Impact of different dietary approaches on blood lipid control in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis

The effects of major dietary patterns on patients with type 2 diabetes: Protocol for a systematic review and network meta-analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) represents a significant worldwide health issue, experiencing an increasing incidence rate. Effective dietary strategies are vital for T2DM management, but the optimal dietary patterns remain debated due to inconsistent research outcomes and single-outcome reporting. Network Meta-Analysis (NMA) provides a powerful approach for integrating data from randomized controlled trials (RCTs), enabling a detailed evaluation of the impact of different dietary patterns. This document presents our strategy for a systematic review and network meta-analysis, aimed at assessing the influence of key dietary patterns on glycemic control, lipid profiles, and weight management in individuals with Type 2 Diabetes Mellitus (T2DM).

MATERIALS AND METHODS

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and network meta-analyses guidelines, we conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library, without language or date restrictions. Our objective is to assess the efficacy of various dietary interventions in managing Type 2 Diabetes Mellitus (T2DM). We used standardized mean differences for pairwise comparisons and a Bayesian framework for ranking interventions via Surface Under the Cumulative Ranking Curve (SUCRA). Key analyses include heterogeneity, transitivity, and sensitivity assessments, along with quality and risk evaluations using the Cochrane Collaboration's tool and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

ETHICS AND DISSEMINATION

This systematic review and network meta-analysis involve aggregate data from previous trials, obviating the need for additional ethical approval. The search strategy will be executed starting October 2023, with all searches completed by December 2023, to encompass the most current studies available. Findings will be shared through academic conferences and peer-reviewed journals focused on diabetes care and nutrition.

TRIAL REGISTRATION

PROSPERO registration number CRD42023465791.

The potential causal effect of the pre-pregnancy dietary phytochemical index on gestational diabetes mellitus: a prospective cohort study

BACKGROUND

Phytochemicals are non-nutritive bioactive compounds with beneficial effects on the metabolism of glucose. This study aimed to clarify the possible causal effect of the pre-pregnancy dietary phytochemical index (DPI) on gestational diabetes mellitus (GDM).

METHODS

In this prospective cohort study 1,856 pregnant women aged 18-45 years who were in their first trimester, were recruited and followed up until delivery. The dietary intakes of participants were examined using an interviewer-administered validated 168-item semi-quantitative food frequency questionnaire (FFQ). Inverse probability weighting (IPW) of propensity scores (PS), estimated from the generalized boosted model (GBM) were used to obtain a adjusted risk ratio (aRR) for potential confounders.

RESULTS

During the follow-up period, 369 (19.88%) women were diagnosed with GDM. DPI scores ranged from 6.09 to 89.45. There was no association between DPI scores and GDM (aRR: 1.01, 95% confidence interval [CI]: 0.92, 1.08; p trend = 0.922). When comparing DPI quartile 4 (most pro-phytochemical content) to quartile 1 (few phytochemical contents), there was no significant difference between them (aRR: 0.97; 95% CI: 0.75, 1.25; p = 0.852). Also, there was no significant difference between DPI quartile 3 and quartile 1 (aRR: 1.04; 95% CI: 0.81, 1.34; p = 0.741) as well as DPI quartile 2 and quartile 1 (aRR: 0.92; 95% CI: 0.71, 1.21; p = 0.593).

CONCLUSIONS

Although this data did not support the association between pre-pregnancy DPI scores and GDM, further cohort studies to ascertain the causal association between them are warranted.

Association of dietary patterns with diabetes-related comorbidities varies among diabetes endotypes

BACKGROUND AND AIMS

Differences of dietary pattern adherence across the novel diabetes endotypes are unknown. This study assessed adherence to pre-specified dietary patterns and their associations with cardiovascular risk factors, kidney function, and neuropathy among diabetes endotypes.

METHODS AND RESULTS

The cross-sectional analysis included 765 individuals with recent-onset (67 %) and prevalent diabetes (33 %) from the German Diabetes Study (GDS) allocated into severe autoimmune diabetes (SAID, 35 %), severe insulin-deficient diabetes (SIDD, 3 %), severe insulin-resistant diabetes (SIRD, 5 %), mild obesity-related diabetes (MOD, 28 %), and mild age-related diabetes (MARD, 29 %). Adherence to a Mediterranean diet score (MDS), Dietary Approaches to Stop Hypertension (DASH) score, overall plant-based diet (PDI), healthful (hPDI) and unhealthful plant-based diet index (uPDI) was derived from a food frequency questionnaire and associated with cardiovascular risk factors, kidney function, and neuropathy using multivariable linear regression analysis. Differences in dietary pattern adherence between endotypes were assessed using generalized mixed models. People with MARD showed the highest, those with SIDD and MOD the lowest adherence to the hPDI. Adherence to the MDS, DASH, overall PDI, and hPDI was inversely associated with high-sensitivity C-reactive protein (hsCRP) among people with MARD (β (95%CI): -9.18 % (-15.61; -2.26); -13.61 % (-24.17; -1.58); -19.15 % (-34.28; -0.53); -16.10 % (-28.81; -1.12), respectively). Adherence to the PDIs was associated with LDL cholesterol among people with SAID, SIRD, and MOD.

CONCLUSIONS

Minor differences in dietary pattern adherence (in particular for hPDI) and associations with markers of diabetes-related complications (e.g. hsCRP) were observed between endotypes. So far, evidence is insufficient to derive endotype-specific dietary recommendations.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01055093.

Relationships between sodium, fats and carbohydrates on blood pressure, cholesterol and HbA1c: an umbrella review of systematic reviews

Background

The relationship between nutrition and health is complex and the evidence to describe it broad and diffuse. This review brings together evidence for the effect of nutrients on cardiometabolic risk factors.

Methods

An umbrella review identified systematic reviews of randomised controlled trials and meta-analyses estimating the effects of fats, carbohydrates and sodium on blood pressure, cholesterol and haemoglobin A1c (HbA1c). Medline, Embase, Cochrane Library and Science Citation Index were search through 26 May 2020, with supplementary searches of grey literature and websites. English language systematic reviews and meta-analyses were included that assessed the effect of sodium, carbohydrates or fat on blood pressure, cholesterol and HbA1c. Reviews were purposively selected using a sampling framework matrix. The quality of evidence was assessed with A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR2) checklist, evidence synthesised in a narrative review and causal pathways diagram.

Results

Forty-three systematic reviews were included. Blood pressure was significantly associated with sodium, fibre and fat. Sodium, fats and carbohydrates were significantly associated with cholesterol. Monounsaturated fat, fibre and sugars were associated with HbA1c.

Conclusion

Multiple relationships between nutrients and cardiometabolic risk factors were identified and summarised in an accessible way for public health researchers. The review identifies associations, inconsistencies and gaps in evidence linking nutrition to cardiometabolic health.

Mediterranean diet trajectories and 20-year incidence of cardiovascular disease: The ATTICA cohort study (2002-2022)

BACKGROUND AND AIMS

Only few studies have assessed longitudinal dietary trends in relation to cardiovascular disease (CVD) risk. We aimed to evaluate the association between adherence to the Mediterranean diet, both baseline and longitudinal, and 20-year CVD incidence.

