on the host. Historical changes in fiber intake may be contributing to the increase of allergic and hypersensitivity disorders as fiber-derived metabolites are evolutionarily hardwired into the molecular circuitry governing immune cell decision-making processes. In this review, we highlight the importance of fiber as a dietary ingredient, its effects on the microbiome, its effects on immune regulation, the importance of appropriate timing of intervention to target any potential window of opportunity, and potential mechanisms for dietary fibers in the prevention and management of allergic diseases. In addition, we review the human studies examining fiber or prebiotic interventions on asthma and respiratory outcomes, allergic rhinitis, atopic dermatitis, and overall risk of atopic disorders. While exposures, interventions, and outcomes were too heterogeneous for meta-analysis, there is significant potential for using fiber in targeted manipulations of the gut microbiome and its metabolic functions in promoting immune health.

Update on Nutrition in Diabetes Management

Nutrition is a corner stone of diabetes management, and should be regarded as fundamental to achieving blood glucose control. The current advice for nutrition in diabetes management is discussed, with a focus on body weight, macro and micro nutrients, foods and food groups, dietary patterns, and the lifestyle context. More recent evidence on topics such as body weight and dietary patterns indicate flexibility in what can be recommended, which enables patient preference and may aid adherence. Importantly, a healthy diet for those with diabetes is also appropriate to recommend for their families and the general population.

Dietary Protein Sources, Mediating Biomarkers, and Incidence of Type 2 Diabetes: Findings From the Women's Health Initiative and the UK Biobank

OBJECTIVE

Whether and how dietary protein intake is linked to type 2 diabetes (T2D) remains unclear. The aim of this study was to investigate the associations of protein intake with development of T2D and the potential mediating roles of T2D biomarkers.

RESEARCH DESIGN AND METHODS

We included 108,681 postmenopausal women without T2D at baseline from the Women's Health Initiative (WHI) (primary cohort) and 34,616 adults without T2D from the U.K. Biobank (UKB) (replication cohort). Cox proportional hazard models were used for estimation of protein-T2D associations. Mediation analysis was performed to assess the mediating roles of biomarkers in case-control studies nested in the WHI.

RESULTS

In the WHI, 15,842 incident T2D cases were identified during a median follow-up of 15.8 years. Intake of animal protein was associated with increased T2D risk (hazard ratio in comparing the highest to the lowest quintile = 1.31 [95% CI 1.24-1.37]) and plant protein with decreased risk (0.82 [0.78-0.86]). Intakes of red meat, processed meat, poultry, and eggs were associated with increased T2D risk and whole grains with decreased risk. Findings from the UKB were similar. These findings were materially attenuated after additional adjustment for BMI. Substituting 5% energy from plant protein for animal protein was associated with 21% decreased T2D risk (0.79 [0.74-0.84]), which was mediated by levels of hs-CRP, interleukin-6, leptin, and SHBG.

CONCLUSIONS

Findings from these two large prospective cohorts support the notion that substituting plant protein for animal protein may decrease T2D risk mainly by reducing obesity-related inflammation.

Dietary Plant Sterols and Phytosterol-Enriched Margarines and Their Relationship with Cardiovascular Disease among Polish Men and Women: The WOBASZ II Cross-Sectional Study

Dietary cholesterol has been suggested to increase the risk of cardiovascular disease (CVD). Phytosterols, present in food or phytosterol-enriched products, can reduce cholesterol available for absorption. The present study aimed to investigate the association between habitual intake of total and individual plant sterols (β-sitosterol, campesterol, and stigmasterol) or a diet combined with phytosterol-enriched products and CVD in a cross-section of Polish adults, participants of the Multicenter National Health Survey II (WOBASZ II). Among men (n = 2554), median intakes of plant sterols in terciles ranged between 183−456 mg/d and among women (n = 3136), 146−350 mg/d in terciles. The intake of phytosterols, when consumed with food containing phytosterols, including margarine, ranged between 184−459 mg/d for men and 147−352 mg/d for women. Among both men and women, beta-sitosterol intake predominated. Plant sterol intake was lower among both men and women with CVD (p = 0.016) compared to those without CVD. Diet quality, as measured by the Healthy Diet Index (HDI), was significantly higher in the third tercile of plant sterol intake for both men and women and the entire study group (p < 0.0001). This study suggests that habitual dietary intake of plant sterols may be associated with a lower chance of developing CVD, particularly in men.

