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Karam G, Agarwal A, Sadeghirad B, Jalink M, Hitchcock CL, Ge L, Kiflen R, Ahmed W, Zea AM, Milenkovic J, Chedrawe MA, Rabassa M, El Dib R, Goldenberg JZ, Guyatt GH, Boyce E, Johnston BC. Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk: systematic review and network meta-analysis. BMJ 2023; 380:e072003. [PMID: 36990505 PMCID: PMC10053756 DOI: 10.1136/bmj-2022-072003] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To determine the relative efficacy of structured named diet and health behaviour programmes (dietary programmes) for prevention of mortality and major cardiovascular events in patients at increased risk of cardiovascular disease. DESIGN Systematic review and network meta-analysis of randomised controlled trials. DATA SOURCES AMED (Allied and Complementary Medicine Database), CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and ClinicalTrials.gov were searched up to September 2021. STUDY SELECTION Randomised trials of patients at increased risk of cardiovascular disease that compared dietary programmes with minimal intervention (eg, healthy diet brochure) or alternative programmes with at least nine months of follow-up and reporting on mortality or major cardiovascular events (such as stroke or non-fatal myocardial infarction). In addition to dietary intervention, dietary programmes could also include exercise, behavioural support, and other secondary interventions such as drug treatment. OUTCOMES AND MEASURES All cause mortality, cardiovascular mortality, and individual cardiovascular events (stroke, non-fatal myocardial infarction, and unplanned cardiovascular interventions). REVIEW METHODS Pairs of reviewers independently extracted data and assessed risk of bias. A random effects network meta-analysis was performed using a frequentist approach and grading of recommendations assessment, development and evaluation (GRADE) methods to determine the certainty of evidence for each outcome. RESULTS 40 eligible trials were identified with 35 548 participants across seven named dietary programmes (low fat, 18 studies; Mediterranean, 12; very low fat, 6; modified fat, 4; combined low fat and low sodium, 3; Ornish, 3; Pritikin, 1). At last reported follow-up, based on moderate certainty evidence, Mediterranean dietary programmes proved superior to minimal intervention for the prevention of all cause mortality (odds ratio 0.72, 95% confidence interval 0.56 to 0.92; patients at intermediate risk: risk difference 17 fewer per 1000 followed over five years), cardiovascular mortality (0.55, 0.39 to 0.78; 13 fewer per 1000), stroke (0.65, 0.46 to 0.93; 7 fewer per 1000), and non-fatal myocardial infarction (0.48, 0.36 to 0.65; 17 fewer per 1000). Based on moderate certainty evidence, low fat programmes proved superior to minimal intervention for prevention of all cause mortality (0.84, 0.74 to 0.95; 9 fewer per 1000) and non-fatal myocardial infarction (0.77, 0.61 to 0.96; 7 fewer per 1000). The absolute effects for both dietary programmes were more pronounced for patients at high risk. There were no convincing differences between Mediterranean and low fat programmes for mortality or non-fatal myocardial infarction. The five remaining dietary programmes generally had little or no benefit compared with minimal intervention typically based on low to moderate certainty evidence. CONCLUSIONS Moderate certainty evidence shows that programmes promoting Mediterranean and low fat diets, with or without physical activity or other interventions, reduce all cause mortality and non-fatal myocardial infarction in patients with increased cardiovascular risk. Mediterranean programmes are also likely to reduce stroke risk. Generally, other named dietary programmes were not superior to minimal intervention. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016047939.