METHODS AND RESULTS

This was a prospective study among 1988 Greek adults (50% men, age: 45 ± 14years). Adherence to the Mediterranean diet was evaluated at baseline and 10 years through the MedDietScore, based on which longitudinal Mediterranean diet trajectories were identified. CVD incidence was recorded at 20 years. Each one-unit increase in baseline MedDietScore was associated with an 8% reduction in 20-year CVD incidence. Compared to subjects in the lowest tertile of baseline MedDietScore, those in the highest exhibited a 44% lower 20-year CVD risk (relative risk: 0.56, 95% confidence interval: 0.32, 0.97) adjusted for age, sex, baseline body mass index, smoking, physical activity, presence of hypercholesterolemia, hypertension and diabetes mellitus, and family history of CVD; further adjustment for high-sensitivity C-reactive protein, uric acid and estimated glomerular filtration rate attenuated this association. Results were similar in models adjusted for longitudinal changes in body weight, physical activity and smoking, and 10-year medical status. Mediterranean diet trajectory analysis revealed that 24.7%, 8.6%, 45.8% and 20.9% of participants longitudinally sustained a low adherence, moved closer, moved away or sustained a high adherence, respectively; among those, the corresponding CVD incidence was 63.3%, 65.5%, 28.1% and 9.4% (p-value<0.001).

CONCLUSION

The Mediterranean diet offers long-term protection against CVD, part of which is mediated by inflammation, uricemia and renal function.

Effects of combined aerobic exercise and diet on cardiometabolic health in patients with obesity and type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Lifestyle modifications involving diet and exercise are recommended for patients diagnosed with obesity and type 2 diabetes mellitus (T2DM). The purpose of this review was to systematically evaluate the effects of combined aerobic exercise and diet (AEDT) on various cardiometabolic health-related indicators among individuals with obesity and T2DM.

METHODOLOGY

A comprehensive search of the PubMed/Medline, Web of Science, Scopus, Science Direct, Cochrane, and Google Scholar databases was conducted for this meta-analysis. The Cochrane risk of bias tool was used to evaluate eligible studies, and the GRADE tool was used to rate the certainty of evidence. A random-effects model for continuous variables was used, and the results were presented as mean differences or standardised mean differences with 95% confidence intervals.

RESULTS

A total of 16,129 studies were retrieved; 20 studies were included, and data were extracted from 1,192 participants. The findings revealed significant improvements in body mass index, body weight, waist circumference, systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, fasting blood glucose, fasting plasma insulin, glycated hemoglobin, leptin, interleukin-6, C-reactive protein, and adiponectin (p < 0.05) compared to the standard treatment (ST) group. No significant differences were observed between the AEDT and ST groups in fat mass, hip circumference, waist-to-hip ratio, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and tumor necrosis factor-alpha. The present findings are based on low- to moderate-quality evidence.

CONCLUSIONS

AEDT may be a critical behavior for holistic cardiometabolic health-related benefits as a contemporary anti-obesity medication due to its significant positive impact on patients with obesity and T2DM. Nevertheless, further robust evidence is necessary to determine whether AEDT is an effective intervention for lowering cardiovascular and metabolic risk factors among individuals with obesity and T2DM.

Diet in the management of type 2 diabetes: umbrella review of systematic reviews with meta-analyses of randomised controlled trials

Objective

To systematically summarise and evaluate the existing evidence on the effect of diet on the management of type 2 diabetes and prevention of complications.

Design

Umbrella review of systematic reviews with meta-analyses of randomised controlled trials.

Data sources

PubMed, Embase, Epistemonikos, and Cochrane, from inception up to 5 June 2022.

Eligibility criteria for selecting studies

Systematic reviews with meta-analyses of randomised controlled trials reporting summary effect estimates on the effect of diet on any health outcome in populations with type 2 diabetes were included in the review. Only meta-analyses with randomised controlled trials with the duration of at least 12 weeks were eligible for inclusion. Summary data were extracted by two investigators independently. Summary effect estimates with 95% confidence intervals were recalculated with a random effects model if the information provided was insufficient. Methodological quality was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 tool and the certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach.

Results

88 publications with 312 meta-analyses of randomised controlled trials were included. Methodological quality was high to moderate in 23% and low to very low in 77% of the included publications. A high certainty of evidence was found for the beneficial effects of liquid meal replacement on reducing body weight (mean difference -2.37 kg, 95% confidence interval -3.30 to -1.44; n=9 randomised controlled trials included in the meta-analysis) and body mass index (-0.87, -1.32 to -0.43; n=8 randomised controlled trials), and of a low carbohydrate diet (<26% of total energy) on levels of haemoglobin A1c (-0.47%, -0.60% to -0.34%; n=17 randomised controlled trials) and triglycerides (-0.30 mmol/L, -0.43 to -0.17; n=19 randomised controlled trials). A moderate certainty of evidence was found for the beneficial effects of liquid meal replacement, plant based, Mediterranean, high protein, low glycaemic index, and low carbohydrate diets (<26% total energy) on various cardiometabolic measures. The remaining results had low to very low certainty of evidence.

Conclusions

The evidence indicated that diet has a multifaceted role in the management of type 2 diabetes. An energy restricted diet can reduce body weight and improve cardiometabolic health. Beyond energy restriction, dietary approaches such as plant based, Mediterranean, low carbohydrate (<26% total energy), or high protein diets, and a higher intake of omega 3 fatty acids can be beneficial for cardiometabolic health in individuals with type 2 diabetes.

Systematic review registration

PROSPERO CRD42021252309.

Effects of Nutrition Education with Intervention Mapping on Cardiovascular Disease Risk Factors in Women with Borderline Dyslipidemia: Analysis According to Menopausal Status

Background

Menopause causes hormonal, physical, and psychological changes that are associated with an increase in risk of cardiovascular disease (CVD). This study examined the effects of medical nutrition therapy (MNT) on CVD risk factors in pre- and post-menopausal women with borderline dyslipidemia in Korea.

Methods

In total, 76 participants were divided into the MNT and control groups. MNT was performed for 12 weeks using intervention mapping with consideration of weight, blood lipid levels, and dietary assessment results. Anthropometric and biochemical measurements and dietary intake were analyzed.

Results

The dietary energy and cholesterol intake, waist circumference (WC), blood triacylglycerol and very-low-density lipoprotein cholesterol levels, and atherogenic index (AI) of the pre-menopausal MNT group decreased significantly after the intervention. Moreover, dietary cholesterol intake, WC, waist-to-hip ratio, body fat percentage, total blood cholesterol, low-density lipoprotein to high-density lipoprotein ratio, and AI decreased significantly in the post-menopausal MNT group after the intervention.

Conclusion

MNT for 12 weeks is effective in decreasing risk factors associated with CVD in Korean women with borderline dyslipidemia, and the effects differ between pre- and post-menopausal women.