Adherence to a cholesterol-lowering diet and the risk of prostate cancer

Evidence suggests a role of serum cholesterol in prostate cancer (PCa) development and of lipid lowering medications in PCa risk reduction. We developed a score for adherence to an established cholesterol-lowering diet and evaluated its association with PCa risk in a multicentric hospital-based case-control study (1294 cases; 1451 matched controls) in Italy (1992-2001). The score was derived from seven dietary indicators which have been reported to lower cholesterol levels: high intake of non-cellulosic polysaccharides (viscous fibres), monounsaturated fatty acids, legumes, seeds/corn oil; low intake of saturated fatty acids, dietary cholesterol, and glycaemic index. Odds ratios (ORs) and corresponding confidence intervals (CIs) were calculated through the unconditional logistic regression model. Although most of the dietary indicators alone were not significantly associated with reduced PCa risk, men who fulfilled 5 to 7 dietary indicators (187 cases and 281 controls) showed a 43% reduction in PCa risk compared to those with 0 to 2 indicators (OR: 0.57; 95% CI: 0.43-0.77). This association was not modified by socio-demographic characteristics or lifestyle factors. In conclusion, adherence to a cholesterol-lowering diet is a favourable factor against the risk of PCa, providing support to dietary guidelines that promote cholesterol reduction through plant-based diets.

Reduction in Serum LDL Cholesterol Using a Nutrient Compendium in Hyperlipidemic Adults Unable or Unwilling to Use Statin Therapy: A Double-Blind Randomized Crossover Clinical Trial

BACKGROUND

Many hyperlipidemic patients prescribed β-hydroxy-β-methylglutaryl coenzyme A reductase inhibitors (statins) are unable or unwilling to take them. A hedonically acceptable snack-based solution formulated from cholesterol-lowering food ingredients could represent a therapeutic alternative but has not been tested in this population.

OBJECTIVES

To evaluate the effect of snacks containing a compendium of functional bioactives on fasting LDL cholesterol in statin candidates unwilling to use or intolerant to ≥1 statin drug. Secondary outcomes included changes in circulating total cholesterol (TC), triglycerides, HDL cholesterol, fasting glucose, insulin, and high-sensitivity C-reactive protein concentrations, as well as effects of single-nucleotide polymorphisms (SNPs) on outcome.

METHODS

This multicenter, randomized, double-blind, free-living crossover study was composed of 2 regimented phases of 4 wk each, separated by a 4-wk washout. Eighteen men and 36 women, with a mean ± SD age of 49 ± 12 y and mean ± SD LDL cholesterol of 131 ± 32.1 mg/dL,  were instructed to ingest a variety of ready-to-eat snacks twice daily as a substitute for something they were consuming already. Other behavior changes were actively discouraged. Treatment products provided ≥5 g fiber, 1000 mg ω-3 (n-3) fatty acids, 1000 mg phytosterols, and 1800 μmol antioxidants per serving. Control products were calorie-matched like-items drawn from the general grocery marketplace. Serum lipids were measured at baseline and the end of each phase and compared using the ANOVA model. Compliance to study foods was confirmed by serum 18:3n-3 concentration assessment.

RESULTS

Comparing intervention phase endpoints, LDL cholesterol was reduced a mean ± SD of 8.80 ± 1.69% (P < 0.0001), and TC was reduced a mean ± SD of 5.08 ± 1.12% (P < 0.0001) by treatment foods compared with control foods, whereas effects on other analytes did not differ between treatments. SNPs were not significantly related to outcomes (P ≥ 0.230). Compliance with study foods was 95%.