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Affiliation(s)
- Giorgio Karam
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Jalink
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Long Ge
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
| | - Ruhi Kiflen
- Ontario Hospital Association, Toronto, Ontario, Canada
| | - Waleed Ahmed
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adriana M Zea
- School of Nutrition and Dietetics, Universidad de Antioquia, Medellin, Colombia
| | - Jovana Milenkovic
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Aj Chedrawe
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Regina El Dib
- Institute of Science and Technology, University Estadual Paulista, São José dos Campos, São Paulo, Brazil
| | - Joshua Z Goldenberg
- Department of Nutrition, College of Agriculture and Life Sciences, Texas A&M University, College Station, TX, USA
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Bradley C Johnston
- Department of Nutrition, College of Agriculture and Life Sciences, Texas A&M University, College Station, TX, USA
- Department of Epidemiology and Biostatistics, School of Public Health, College Station, TX, USA
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2
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Johnston BC, Zeraatkar D, Steen J, de Jauregui DRF, Zhu H, Sun M, Cooper M, Maraj M, Prokop-Dorner A, Reyes BC, Valli C, Storman D, Karam G, Zajac J, Ge L, Swierz MJ, Ghosh N, Vernooij RWM, Chang Y, Zhao Y, Thabane L, Guyatt GH, Alonso-Coello P, Hooper L, Bala MM. Saturated fat and human health: a protocol for a methodologically innovative systematic review and meta-analysis to inform public health nutrition guidelines. Syst Rev 2023; 12:39. [PMID: 36918997 PMCID: PMC10012519 DOI: 10.1186/s13643-023-02209-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/01/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND The health effects of dietary fats are a controversial issue on which experts and authoritative organizations have often disagreed. Care providers, guideline developers, policy-makers, and researchers use systematic reviews to advise patients and members of the public on optimal dietary habits, and to formulate public health recommendations and policies. Existing reviews, however, have serious limitations that impede optimal dietary fat recommendations, such as a lack of focus on outcomes important to people, substantial risk of bias (RoB) issues, ignoring absolute estimates of effects together with comprehensive assessments of the certainty of the estimates for all outcomes. OBJECTIVE We therefore propose a methodologically innovative systematic review using direct and indirect evidence on diet and food-based fats (i.e., reduction or replacement of saturated fat with monounsaturated or polyunsaturated fat, or carbohydrates or protein) and the risk of important health outcomes. METHODS We will collaborate with an experienced research librarian to search MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews (CDSR) for randomized clinical trials (RCTs) addressing saturated fat and our health outcomes of interest. In duplicate, we will screen, extract results from primary studies, assess their RoB, conduct de novo meta-analyses and/or network meta-analysis, assess the impact of missing outcome data on meta-analyses, present absolute effect estimates, and assess the certainty of evidence for each outcome using the GRADE contextualized approach. Our work will inform recommendations on saturated fat based on international standards for reporting systematic reviews and guidelines. CONCLUSION Our systematic review and meta-analysis will provide the most comprehensive and rigorous summary of the evidence addressing the relationship between saturated fat modification for people-important health outcomes. The evidence from this review will be used to inform public health nutrition guidelines. TRIAL REGISTRATION PROSPERO Registration: CRD42023387377 .
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Affiliation(s)
- Bradley C Johnston
- Department of Nutrition, College of Agriculture and Life Science, Texas A&M University, College Station, TX, USA. .,Department of Epidemiology and Biostatistics, School of Public Health, College Station, TX, USA.