Association between an Anti-Inflammatory Dietary Score and Periodontitis-Evidence from the Population-Based Hamburg City Health Study

While the effects of dietary patterns on cardiovascular risk and diabetes have been well studied, the evidence is scarce as to which diet has the greatest anti-inflammatory potential and how dietary patterns are associated with periodontitis. In the Hamburg City Health Study (HCHS), we developed an anti-inflammatory dietary score using a data-driven approach based on the relationship of relevant selected food groups with inflammatory biomarkers (hsCRP and IL-6). The aim of this cross-sectional study was to evaluate the association between the anti-inflammatory dietary score and the incidence of periodontitis in Hamburg, Germany. A total of n = 5642 participants fit the required inclusion criteria and were selected for analysis. Periodontal disease was assessed using probing depth, gingival recession, and bleeding on probing. Dietary intake was measured using a food frequency questionnaire (FFQ). A self-developed anti-inflammatory dietary score served as the key explanatory variable. Higher scores reflected lower inflammatory processes (measured through the biomarkers hsCRP and IL-6). Several covariates were included in the regression analysis. Regressions revealed that a higher anti-inflammatory dietary score was significantly associated with lower odds to be affected by periodontal disease in an unadjusted model (OR 0.86, 95% CI 0.82-0.89, p < 0.001) and in an adjusted model (age, sex, smoking, diabetes, hypertension, and physical activity) (OR 0.93, 95% CI 0.89-0.98, p = 0.003). Our study demonstrated a significant inverse association between an anti-inflammatory dietary score and periodontitis. Individuals with higher intake of proinflammatory nutrition should be specifically addressed to avoid periodontitis.

Consumption of Pulses among Chilean Vegetarians and Non-Vegetarians during the Covid-19 Pandemic

The aim of the present study was to compare the frequency of consumption, access to purchase, and type of preparations with pulses among people who eat a vegetarian/vegan or non-vegetarian diet during the COVID-19 pandemic.

Cross-sectional surveys were distributed using different digital platforms and social networks. We investigated the frequency of consumption, access to purchase any type of preparations. Descriptive analyses were performed. Differences between the types of diet were tested by Chi-squared statistics.

A total of 3339 adults participated in the survey in March 2021, 80% of the total participants were females; 13.6% were vegetarian or vegan (VV). The consumption of pulses increased by 25% among non-vegetarians and 54.5% in VV (p by 25% among non-vegetarians and 54.5% in VV (vey in March 2021, 80% of the total participants were females; 13.6% were vegetarian or vegan (VV). The consumption of pulses preparations. Descriptive analyses were performfood with high satiating power, when compared with the opinions of non-vegetarians (p ood with high satiating power, when cconsumption of pulses were observed in less than 30% of the respondents, but the percentage was lower among VV, the most common negative beliefs are "They are difficult to prepare" and "My family does not like them." Food preparations including pulses are more diverse among VV, and consumption being significantly higher in the 10 alternatives of preparations included in the study.

These results highlight the importance of identifying the knowledge, practices, frequency, and preferences of consumption of legumes in the population to stimulate their consumption. Although we observed an increase in the consumption of legumes among those in the sample, the VV group showed a higher frequency of consumption, consumption of different types of legumes and varied preparation, and greater knowledge about the beneficial properties of legumes.

Does the Mediterranean Diet Have Any Effect on Lipid Profile, Central Obesity and Liver Enzymes in Non-Alcoholic Fatty Liver Disease (NAFLD) Subjects? A Systematic Review and Meta-Analysis of Randomized Control Trials

The effectiveness of the Mediterranean diet (MD) in non-alcoholic fatty liver disease (NAFLD) subjects has been evaluated in several randomized controlled trials (RCTs). This systematic review and meta-analysis aimed to evaluate the overall effects of MD intervention in a cohort of NAFLD patients targeting specific markers such as central obesity, lipid profile, liver enzymes and fibrosis, and intrahepatic fat (IHF). Google Scholar, PubMed, and Scopus were explored to collect relevant studies from the last 10 years. RCTs with NAFLD subjects were included in this systematic review with a mean intervention duration from 6 weeks to 1 year, and different intervention strategies, mainly including energy restriction MD (normal or low glycaemic index), low-fat MD with increased monounsaturated and polyunsaturated fatty acids, and increased exercise expenditure. The outcomes measured in this meta-analysis were gamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), total cholesterol (TC), waist circumference (WC), and liver fibrosis. Ten randomized controlled trials, which involved a total of 737 adults with NAFLD, were included. According to the results, the MD seems to decrease the liver stiffness (kPa) by -0.42 (CI95% -0.92, 0.09) (p = 0.10) and significantly reduce the TC by -0.46 mg/dl (CI95% -0.55, -0.38) (p = 0.001), while no significant findings were documented for liver enzymes and WC among patients with NAFLD. In conclusion, the MD might reduce indirect and direct outcomes linked with NAFLD severity, such as TC, liver fibrosis, and WC, although it is important to consider the variations across trials. Further RCTs are necessary to corroborate the findings obtained and provide further evidence on the role of the MD in the modulation of other disorders related to NAFLD.

Association of Mediterranean diet adherence during pregnancy with maternal and neonatal lipid, glycemic and inflammatory markers: The GESTAFIT project

To examine the association of Mediterranean diet (MD) adherence during pregnancy with maternal and neonatal lipid, glycemic, and inflammatory markers. This study included 152 women from the GESTAFIT trial and a subsample of 35 newborns. The Mediterranean Diet Score, derived from food frequency questionnaires, was employed to assess MD adherence. Total cholesterol, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), triglycerides, and glucose were assessed in the mother (at the 16th and 34th gestational weeks [g.w.]) and in cord arterial and venous serum with standard procedures using an autoanalyzer. Pro-inflammatory and anti-inflammatory cytokines (interleukin [IL]-6, IL-8, IL-10, IL-1beta, interferon gamma, and tumour necrosis factor alpha [TNF-α]) were measured with Luminex xMAP technology. A greater MD adherence was associated with higher HDL-C and lower LDL-C, LDL-C/HDL-C ratio, triglycerides, triglycerides/HDL-C ratio, and TNF-α in the mother at the 16th and the 34th g.w. (|β|: 0.191-0.388, p < 0.05). A higher intake of whole grain cereals, fruits, vegetables and fish and a lower intake of sweets were associated with higher HDL-C and lower LDL-C, LDL-C/HDL-C ratio, triglycerides, triglycerides/HDL-C ratio, and TNF-α at the 16th and 34th g.w. (|β|: 0.188-0.334, p < 0.05). No associations were found with the cord arterial and venous serum markers (p > 0.05). A greater MD adherence during pregnancy, driven by a higher intake of whole grain cereals, fruits, vegetables and fish, and a lower intake of sweets, was positively associated with the maternal lipid and inflammatory serum markers throughout gestation. MD adherence during pregnancy was not associated with cord serum markers.

Effect of calorie restriction in comparison to usual diet or usual care on remission of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Limited evidence is available about the dose-dependent effects of calorie restriction in patients with type 2 diabetes.

OBJECTIVE

To gather available evidence on the effect of calorie restriction on management of type 2 diabetes.