CONCLUSIONS

Consumption of hedonically acceptable snacks containing a compendium of cholesterol-lowering bioactive compounds can rapidly and meaningfully reduce LDL cholesterol in adult patients unable or unwilling to take statin drugs. This trial was registered at clinicaltrials.gov as NCT02341924.

A Sample of Female Adolescent Self-Identified Vegetarians in New Zealand Consume Less Protein and Saturated Fat, but More Fiber than Their Omnivorous Peers

This study aimed to describe the intake and food sources of macronutrients in vegetarian and non-vegetarian adolescent females. Cross-sectional data was collected between February and September 2019. Adolescent females, aged 15 to 18 years old, were recruited throughout New Zealand. Intakes were assessed via two 24-h diet recalls, adjusted to represent usual intake using the multiple source method. Of the 254 participants, 38 self-identified as vegetarian. Vegetarians had similar carbohydrate and fat intakes compared to non-vegetarians; however, their protein intakes were 2.1% kJ lower (95% confidence interval (CI) −3.0 to −1.1%). Vegetarians also consumed 1.1% kJ less saturated fat (95% CI –2.1 to −0.1%), 1.3% kJ (95% CI 0.7 to 1.9) more polyunsaturated fat, and 5 g/day (95% CI 1.8 to 8.0) more fiber than non-vegetarians. When consumed, bread-based dishes and discretionary foods were the highest sources of energy, fat, and carbohydrate in both vegetarians and non-vegetarians. This suggests that some adolescents, including vegetarians, were obtaining high amounts of fat and carbohydrate from food groups associated with poorer dietary quality. We recommend further research to assess how the changing food environment is influencing vegetarian eating patterns and their associations with health outcomes in the wider population.

Association between dietary choline and betaine intake and 10.6-year cardiovascular disease in adults

Background

Several studies have assessed the association between dietary choline and betaine and cardiovascular disease (CVD), but their results are inconsistent. The present study aimed to determine the association between dietary intake of choline and betaine and the risk of CVD in the general population over a 10.6-year period of follow-up.

Methods

The present cohort study was conducted on participants in the third wave of the Tehran Lipid and Glucose Study (2006–2008) and was followed-up until March 2018. Dietary intake of choline and betaine was calculated using the United States Department of Agriculture (USDA) database. Patients’ medical records were used to collect data on CVD.

Results

In this study, 2606 subjects with no previous CVD participated and were followed-up for a median of 10.6 years. During the follow-up periods, 187 incidences of CVD were detected. Results of the Cox proportional hazards regression indicated that neither energy-adjusted total choline nor betaine was associated with the incidence of CVD. Among individual choline forms, only higher intake of free choline (FC) was associated with a lower risk of CVD (HR: 0.64, 95% CI: 0.42–0.98). There was no significant association between each 10 mg/d increase in choline and betaine content of each food category and CVD.

Conclusion

Our investigation indicates no association between energy-adjusted total choline and betaine and a 10.6-year risk of CVD among adults. Besides, we found no relationship between individual choline forms (except FC) and CVD. We also found energy-adjusted choline and betaine obtained from food categories were not associated with the risk of CVD.

Meal Replacements for Weight-Related Complications in Type 2 Diabetes: What Is the State of the Evidence?

Comprehensive lifestyle management is a fundamental aspect of diabetes care. Clinical practice guidelines for the nutritional management of diabetes have evolved considerably over the last 25 years shifting from a focus on single nutrients to food- and dietary pattern-based recommendations. Use of meal replacements as a temporary short-term strategy to induce weight loss and then transitioning to a healthier dietary pattern (e.g., Mediterranean or Portfolio) for weight loss maintenance fits well with this new shift in focus of clinical practice guidelines. As adherence is the most important determinant for attaining the benefits of any diet, health professionals should recommend evidence-based dietary patterns (including meal replacements) that align best with the patient's values, preferences, and treatment goals.