| | - Dena Zeraatkar
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeremy Steen
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Diego Rada Fernandez de Jauregui
- Preventive Medicine and Public Health Department, School of Pharmacy, University of the Basque Country/Euskal Herriko Unibertsitatea (UPV/EHU), Vitoria-Gasteiz, Spain.,Department of Nutrition, Texas A&M University, College Station, TX, USA
| | - Hongfei Zhu
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China.,Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
| | - Mingyao Sun
- Evidence Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, China
| | - Matthew Cooper
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Malgorzata Maraj
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Prokop-Dorner
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Boris Castro Reyes
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Claudia Valli
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain.,Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Dawid Storman
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland.,Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland.,Department of Adult Psychiatry, University Hospital, Krakow, Poland
| | - Giorgio Karam
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Joanna Zajac
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Jagiellonian University Medical College, Krakow, Poland
| | - Long Ge
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China.,Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
| | - Mateusz J Swierz
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland.,Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Nirjhar Ghosh
- Department of Nutrition, Texas A&M University, College Station, TX, USA
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yaping Chang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yunli Zhao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,The Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Faculty of Health Sciences, Hamilton, ON, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain.,CIBER de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland.,Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
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3
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Xun Y, Luo X, Lv M, Yang B, Lei R, Liu X, Zhang J, Zhang X, Liu H, Shi Q, Liu K, Yang Y, Chen Y, Chen L, Wang R, Norris SL, Amer YS, Qaseem A, Chen Y, Estill J. Protocols for clinical practice guidelines. J Evid Based Med 2023; 16:3-9. [PMID: 36354129 DOI: 10.1111/jebm.12502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Yangqin Xun
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Xufei Luo
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Meng Lv
- Chevidence Lab of Child & Adolescent Health, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Bo Yang
- Shapingba District Center for Disease Control and Prevention of Chongqing, Chongqing, China
| | - Ruobing Lei
- Chevidence Lab of Child & Adolescent Health, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiao Liu
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Jingyi Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Xianzhuo Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Hui Liu
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Qianling Shi
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Kefeng Liu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Drug Clinical Comprehensive Evaluation Center, Zhengzhou, China
| | - Yongjie Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Drug Clinical Comprehensive Evaluation Center, Zhengzhou, China
| | - Yuyue Chen
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Lan Chen
- School of Nursing, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Runwu Wang
- Department of Urology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | | | - Yasser Sami Amer
- Pediatrics Department, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
- Clinical Practice Guidelines Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
- Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia
- Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University Medical Council, Alexandria University, Alexandria, Egypt
| | - Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania, United States
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Research Unit of Evidence-Based Evaluation and Guidelines, Chinese Academy of Medical Sciences (2021RU017), School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Institute of Health Data Science, Lanzhou University, Lanzhou, China
- WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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4
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Hill ER, O'Connor LE, Wang Y, Clark CM, McGowan BS, Forman MR, Campbell WW. Red and processed meat intakes and cardiovascular disease and type 2 diabetes mellitus: An umbrella systematic review and assessment of causal relations using Bradford Hill's criteria. Crit Rev Food Sci Nutr 2022; 64:2423-2440. [PMID: 36154543 DOI: 10.1080/10408398.2022.2123778] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Observational research suggests higher red and processed meat intakes predict greater risks of developing or dying from cardiovascular diseases (CVD) and type 2 diabetes mellitus (T2DM), but this research limits causal inference. This systematic review of reviews utilizes both observational and experimental research findings to infer causality of these relations. Reviews from four databases were screened by two researchers. Reviews included unprocessed red meat (URM), processed meat (PM), or mixed URM + PM intake, and reported CVD or T2DM outcomes. Twenty-nine reviews were included, and causality was inferred using Bradford Hill's Criteria. Observational assessments of CVD outcomes and all meat types consistently reported weak associations while, T2DM outcomes and PM and Mixed URM + PM assessments consistently reported strong associations. Experimental assessments of Mixed URM + PM on CVD and T2DM risk factors were predominately not significant which lacked coherence with observational findings. For all meat types and outcomes, temporality and plausible mechanisms were established, but specificity and analogous relationships do not support causality. Evidence was insufficient for URM and T2DM. More experimental research is needed to strengthen these inferences. These results suggest that red and processed meat intakes are not likely causally related to CVD but there is potential for a causal relationship with T2DM.