METHODS

We systematically searched PubMed, Scopus, CENTRAL, Web of Science, and gray literature to November 2022 for randomized trials longer than 12 weeks looking at the effect of a pre-specified calorie-restricted diet on remission of type 2 diabetes. We performed random-effects meta-analyses to estimate the absolute effect (risk difference) at 6-month (6±3 months) and 12-month (12±3 months) follow-ups. We performed dose-response meta-analyses to estimate mean difference (MD) for the effects of calorie restriction on cardiometabolic outcomes. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to judge the certainty of evidence.

RESULTS

28 randomized trials with 6281 participants were included. Using a remission definition of glycated hemoglobin (HbA_1c) <6.5% without antidiabetic medication use, calorie-restricted diets increased remission by 38 more per 100 patients (95%CI: 9 more, 67 more; n=5 trials, GRADE=moderate) at 6-month, and by 13 more per 100 patients (95%CI: 10 more, 18 more; n=4, GRADE=moderate) at 12-month in comparison to usual diet or usual care. Using a definition of HbA_1c<6.5% after at least two months cessation of antidiabetic medications, remission increased by 34 more per 100 patients (95%CI: 15 more, 53 more; n=1, GRADE=very low) at 6-month and by 16 more per 100 patients (95%CI: 4 more, 49 more; n=2, GRADE=low) at 12-month. At 6-month, each 500 kcal/day decrease in energy intake resulted in clinically meaningful reductions in body weight (MD: -6.33 kg, 95%CI: -7.76, -4.90; n=22; GRADE=high) and HbA_1c (MD: -0.82%, 95%CI: -1.05, -0.59; n=18, GRADE=high), which attenuated remarkably at 12-month.

CONCLUSIONS

Calorie-restricted diets may be effective interventions for type 2 diabetes remission, especially when coupled with an intensive lifestyle modification program.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42022300875).

Design of a randomized cross-over study evaluating effects of carbohydrate intake on glycemic control in persons with type 1 diabetes

Introduction

Diet is an important factor in managing glycemic control in type 1 diabetes (T1D). Reducing carbohydrate intake may be important for stabilizing blood glucose levels in certain groups of patients with T1D. There are few studies examining the effects of a low carbohydrate diet in patients with T1D. The aim of this study is to investigate the effects of carbohydrate intake on glucose control in adults with T1D.

Materials and methods

Adults with T1D (N = 54) and inadequate glycemic control (HbA1c ≥ 7.5%; 58 mmol/mol) were randomized in a cross-over design to a moderate carbohydrate diet (30 percent of total energy from carbohydrates) versus a traditional diabetes diet (50 percent of total energy from carbohydrates) for 4 weeks with a between wash-out period of 4 weeks. Masked continuous glucose monitoring was used throughout the study to evaluate effects on mean blood glucose levels, time-in-range, hypoglycemia, hyperglycemia, and glycemic variability. Diabetes treatment satisfaction, hypoglycemic confidence, and physical activity were measured using questionnaires during different phases of the trial. HbA1c, blood lipids, blood pressure, and ketone levels were also measured. The primary endpoint is the difference in mean blood glucose level between the diet periods. Study completion is anticipated during winter 2022.

Discussion

The study seeks to increase knowledge about the effects of dietary carbohydrate intake on glycemic control and other health parameters in patients with T1D. If beneficial effects on mean blood glucose level without elevated risk of hypoglycemia or ketoacidosis are shown, a moderate carbohydrate diet may be a treatment option for people with T1D that have unsatisfactory blood glucose levels.

Clinical Trials Registration:www.clinicaltrials.gov, ID: NCT03400618.

Effect of dietary patterns on cardiovascular risk factors in people with type 2 diabetes. A systematic review and network meta-analysis

AIMS

To identify the most effective dietary pattern for improving cardiovascular risk factors in people with type 2 diabetes.

METHODS

PubMed, Embase, the Cochrane library, SCOPUS and Web of Science were systematically searched for randomized controlled trials comparing the effects of dietary patterns on body weight, blood pressure, HbA1c and lipids after 6 and 12 months. Treatment effects were synthesized using Bayesian network meta-analysis. Six-month changes in HbA1c, SBP and LDL-C were used to estimate relative risk reductions (RRR) for cardiovascular events.

RESULTS

Seventy-three RCTs on eight different dietary patterns were included. All reduced body weight and HbA1c after 6 months, with the largest effects from the low carbohydrate (body weight -4.8 kg, 95 %credibility interval (95 %CrI) -6.5;-3.2 kg) and Mediterranean diet (HbA1c -1.0 %, 95 %CrI -15;-0.4 % vs usual diet). There were no significant 6-month blood pressure or lipid effects. Dietary patterns had non-statistically significant 12-months effects. The Mediterranean diet resulted in the largest expected RRR for cardiovascular events: -16 % (95 %CI -31;3.0) vs usual diet.

CONCLUSIONS

In patients with type 2 diabetes, all dietary patterns outperformed usual diet in improving body weight and HbA1c after 6 months and clinically relevant cardiovascular risk reduction could be achieved. There was insufficient evidence to select one optimal dietary pattern.

Dietary Patterns and Non-Communicable Disease Biomarkers: A Network Meta-Analysis and Nutritional Geometry Approach

Quantitative rankings of multiple dietary patterns for their effects on non-communicable disease (NCD) biomarkers is lacking and would inform primary prevention strategies. Accordingly, a network meta-analysis (NMA) was conducted to compare and rank the effects of different dietary patterns on NCD biomarkers, and associations of dietary patterns’ underlying macronutrient composition with NCD biomarkers were determined by a nutritional geometry approach. Randomised controlled trials (RCTs) were eligible for inclusion if they enrolled healthy participants, employed food-based dietary pattern interventions without energy restriction, and reported NCD biomarker outcomes. NCD biomarkers were included as an outcome if ≥10 trials were available. A systematic search of five electronic databases identified 4008 records. Sixty-eight articles from 59 RCTs reporting lipids, glycemic, and inflammatory biomarkers were included for quantitative syntheses. Risk-of-bias was predominantly categorized as low or having some concerns, and confidence-of-evidence low. Relative to western habitual diet, the Mediterranean, Dietary Approaches to Stop Hypertension (DASH), dietary guidelines-based, plant-based, and low-fat diets reduced low-density lipoprotein cholesterol (mean difference range: −0.29 to −0.17 mmol/L), total cholesterol (−0.36 to −0.24 mmol/L), and apolipoprotein B (−0.11 to −0.07 g/L) (all p < 0.05); the Paleo, plant-based and dietary guidelines-based diets reduced homeostasis model assessment of insulin resistance (−0.95 to −0.35, all p < 0.05). No dietary pattern ranked consistently highest. The Paleo diet received the highest all-outcomes-combined average Surface Under the Cumulative Ranking Curve value (67%), followed by DASH (62%) and Mediterranean diets (57%), whereas western habitual diet was lowest (36%). Our findings were independent of macronutrient composition, highlighting the significance of dietary pattern-level analysis.