Changes in blood lipid levels after a digitally-enabled, cardiometabolic preventive health program: a pre-post study in an adult, Dutch general population cohort (Preprint)

Background

Despite widespread education, many individuals fail to follow basic health behaviors such as consuming a healthy diet and exercising. Positive changes in lifestyle habits are associated with improvements in multiple cardiometabolic health risk factors, including lipid levels. Digital lifestyle interventions have been suggested as a viable complement or potential alternative to conventional health behavior change strategies. However, the benefit of digital preventive interventions for lipid levels in a preventive health context remains unclear.

Objective

This observational study aimed to determine how the levels of lipids, namely total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, non-HDL cholesterol, and triglycerides, changed over time in a Dutch general population cohort undergoing a digital preventive health program. Moreover, we looked to establish associations between lifestyle factors at baseline and lipid levels.

Methods

We included 348 adults from the Dutch general population who underwent a digitally enabled preventive health program at Ancora Health between January 2020 and October 2021. Upon enrollment, participants underwent a baseline assessment involving a comprehensive lifestyle questionnaire, a blood biochemistry panel, physical measurements, and cardiopulmonary fitness measurements. Thereafter, users underwent a lifestyle coaching program and could access the digital application to register and track health behaviors, weight, and anthropometric data at any time. Lipid levels were categorized as normal, elevated, high, and clinical dyslipidemia according to accepted international standards. If at least one lipid marker was high or HDL was low, participants received specific coaching and advice for cardiometabolic health. We retrospectively analyzed the mean and percentage changes in lipid markers in users who were remeasured after a cardiometabolic health–focused intervention, and studied the association between baseline user lifestyle characteristics and having normal lipid levels.

Results

In our cohort, 199 (57.2%) participants had dyslipidemia at baseline, of which 104 participants were advised to follow a cardiometabolic health–focused intervention. Eating more amounts of favorable food groups and being more active were associated with normal lipid profiles. Among the participants who underwent remeasurement 9 months after intervention completion, 57% (17/30), 61% (19/31), 56% (15/27), 82% (9/11), and 100% (8/8) showed improvements at remeasurement for total, LDL, HDL, and non-HDL cholesterol, and triglycerides, respectively. Moreover, between 35.3% and 77.8% showed a return to normal levels. In those with high lipid levels at baseline, total cholesterol decreased by 0.5 mmol/L (7.5%), LDL cholesterol decreased by 0.39 mmol/L (10.0%), non-HDL cholesterol decreased by 0.44 mmol/L (8.3%), triglycerides decreased by 0.97 mmol/L (32.0%), and HDL increased by 0.17 mmol/L (15.6%), after the intervention.

Conclusions

A cardiometabolic screening program in a general population cohort identified a significant portion of individuals with subclinical and clinical lipid levels. Individuals who, after screening, actively engaged in a cardiometabolic health–focused lifestyle program improved their lipid levels.

Prospective Association of the Portfolio Diet with All-Cause and Cause-Specific Mortality Risk in the Mr. OS and Ms. OS Study