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Affiliation(s)
- Erica R Hill
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Lauren E O'Connor
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
- Agricultural Research Service, United States Department of Agriculture, Beltsville, Maryland, USA
| | - Yu Wang
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Caroline M Clark
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Bethany S McGowan
- Purdue University Libraries and School of Information Studies, Purdue University, West Lafayette, Indiana, USA
| | - Michele R Forman
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Wayne W Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
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5
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Prokop-Dorner A, Piłat-Kobla A, Zając J, Luśtyk M, Valli C, Łapczuk A, Brzyska M, Johnston B, Zera D, Guyatt G, Alonso-Coello P, Bala MM. Values and preferences influencing willingness to change red and processed meat consumption in response to evidence-based information: a mixed methods study. Public Health Nutr 2022; 25:1-34. [PMID: 35392999 PMCID: PMC9991620 DOI: 10.1017/s1368980022000866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/09/2022] [Accepted: 04/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES (1) to assess the extent to which omnivores are willing to stop or reduce their consumption of red and processed meat in response to evidence-based information regarding the possible reduction of cancer mortality and incidence achieved by dietary modification; (2) to identify sociodemographic categories associated with higher willingness to change meat consumption; (3) to understand the motives facilitating and hindering such a change. DESIGN During an initial computer-assisted web interview, respondents were presented with scenarios containing the estimates of the absolute risk reduction in overall cancer incidence and mortality tailored to their declared level of red and processed meat consumption. Respondents were asked whether they would stop or reduce their average meat consumption based on the information provided. Their dietary choices were assessed at 6-month follow-up. Additionally, we conducted semi-structured interviews to better understand the rationale for dietary practices and the perception of health information. PARTICIPANTS The study was conducted among students and staff of 3 universities in Krakow, Poland. RESULTS Most of the 513 respondents were unwilling to change their consumption habits. We found gender to be a significant predictor of the willingness. Finally, we identified 4 themes reflecting key motives that determined meat consumption preferences: the importance of taste and texture, health consciousness, the habitual nature of cooking, and persistence of omnivorous habits. CONCLUSIONS When faced with health information about the uncertain reduction in the risk of cancer mortality and incidence, the vast majority of study participants were unwilling to introduce changes in their consumption habits.
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Affiliation(s)
- Anna Prokop-Dorner
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034Krakow, Poland
| | - Aleksandra Piłat-Kobla
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034Krakow, Poland
| | - Joanna Zając
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Michalina Luśtyk
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034Krakow, Poland
| | - Claudia Valli
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Aneta Łapczuk
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034Krakow, Poland
| | - Monika Brzyska
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-034Krakow, Poland
| | - Bradley Johnston
- College of Agriculture and Life Scinces, Texas A&M University, College Station, TX, USA
- Department of Epidemiology & Biostatistics, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Dena Zera
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
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6
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Animal board invited review: Animal source foods in healthy, sustainable, and ethical diets - An argument against drastic limitation of livestock in the food system. Animal 2022; 16:100457. [PMID: 35158307 DOI: 10.1016/j.animal.2022.100457] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 02/07/2023] Open
Abstract
Animal source foods are evolutionarily appropriate foods for humans. It is therefore remarkable that they are now presented by some as unhealthy, unsustainable, and unethical, particularly in the urban West. The benefits of consuming them are nonetheless substantial, as they offer a wide spectrum of nutrients that are needed for cell and tissue development, function, and survival. They play a role in proper physical and cognitive development of infants, children, and adolescents, and help promote maintenance of physical function with ageing. While high-red meat consumption in the West is associated with several forms of chronic disease, these associations remain uncertain in other cultural contexts or when consumption is part of wholesome diets. Besides health concerns, there is also widespread anxiety about the environmental impacts of animal source foods. Although several production methods are detrimental (intensive cropping for feed, overgrazing, deforestation, water pollution, etc.) and require substantial mitigation, damaging impacts are not intrinsic to animal husbandry. When well-managed, livestock farming contributes to ecosystem management and soil health, while delivering high-quality foodstuffs through the upcycling of resources that are otherwise non-suitable for food production, making use of marginal land and inedible materials (forage, by-products, etc.), integrating livestock and crop farming where possible has the potential to benefit plant food production through enhanced nutrient recycling, while minimising external input needs such as fertilisers and pesticides. Moreover, the impacts on land use, water wastage, and greenhouse gas emissions are highly contextual, and their estimation is often erroneous due to a reductionist use of metrics. Similarly, whether animal husbandry is ethical or not depends on practical specificities, not on the fact that animals are involved. Such discussions also need to factor in that animal husbandry plays an important role in culture, societal well-being, food security, and the provision of livelihoods. We seize this opportunity to argue for less preconceived assumptions about alleged effects of animal source foods on the health of the planet and the humans and animals involved, for less top-down planning based on isolated metrics or (Western) technocratic perspectives, and for more holistic and circumstantial approaches to the food system.