Comparative efficacy of different eating patterns in the management of type 2 diabetes and prediabetes: An arm-based Bayesian network meta-analysis

AIMS/INTRODUCTION

Diet therapy is a vital approach to manage type 2 diabetes and prediabetes. However, the comparative efficacy of different eating patterns is not clear enough. We aimed to compare the efficacy of various eating patterns for glycemic control, anthropometrics, and serum lipid profiles in the management of type 2 diabetes and prediabetes.

MATERIALS AND METHODS

We conducted a network meta-analysis using arm-based Bayesian methods and random effect models, and drew the conclusions using the partially contextualized framework. We searched twelve databases and yielded 9,534 related references, where 107 studies were eligible, comprising 8,909 participants.

RESULTS

Eleven diets were evaluated for 14 outcomes. Caloric restriction was ranked as the best pattern for weight loss (SUCRA 86.8%) and waist circumference (82.2%), low-carbohydrate diets for body mass index (81.6%), and high-density lipoprotein (84.0%), and low-glycemic-index diets for total cholesterol (87.5%) and low-density lipoprotein (86.6%). Other interventions showed some superiorities, but were imprecise due to insufficient participants and needed further investigation. The attrition rates of interventions were similar. Meta-regression suggested that macronutrients, energy intake, and weight may modify outcomes differently. The evidence was of moderate-to-low quality, and 38.2% of the evidence items met the minimal clinically important differences.

CONCLUSIONS

The selection and development of dietary strategies for diabetic/prediabetic patients should depend on their holistic conditions, i.e., serum lipid profiles, glucometabolic patterns, weight, and blood pressure. It is recommended to identify the most critical and urgent metabolic indicator to control for one specific patient, and then choose the most appropriate eating pattern accordingly.

Very low carbohydrate (ketogenic) diets in type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIM

Very low carbohydrate/ketogenic diets (VLC/KDs) are popular but their role in managing pre-diabetes and type 2 diabetes (T2D) is uncertain. This study uses a systematic review and meta-analysis of randomized controlled trials to estimate the effect of these diets in this population.

MATERIALS AND METHODS

A systematic review identified randomized controlled trials of at least 6 months duration comparing efficacy and safety of VLC/KDs (≤50 g carbohydrate or ≤10% total energy from carbohydrate per day) with a control diet (carbohydrate above the VLC/KD threshold) in adults with pre-diabetes or T2D. The primary outcome variable was glycated haemoglobin (HbA1c) after 12 months. The meta-analysis method was inverse variance weighting of mean values for continuous variables.

RESULTS

Key word searches identified 2290 studies; 2221 were not in scope. A full text review of 69 studies identified eight meeting inclusion criteria; in total, it involved 606 participants. Six studies reported HbA1c (%) at 12 months; four as change from baseline with a fixed effects estimate (95% confidence interval): VLC/KD minus control of 0.01% (-0.22 to 0.25), p = .91; and two as change from baseline: -0.65% (-0.99; -0.31) [-7.1 mmol/mol (-10.8; -3.4)], p < .001. Serum triglycerides were lower with VLC/KD versus control: -0.28 mmol/L (-0.44 to -0.11), p < .001. High-density lipoprotein was higher with an estimate of 0.04 mmol/L (0.01 to 0.08), p = .03, in the five studies reporting 12-month summary data.

CONCLUSIONS

A VLC/KD may cause reductions in HbA1c and triglycerides in those with pre-diabetes or T2D but evidence of an advantage over other strategies is limited. More well-designed studies are required to provide certain evidence.

[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD)

Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.

Dose-dependent effect of carbohydrate restriction for type 2 diabetes management: a systematic review and dose-response meta-analysis of randomized controlled trials

BACKGROUND

Carbohydrate restriction is effective for type 2 diabetes management.

OBJECTIVES

We aimed to evaluate the dose-dependent effect of carbohydrate restriction in patients with type 2 diabetes.

METHODS

We systematically searched PubMed, Scopus, and Web of Science to May 2021 for randomized controlled trials evaluating the effect of a carbohydrate-restricted diet (≤45% total calories) in patients with type 2 diabetes. The primary outcome was glycated hemoglobin (HbA1c). Secondary outcomes included fasting plasma glucose (FPG); body weight; serum total, LDL, and HDL cholesterol; triglyceride (TG); and systolic blood pressure (SBP). We performed random-effects dose-response meta-analyses to estimate mean differences (MDs) for a 10% decrease in carbohydrate intake.

RESULTS

Fifty trials with 4291 patients were identified. At 6 months, compared with a carbohydrate intake between 55%-65% and through a maximum reduction down to 10%, each 10% reduction in carbohydrate intake reduced HbA1c (MD, -0.20%; 95% CI, -0.27% to -0.13%), FPG (MD, -0.34 mmol/L; 95% CI, -0.56 to -0.12 mmol/L), and body weight (MD, -1.44 kg; 95% CI, -1.82 to -1.06 kg). There were also reductions in total cholesterol, LDL cholesterol, TG, and SBP. Levels of HbA1c, FPG, body weight, TG, and SBP decreased linearly with the decrease in carbohydrate intake from 65% to 10%. A U-shaped effect was seen for total cholesterol and LDL cholesterol, with the greatest reduction at 40%. At 12 months, a linear reduction was seen for HbA1c and TG. A U-shaped effect was seen for body weight, with the greatest reduction at 35%.

CONCLUSIONS

Carbohydrate restriction can exert a significant and important reduction on levels of cardiometabolic risk factors in patients with type 2 diabetes. Levels of most cardiometabolic outcomes decreased linearly with the decrease in carbohydrate intake. U-shaped effects were seen for total cholesterol and LDL cholesterol at 6 months and for body weight at 12 months.

Adherence to the Dutch healthy diet index and change in glycemic control and cardiometabolic markers in people with type 2 diabetes

Purpose

To investigate whether adherence to the Dutch Healthy Diet index 2015 (DHD15-index) is associated with change in glycemic control and cardio-metabolic markers over two-year follow-up in people with type 2 diabetes (T2D).

Methods

This prospective cohort study included 1202 individuals with T2D (mean age 68.7 ± 9.0 years; 62.5% male; mean HbA1c 53.8 ± 11.7 mmol/mol) from the Diabetes Care System cohort. Baseline dietary intake was assessed using a validated food frequency questionnaire, and adherence to the DHD15-index was estimated (range 0–130). HbA1c, fasting glucose, blood lipids (HDL and LDL cholesterol, cholesterol ratio), blood pressure, estimated glomerular filtration rate (eGFR), and BMI were measured at baseline, and after one- and two-year follow-up. Linear mixed model analyses were conducted to examine the associations between adherence to the DHD15-index and glycemic control and the cardio-metabolic outcomes, adjusting for energy intake, sociodemographic and lifestyle characteristics, and medication.

Results

Highest adherence (T3) to the DHD15-index was not associated with change in HbA1c, compared to lowest adherence (T1) [β_T3vsT1: 0.62 mmol/mol (− 0.94; 2.19), P_trend = 0.44]. There was a non-linear association with fasting glucose, where moderate adherence (T2) was associated with a decrease in fasting glucose [β_T2vsT1: − 0.29 mmol/L (− 0.55; − 0.03), P_trend = 0.30]. Higher adherence to the DHD15-index was associated with a decrease in BMI [β_10point: − 0.41 kg/m² (− 0.60; − 0.21), P_trend < 0.001], but not with blood lipids, blood pressure or kidney function.