The Portfolio Diet has demonstrated its cardiovascular benefit from interventions, but the association between Portfolio Diet adherence and the risk of all-cause and cause-specific mortality has not been examined in Chinese population. The present study has collected Portfolio Diet adherence (assessed by food frequency questionnaire), lifestyle factors and mortality status of 3991 participants in the Mr. Osteoporosis (OS) and Ms. OS Study. Cox regression models were used to examine the association between the Portfolio Diet adherence and mortality risk (all-cause, cardiovascular disease or cancer). The highest quartile of the Portfolio Diet score was associated with a 28% lower risk of all-cause (hazard ratio, HR: 0.72) and cancer (HR: 0.72) mortality, respectively. The association between Portfolio Diet adherence and cardiovascular disease mortality did not reach statistical significance (HR: 0.90, 95% CI = 0.64, 1.26). Among male participants, the highest adherence to the Portfolio Diet was also associated with a lower risk of all-cause (HR: 0.63) and cancer mortality (HR: 0.59), and there was an inverse association between food sources of plant protein and the risk of cardiovascular mortality (HR: 0.50). However, most associations between the Portfolio Diet and mortality were not significant among females. The protection for cancer mortality risk might reach the plateau at the highest adherence to the Portfolio Diet for females. To conclude, greater adherence to the Portfolio Diet was significantly associated with a lower risk of mortality in Hong Kong older adults, and the associations appeared stronger among males.

Adherence to a Plant-Based Diet and Consumption of Specific Plant Foods-Associations with 3-Year Weight-Loss Maintenance and Cardiometabolic Risk Factors: A Secondary Analysis of the PREVIEW Intervention Study

Plant-based diets are recommended by dietary guidelines. This secondary analysis aimed to assess longitudinal associations of an overall plant-based diet and specific plant foods with weight-loss maintenance and cardiometabolic risk factors. Longitudinal data on 710 participants (aged 26–70 years) with overweight or obesity and pre-diabetes from the 3-year weight-loss maintenance phase of the PREVIEW intervention were analyzed. Adherence to an overall plant-based diet was evaluated using a novel plant-based diet index, where all plant-based foods received positive scores and all animal-based foods received negative scores. After adjustment for potential confounders, linear mixed models with repeated measures showed that the plant-based diet index was inversely associated with weight regain, but not with cardiometabolic risk factors. Nut intake was inversely associated with regain of weight and fat mass and increments in total cholesterol and LDL cholesterol. Fruit intake was inversely associated with increments in diastolic blood pressure, total cholesterol, and LDL cholesterol. Vegetable intake was inversely associated with an increment in diastolic blood pressure and triglycerides and was positively associated with an increase in HDL cholesterol. All reported associations with cardiometabolic risk factors were independent of weight change. Long-term consumption of nuts, fruits, and vegetables may be beneficial for weight management and cardiometabolic health, whereas an overall plant-based diet may improve weight management only.

Development of a Portfolio Diet Score and Its Concurrent and Predictive Validity Assessed by a Food Frequency Questionnaire

The Portfolio Diet, a plant-based portfolio of cholesterol-lowering foods, has been shown to reduce low-density lipoprotein cholesterol (LDL-C), and other cardiovascular risk factors, in randomized controlled trials (RCTs). It is not known if these beneficial effects translate to a lower incidence OF cardiovascular disease (CVD). To support examinations between Portfolio Diet adherence and disease, a Portfolio Diet score (PDS) was developed and its predictive and concurrent validity was assessed within the Toronto Healthy Diet Study, a six-month RCT in overweight adults. Predictive validity was assessed using change in the PDS measured by food frequency questionnaire (FFQ) and concomitant change in LDL-C from baseline to six months using multiple linear regression, adjusted for potential confounders (n = 652). Concurrent validity was assessed in a subset of participants (n = 50) who completed the FFQ and a 7-day diet record (7DDR) at baseline. The PDS determined from each diet assessment method was used to derive correlation coefficients and Bland–Altman plots to assess the between-method agreement. The change in PDS was inversely associated with change in LDL-C (β coefficients: −0.01 mmol/L (95% confidence intervals (CIs): −0.02, −0.002; p = 0.02). The correlation between the PDS from the FFQ and 7DDR was 0.69 (95% CIs: 0.48, 0.85). The Bland–Altman plot showed reasonable agreement between the score from the FFQ and 7DDR. These findings indicate predictive validity of the PDS with lower LDL-C, and reasonable concurrent validity of the PDS as assessed by an FFQ against a 7DDR.