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7
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Weldon I, Parkhurst J. Governing evidence use in the nutrition policy process: evidence and lessons from the 2020 Canada food guide. Nutr Rev 2022; 80:467-478. [PMID: 35043195 PMCID: PMC8829674 DOI: 10.1093/nutrit/nuab105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Nutrition guideline development is traditionally seen as a mechanism by which evidence is used to inform policy decisions. However, applying evidence in policy is a decidedly complex and politically embedded process, with no single universally agreed-upon body of evidence on which to base decisions, and multiple social concerns to address. Rather than simply calling for “evidence-based policy,” an alternative is to look at the governing features of the evidence use system and reflect on what constitutes improved evidence use from a range of explicitly identified normative concerns. This study evaluated the use of evidence within the Canada Food Guide policy process by applying concepts of the “good governance of evidence” – an approach that incorporates multiple normative principles of scientific and democratic best practice to consider the structure and functioning of evidence advisory systems. The findings indicated that institutionalizing a process for evidence use grounded in democratic and scientific principles can improve evidence use in nutrition policy making.
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Affiliation(s)
- Isaac Weldon
- I. Weldon is with the Department of Politics and with the Global Strategy Lab, Dahdaleh Institute for Global Health Research, School of Global Health and Osgoode Hall Law School, York University, Toronto, Canada. J. Parkhurst is with the Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Justin Parkhurst
- I. Weldon is with the Department of Politics and with the Global Strategy Lab, Dahdaleh Institute for Global Health Research, School of Global Health and Osgoode Hall Law School, York University, Toronto, Canada. J. Parkhurst is with the Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
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8
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Storman D, Koperny M, Zając J, Polak M, Weglarz P, Bochenek-Cibor J, Swierz MJ, Staskiewicz W, Gorecka M, Skuza A, Wach AA, Kaluzinska K, Bała MM. Predictors of Higher Quality of Systematic Reviews Addressing Nutrition and Cancer Prevention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010506. [PMID: 35010766 PMCID: PMC8744691 DOI: 10.3390/ijerph19010506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/15/2021] [Accepted: 12/26/2021] [Indexed: 02/04/2023]
Abstract
Systematic reviews/meta-analyses (SR/MAs) are considered a reliable source of information in healthcare. We aimed to explore the association of several characteristics of SR/MAs addressing nutrition in cancer prevention and their quality/risk of bias (using assessments from AMSTAR-2 and ROBIS tools). The analysis included 101 SR/MAs identified in a systematic survey. Associations of each specified characteristic (e.g., information about the protocol, publication year, reported use of GRADE, or other methods for assessing overall certainty of evidence) with the number of AMSTAR-2 not met (‘No’ responses) and the number of ROBIS items met (‘Probably Yes’ or “Yes’ responses) were examined. Poisson regression was used to identify predictors of the number of ‘No’ answers (indicating lower quality) for all AMSTAR-2 items and the number of ‘Yes’ or ‘Probably Yes’ answers (indicating higher quality/lower concern for bias) for all ROBIS items. Logistic regression was used to identify variables associated with at least one domain assessed as ‘low concern for bias’ in the ROBIS tool. In multivariable analysis, SR/MAs not reporting use of any quality/risk of bias assessment instrument for primary studies were associated with a higher number of ‘No’ answers for all AMSTAR-2 items (incidence rate ratio (IRR) 1.26, 95% confidence interval (CI) 1.09–1.45), and a lower number of ‘Yes’ or ‘Probably Yes’ answers for all ROBIS items (IRR 0.76, 95% CI 0.66–0.87). Providing information about the protocol and search for unpublished studies was associated with a lower number of ‘No’ answers (IRR 0.73, 95% CI 0.56–0.97 and IRR 0.75, 95% CI 0.59–0.95, respectively) and a higher number of ‘Yes’ or ‘Probably Yes’ answers (IRR 1.43, 95% CI 1.17–1.74 and IRR 1.28, 95% CI 1.07–1.52, respectively). Not using at least one quality/risk of bias assessment tool for primary studies within an SR/MA was associated with lower odds that a study would be assessed as ‘low concern for bias’ in at least one ROBIS domain (odds ratio 0.061, 95% CI 0.007–0.527). Adherence to methodological standards in the development of SR/MAs was associated with a higher overall quality of SR/MAs addressing nutrition for cancer prevention.