Conclusion

In this well-controlled population of people with T2D, adherence to the DHD15-index was associated with a decrease in BMI, but not with change in glycemic control or other cardio-metabolic parameters.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-022-02847-6.

A Generation Shift in Mediterranean Diet Adherence and Its Association with Biological Markers and Health in Dalmatia, Croatia

Previous studies have confirmed the beneficial effect of a Mediterranean diet in mitigating health issues related to cardiovascular disease, diabetes and obesity. However, rapid changes in the traditional way of life and the “westernization” of the diet in Mediterranean populations, especially in younger generations, has led to progressive abandonment of healthy dietary patterns. In order to investigate the generation shift in dietary patterns and lifestyle habits in the Mediterranean part of Croatia, we compared two cohorts of 610 women (266 pregnant and 344 non-pregnant) from the same region, but from different age groups. The MDSS score was derived from food frequency questionnaires. The results showed that the young, reproductively active generation (pregnant women) in Dalmatia, Croatia, although having a higher education and socioeconomic status, exhibits a more adverse eating behaviour (lower adherence to the Mediterranean diet) and lifestyle (excessive smoking in pregnancy) than the older population from the same region. Lower MDSS scores across aggregated age groups in both cohorts showed significant association with higher blood lipid levels and higher smoking frequency. In conclusion, Mediterranean diet adherence is associated with biological markers (age, lipid profile) and lifestyle (smoking) in our study, with a more adverse trend observed in the younger generation.

Dietary quality, food security and glycemic control among adults with diabetes

BACKGROUND AND AIMS

Nutritionally adequate diets can slow the progression of diabetes, but adherence to recommended dietary choices can be hindered by food insecurity. We examined the relationship between dietary quality, food insecurity, and glycemic control among adults with Type 2 Diabetes.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (2011-2016) for 1682 adults =>20 years old with Type 2 diabetes. Glycemic control was measured by HbA1c. Dietary quality was computed using the Healthy Eating Index 2015 score. Food security was assessed by a questionnaire. We analyzed the data using multinomial regression models.

RESULTS

About 16% of the population had an HbA1c ≥ 9; 31.8% had food insecurity; 68.3% consumed a poor quality diet. About 24% consumed a poor quality diet and had food insecurity. In the multinomial model, an HbA1c of 8-<9% was associated with poor diet quality (adjusted odds ratio (AOR) = 5.2, 95% confidence interval (CI) = 1.4-19.2, p = 0.01) and food insecurity (AOR = 8.5, 95% CI = 1.4-52.0, p = 0.02). Those with both factors had higher odds of both an HbA1c 8-<9% (AOR = 6.1, 95% CI = 1.5-24.8, p = 0.01) and HbA1c ≥ 9% (AOR = 6.7, 95% CI = 2.0-22.2, p < 0.01). Other risk factors for poor glycemic control were being Black or Hispanic, having no regular source of care, and ever having visited a diabetes specialist (p < 0.05).

CONCLUSIONS

Poor glycemic control among adults with diabetes was associated with poor quality of diet and/or food insecurity, being Black, Hispanic, and lacking a regular source of care. There is a need for policies that improve access to healthy food in patients with type 2 diabetes, particularly among minority populations.

A dietary pattern high in full-fat dairy and sweetened beverages is associated with glycated hemoglobin and weight in Mexican patients with type-2 diabetes

OBJECTIVE

the aim of this study was to identify dietary patterns in a sample of patients with type-2 diabetes, and to evaluate their association with markers of metabolic control.

METHODS

a cross-sectional study in 395 patients with type-2 diabetes in primary care was conducted. Fasting blood levels of glycated hemoglobin (A1c), glucose, total cholesterol, low- (LDL-c) and high-density lipoprotein cholesterol (HDL-c), and triglycerides were measured. Waist circumference, body mass index (BMI), and blood pressure were evaluated. Dietary intake was assessed by a food frequency questionnaire, and dietary patterns were derived by cluster analysis. Three dietary patterns were identified: 'fruits and vegetables', 'dairy and sweetened beverages', and 'diverse with alcohol'.

RESULTS

an association between the 'dairy and sweetened beverages' dietary pattern and A1c levels was identified (ß = 0.61; 95 % CI: 0.09, 1.12, p = 0.021), considering the 'fruits and vegetables' dietary pattern as the reference group. We also observed a trend towards an adjusted increased risk of A1c ≥ 7 % (odds ratio [OR]: 1.56; 95 % CI: 0.92, 2.64; p = 0.099) and an increased risk of BMI ≥ 25 kg/m2 (OR: 2.62, 95 % CI: 1.20, 5.71, p = 0.015) among patients in the 'dairy and sweetened beverages' dietary pattern as compared to the reference group.

CONCLUSIONS

a dietary pattern characterized by a high intake of full-fat dairy and sweetened beverages was associated with higher A1c levels and increased risk of high glucose and BMI when compared to a dietary pattern with a higher consumption of fruits and vegetables.

The short- and long-term effects of dietary patterns on cardiometabolic health in adults aged 65 years or older: a systematic review

CONTEXT

Cardiometabolic diseases are leading causes of death and morbidity. Aging increases the risk of disease development. Diet has protective and causal effects on cardiometabolic health.

OBJECTIVE

To consolidate the current evidence on the short- and long-term effects of dietary patterns on cardiometabolic health in adults aged ≥ 65 years.

DATA SOURCES

The Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, Global Health, and Pre-Medline databases, along with ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched.

DATA EXTRACTION

A total of 40 042 records were identified. Quality assessment involved using the revised Cochrane risk-of-bias tool for randomized trials and Joanna Briggs Institute checklists. The certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

Thirteen articles were included (n = 5 cohort studies and n = 3 randomized controlled trials). The low-fat dietary pattern reduced adiposity; however, no effects were evident for hypertension incidence, composite coronary heart disease incidence (including myocardial infarction, coronary heart disease, and coronary revascularization), high-density lipoprotein cholesterol level, and increased blood pressure in the long term. The Mediterranean dietary pattern resulted in reduced triglyceride levels and systolic blood pressure, and had no effects on diastolic blood pressure and glucose in the short term. Other dietary patterns had inconclusive effects.

CONCLUSIONS

The Mediterranean dietary pattern showed the most benefits without harm on cardiometabolic health in older adults. The current body of evidence is small, indicating the need for more research to confirm these findings at a high certainty of evidence, and to include dietary patterns combined with other dietary components, subgroups with cardiometabolic disease or risk factors, longer follow-up, and outcomes that have not yet been investigated. Studies including these factors may help identify the most effective dietary pattern for cardiometabolic health benefits in older adults, to inform future guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020141400.

Dietary Management of Type 2 Diabetes in the MENA Region: A Review of the Evidence

The alarmingly rising trend of type 2 diabetes constitutes a major global public health challenge particularly in the Middle Eastern and North African (MENA) region where the prevalence is among the highest in the world with a projection to increase by 96% by 2045. The economic boom in the MENA region over the past decades has brought exceptionally rapid shifts in eating habits characterized by divergence from the traditional Mediterranean diet towards a more westernized unhealthy dietary pattern, thought to be leading to the dramatic rises in obesity and non-communicable diseases. Research efforts have brought a greater understanding of the different pathways through which diet and obesity may affect diabetes clinical outcomes, emphasizing the crucial role of dietary interventions and weight loss in the prevention and management of diabetes. The purpose of this review is to explore the mechanistic pathways linking obesity with diabetes and to summarize the most recent evidence on the association of the intake of different macronutrients and food groups with the risk of type 2 diabetes. We also summarize the most recent evidence on the effectiveness of different macronutrient manipulations in the prevention and management of diabetes while highlighting the possible underlying mechanisms of action and latest evidence-based recommendations. We finally discuss the need to adequately integrate dietetic services in diabetes care specific to the MENA region and conclude with recommendations to improve dietetic care for diabetes in the region.

Effects of nutrition education using a food-based approach, carbohydrate counting or routine care in type 1 diabetes: 12 months prospective randomized trial

INTRODUCTION

Evidence on the effects of structured nutrition education is weak in adults with type 1 diabetes mellitus (T1D) with moderately impaired glycemic control. Objective was to compare the effects of different types of nutrition education programs on glycemic control, cardiovascular risk factors, quality of life, diet quality and food choices in T1D.

RESEARCH DESIGN AND METHODS

A 12 months randomized controlled study conducted at nine diabetes specialist centers with three parallel arms: (i) a food-based approach (FBA) including foods with low glycemic index or (ii) carbohydrate counting (CC) according to today's standard practice or (iii) individual sessions according to routine care (RC). The primary end point was difference in glycated hemoglobin A1c (HbA1c) between groups at 12 months.

RESULTS

159 patients were randomized (FBA: 51; CC: 52; RC: 55). Mean (SD) age 48.6 (12.0) years, 57.9% females and mean (SD) HbA1c level 63.9 (7.9) mmol/mol, 8% (0.7%). After 3 months, HbA1c improved in both FBA and CC compared with RC. However, there were no significant differences at 12 months in HbA1c; FBA versus RC (-0.4 mmol/mol (1.3), 0.04% (0.1%)), CC versus RC (-0.8 mmol/mol (1.2), 0.1% (0.1%)), FBA versus CC (0.4 mmol/mol (0.3), 0.04% (0.01%)). At 12 months, intake of legumes, nuts and vegetables was improved in FBA versus CC and RC. FBA also reported higher intake of monounsaturated and polyunsaturated fats compared with RC, and dietary fiber, monounsaturated and polyunsaturated fats compared with CC (all p values <0.05). There were no differences in blood pressure levels, lipids, body weight or quality of life.

CONCLUSIONS

Nutrition education using an FBA, CC or RC is equivalent in terms of HbA1c and cardiovascular risk factors in persons with T1D with moderately impaired glycemic control. An FBA had benefits regarding food choices compared with CC and RC.

Development of a salutogenic intervention for healthy eating among Dutch type 2 diabetes mellitus patients

Healthy eating can be challenging for type 2 diabetes mellitus (T2DM) patients. The theory of salutogenesis, which focuses on the resources required to organize behavioural changes in everyday life, was used to develop an intervention for healthy eating. The aim was to describe the development, structure and content of this salutogenic intervention. The development consisted of two phases that were based on the operationalization of important key principles of salutogenesis. In Phase 1 (Exploration and synthesis), a systematic review and three qualitative studies were performed to explore important characteristics to enable healthy eating in everyday life. The results were used to develop the draft intervention. In Phase 2 (Validation and adjustment), interviews and workshops were conducted with T2DM patients, healthcare providers and scientists. Based on this, the draft intervention was modified into its final form. The developmental process resulted in a 12-week, group-based intervention that aimed to enable important resources for healthy eating via self-examination, reflection, setting goals and sharing experiences. Attention was also paid to disease information, disease acceptance, food literacy, stress management, self-identity and social support. The group sessions began following an individual intake session, with a booster session held 3 months after the intervention. The researcher’s translation of the stakeholders’ priorities into an intervention was corrected for and approved by the stakeholders concerned. This comprehensive salutogenic intervention was developed based on practical and scientific evidence. Providing transparency in developmental processes and content is important because it determines the scientific integrity and credibility of an intervention.

Healthy eating can be difficult for people with the disease type 2 diabetes. This article describes how a programme aimed at helping type 2 diabetes patients to eat healthily was developed. The draft version of the programme was based on a theoretical framework that aims to understand what creates health in everyday life, and on conversations with type 2 diabetes patients and healthcare providers. The draft programme was adjusted based on the feedback of type 2 diabetes patients, healthcare providers and scientists. This resulted in a 12-week, group-based programme that enables people to think about who they are and what they want by setting health goals and sharing experiences. Attention was also paid to disease knowledge, disease acceptance, nutritional skills, dealing with stress, self-identity and social support. The group sessions began following an individual intake session, with a booster session held 3 months after the intervention. By involving everybody, we were able to develop a programme that takes into account the preferences, needs and priorities of all stakeholders. It is important to describe the development and the content of programmes encouraging healthy eating to determine their quality and effectivity.

Spie charts for quantifying treatment effectiveness and safety in multiple outcome network meta-analysis: a proof-of-concept study

BACKGROUND

Network meta-analysis (NMA) simultaneously synthesises direct and indirect evidence on the relative efficacy and safety of at least three treatments. A decision maker may use the coherent results of an NMA to determine which treatment is best for a given outcome. However, this evidence must be balanced across multiple outcomes. This study aims to provide a framework that permits the objective integration of the comparative effectiveness and safety of treatments across multiple outcomes.

METHODS

In the proposed framework, measures of each treatment's performance are plotted on its own pie chart, superimposed on another pie chart representing the performance of a hypothetical treatment that is the best across all outcomes. This creates a spie chart for each treatment, where the coverage area represents the probability a treatment ranks best overall. The angles of each sector may be adjusted to reflect the importance of each outcome to a decision maker. The framework is illustrated using two published NMA datasets comparing dietary oils and fats and psoriasis treatments. Outcome measures are plotted in terms of the surface under the cumulative ranking curve. The use of the spie chart was contrasted with that of the radar plot.

RESULTS

In the NMA comparing the effects of dietary oils and fats on four lipid biomarkers, the ease of incorporating the lipids' relative importance on spie charts was demonstrated using coefficients from a published risk prediction model on coronary heart disease. Radar plots produced two sets of areas based on the ordering of the lipids on the axes, while the spie chart only produced one set. In the NMA comparing psoriasis treatments, the areas inside spie charts containing both efficacy and safety outcomes masked critical information on the treatments' comparative safety. Plotting the areas inside spie charts of the efficacy outcomes against measures of the safety outcome facilitated simultaneous comparisons of the treatments' benefits and harms.

CONCLUSIONS

The spie chart is more optimal than a radar plot for integrating the comparative effectiveness or safety of a treatment across multiple outcomes. Formal validation in the decision-making context, along with statistical comparisons with other recent approaches are required.