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Affiliation(s)
- Dawid Storman
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, 31-034 Krakow, Poland; (D.S.); (J.Z.); (P.W.); (M.J.S.)
| | - Magdalena Koperny
- Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Jagiellonian University Medical College, 31-034 Krakow, Poland;
| | - Joanna Zając
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, 31-034 Krakow, Poland; (D.S.); (J.Z.); (P.W.); (M.J.S.)
| | - Maciej Polak
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, 31-034 Krakow, Poland;
| | - Paulina Weglarz
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, 31-034 Krakow, Poland; (D.S.); (J.Z.); (P.W.); (M.J.S.)
| | | | - Mateusz J. Swierz
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, 31-034 Krakow, Poland; (D.S.); (J.Z.); (P.W.); (M.J.S.)
| | - Wojciech Staskiewicz
- Students’ Scientific Research Group of Systematic Reviews, Jagiellonian University Medical College, 31-034 Krakow, Poland; (W.S.); (M.G.); (A.S.); (A.A.W.); (K.K.)
| | - Magdalena Gorecka
- Students’ Scientific Research Group of Systematic Reviews, Jagiellonian University Medical College, 31-034 Krakow, Poland; (W.S.); (M.G.); (A.S.); (A.A.W.); (K.K.)
| | - Anna Skuza
- Students’ Scientific Research Group of Systematic Reviews, Jagiellonian University Medical College, 31-034 Krakow, Poland; (W.S.); (M.G.); (A.S.); (A.A.W.); (K.K.)
| | - Adam A. Wach
- Students’ Scientific Research Group of Systematic Reviews, Jagiellonian University Medical College, 31-034 Krakow, Poland; (W.S.); (M.G.); (A.S.); (A.A.W.); (K.K.)
| | - Klaudia Kaluzinska
- Students’ Scientific Research Group of Systematic Reviews, Jagiellonian University Medical College, 31-034 Krakow, Poland; (W.S.); (M.G.); (A.S.); (A.A.W.); (K.K.)
| | - Małgorzata M. Bała
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, 31-034 Krakow, Poland; (D.S.); (J.Z.); (P.W.); (M.J.S.)
- Correspondence:
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9
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Health Related Values and Preferences Regarding Meat Intake: A Cross-Sectional Mixed-Methods Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111585. [PMID: 34770099 PMCID: PMC8582724 DOI: 10.3390/ijerph182111585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022]
Abstract
Background. In addition to social and environmental determinants, people’s values and preferences determine daily food choices. This study evaluated adults’ values and preferences regarding unprocessed red meat (URM) and processed meat (PM) and their willingness to change their consumption in the face of possible undesirable health consequences. Methods. A cross-sectional mixed-methods study including a quantitative assessment through an online survey, a qualitative inquiry through semi-structured interviews, and a follow-up assessment through a telephone survey. We performed descriptive statistics, logistic regressions, and thematic analysis. Results. Of 304 participants, over 75% were unwilling to stop their consumption of either URM or PM, and of those unwilling to stop, over 80% were also unwilling to reduce. Men were less likely to stop meat intake than women (odds ratios < 0.4). From the semi-structured interviews, we identified three main themes: the social and/or family context of meat consumption, health- and non-health-related concerns about meat, and uncertainty of the evidence. At three months, 63% of participants reported no changes in meat intake. Conclusions. When informed about the cancer incidence and mortality risks of meat consumption, most respondents would not reduce their intake. Public health and clinical nutrition guidelines should ensure that their recommendations are consistent with population values and preferences.