Interaction between high-density lipoproteins and inflammation: Function matters more than concentration!

High-density lipoprotein (HDL) plays an important role in lipid metabolism and especially contributes to the reverse cholesterol transport pathway. Over recent years it has become clear that the effect of HDL on immune-modulation is not only dependent on HDL concentration but also and perhaps even more so on HDL function. This review will provide a concise general introduction to HDL followed by an overview of post-translational modifications of HDL and a detailed overview of the role of HDL in inflammatory diseases. The clinical potential of HDL and its main apolipoprotein constituent, apoA-I, is also addressed in this context. Finally, some conclusions and remarks that are important for future HDL-based research and further development of HDL-focused therapies are discussed.

Effectiveness of a Diabetes Education Program based on Tailored interventions and Theory of Planned Behaviour: Cluster randomized controlled trial protocol

AIM

To measure the Effectiveness of a Diabetes Education Program for people with T2DM, based on Tailored interventions and the Theory of Planned Behaviour.

DESIGN

Cluster randomized controlled clinical trial.

METHODS

This multicentre study will be carried out at 30 primary healthcare centres, where 436 persons with Type 2 Diabetes Mellitus (T2DM), aged between 18-75 years, will be recruited. The experimental educational program to be applied is modelled using components obtained from a systematic review and prior qualitative analysis. In addition, a taxonomy of nursing practice is used to standardize the program, based on the Theory of Planned Behaviour as a conceptual model. The intervention will be carried out by community nurses, using ADAPP-Ti^® , an application developed with FileMaker Pro v.18. The control group will receive usual care and data will be collected at 6, 12, and 18 months, for both groups. The primary outcome considered will be glycosylated haemoglobin and cardiovascular factors, while the secondary ones will be tobacco consumption, body mass index, barriers to self-care, health-related quality of life, and lifestyle modification. The protocol was approved by the Ethics Committee of the Province of Malaga (Spain) in November 2014.

DISCUSSION

The degree of metabolic control in T2DM is not always associated with healthy lifestyles and significant levels of medication are often prescribed to achieve clinical objectives. An intervention focused on needs, based on the best available evidence and a solid conceptual framework, might successfully consolidate appropriate self-care behaviour in this population.

IMPACT

The study will result in the publication of an educational program featuring well-defined interventions and activities that will enable clinicians to tailor health care to the individual's needs and to combat treatment inertia in attending this population.

Association of Omnivorous and Vegetarian Diets With Antioxidant Defense Mechanisms in Men

Background Evidence that a vegetarian diet rich in antioxidants contributes to cardiovascular health are growing, however, the underlying molecular mechanisms remain unknown. HO-1 (heme-oxygenase-1), a marker of adaptive response, is protective against oxidative stress and has shown cardioprotective effects. Therefore, we evaluated circulating HO-1 levels and the effect of plasma from omnivorous and vegetarians in endothelial cells (human umbilical vein endothelial cells) on modulating NRF2 (nuclear factor erythroid 2-like 2)/HO-1 and nitric oxide production. Methods and Results From 745 participants initially recruited, 44 omnivorous and 44 vegetarian men matched by age and absence of cardiovascular risk factors and diseases were included in this study. Circulating HO-1 was measured using ELISA and human umbilical vein endothelial cells were incubated with plasma from omnivorous and vegetarians. Higher circulating HO-1 concentrations were found in omnivorous compared with vegetarians. Plasma from omnivorous and not from vegetarians induced NRF2/HO-1 and nitric oxide production in human umbilical vein endothelial cells, and increased reactive oxygen species production and caspase activity after incubation with stressor stimulus. Conclusions We suggest that HO-1 induction in omnivorous may indicate a pro-oxidative status since HO-1 is activated under oxidative stress a state not seen in vegetarians.

Objectives, design and main findings until 2020 from the Rotterdam Study

The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the city of Rotterdam, The Netherlands. The study aims to unravel etiology, preclinical course, natural history and potential targets for intervention for chronic diseases in mid-life and late-life. The study focuses on cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1700 research articles and reports. This article provides an update on the rationale and design of the study. It also presents a summary of the major findings from the preceding 3 years and outlines developments for the coming period.

Impact of self-care programmes in type 2 diabetes mellitus population in primary health care: Systematic review and meta-analysis

AIMS AND OBJECTIVES

To evaluate the effectiveness of self-care programmes in type 2 diabetes mellitus (T2DM) population in primary health care.

BACKGROUND

The impact of educational interventions on T2DM has been evaluated in various contexts, but there is uncertainty about their impact in that of primary care.

DESIGN

Systematic review and meta-analysis.

METHODS

A search was conducted in PubMed, CINAHL, WOS and Cochrane databases for randomised controlled trials carried out in the period January 2005-December 2017, including studies with at least one face-to-face educational interventions. The quality of the evidence for the primary outcome was evaluated using the GRADE System. A meta-analysis was used to determine the effect achieved although only the results classified as critical or important were taken into consideration. Checklist of Preferred Reporting Items for Systematic Reviews and Meta-analyses has been followed. PROSPERO registration Number: CRD42016038833.

RESULTS

In total, 21 papers (20 studies) were analysed, representing a population of 12,018 persons with T2DM. For the primary outcome, HbA₁ c, the overall reduction obtained was -0.29%, decreasing the effect in long-term follow-up. The quality of the evidence was low/very low due to very serious risk of bias, inconsistency and indirectness of results. Better results were obtained for individual randomised trials versus cluster designs and in those programmes in which nurses leaded the interventions. The findings for other cardiovascular risk factors were inconsistent.

CONCLUSIONS

Educational interventions in primary care addressing T2DM could be effective for metabolic control, but the low quality of the evidence and the lack of measurement of critical results generates uncertainty and highlights the need for high-quality trials.

RELEVANCE TO CLINICAL PRACTICE

Most of self-care programmes for T2DM in primary care are focused on metabolic control, while other cardiovascular profile variables with greater impact on mortality or patient-reported outcomes are less intensely addressed.

Optimal Dietary Strategies for Prevention of Atherosclerotic Cardiovascular Disease in Diabetes: Evidence and Recommendations

PURPOSE OF REVIEW

This review presents the current available evidence of the effects of several dietary patterns on atherosclerotic cardiovascular disease (ASCVD) risk in patients with type 2 diabetes (T2D).

RECENT FINDINGS

Evidence demonstrates improvements in cardiovascular risk factors with some dietary patterns in the general population. However, evidence is limited for glycemic control and cardiovascular benefit in patients with T2D for Dietary Approaches to Stop Hypertension and plant-based dietary patterns. Evidence suggests that carbohydrate-restricted dietary patterns improve glycemic control and decrease the use of anti-hyperglycemic medications. The Mediterranean dietary pattern has the most evidence for glycemic control and decreased ASCVD risk in patients with T2D. There is no evidence on ASCVD outcomes in patients with T2D for any other dietary pattern. The Mediterranean dietary pattern has the most evidence for cardiovascular benefit in patients with T2D. Future research should examine the effect of dietary patterns on ASCVD outcomes.