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BROWN ANDREWW, ASLIBEKYAN STELLA, BIER DENNIS, DA SILVA RAFAELFERREIRA, HOOVER ADAM, KLURFELD DAVIDM, LOKEN ERIC, MAYO-WILSON EVAN, MENACHEMI NIR, PAVELA GREG, QUINN PATRICKD, SCHOELLER DALE, TEKWE CARMEN, VALDEZ DANNY, VORLAND COLBYJ, WHIGHAM LEAHD, ALLISON DAVIDB. Toward more rigorous and informative nutritional epidemiology: The rational space between dismissal and defense of the status quo. Crit Rev Food Sci Nutr 2021; 63:3150-3167. [PMID: 34678079 PMCID: PMC9023609 DOI: 10.1080/10408398.2021.1985427] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To date, nutritional epidemiology has relied heavily on relatively weak methods including simple observational designs and substandard measurements. Despite low internal validity and other sources of bias, claims of causality are made commonly in this literature. Nutritional epidemiology investigations can be improved through greater scientific rigor and adherence to scientific reporting commensurate with research methods used. Some commentators advocate jettisoning nutritional epidemiology entirely, perhaps believing improvements are impossible. Still others support only normative refinements. But neither abolition nor minor tweaks are appropriate. Nutritional epidemiology, in its present state, offers utility, yet also needs marked, reformational renovation. Changing the status quo will require ongoing, unflinching scrutiny of research questions, practices, and reporting-and a willingness to admit that "good enough" is no longer good enough. As such, a workshop entitled "Toward more rigorous and informative nutritional epidemiology: the rational space between dismissal and defense of the status quo" was held from July 15 to August 14, 2020. This virtual symposium focused on: (1) Stronger Designs, (2) Stronger Measurement, (3) Stronger Analyses, and (4) Stronger Execution and Reporting. Participants from several leading academic institutions explored existing, evolving, and new better practices, tools, and techniques to collaboratively advance specific recommendations for strengthening nutritional epidemiology.
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Affiliation(s)
- ANDREW W. BROWN
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | | | - DENNIS BIER
- Baylor College of Medicine, Houston, Texas, USA
| | | | - ADAM HOOVER
- Clemson University, Clemson, South Carolina, USA
| | - DAVID M. KLURFELD
- United States Department of Agriculture, Agricultural Research Service, Beltsville, Maryland, USA
| | - ERIC LOKEN
- University of Connecticut, Storrs, Connecticut, USA
| | - EVAN MAYO-WILSON
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - NIR MENACHEMI
- Indiana University Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana, USA
| | - GREG PAVELA
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - PATRICK D. QUINN
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - DALE SCHOELLER
- University of Wisconsin-Madison Biotechnology Center, Madison, Wisconsin, USA
| | - CARMEN TEKWE
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - DANNY VALDEZ
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - COLBY J. VORLAND
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - LEAH D. WHIGHAM
- University of Texas Health Science Center School of Public Health, El Paso, Texas, USA
| | - DAVID B. ALLISON
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
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Kelly SE, Greene-Finestone LS, Yetley EA, Benkhedda K, Brooks SPJ, Wells GA, MacFarlane AJ. NUQUEST-NUtrition QUality Evaluation Strengthening Tools: development of tools for the evaluation of risk of bias in nutrition studies. Am J Clin Nutr 2021; 115:256-271. [PMID: 34605544 PMCID: PMC8755056 DOI: 10.1093/ajcn/nqab335] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dietary exposure assessments are a critical issue in evaluating human nutrition studies; however, nutrition-specific criteria are not consistently included in existing bias assessment tools. OBJECTIVES Our objective was to develop a set of risk of bias (RoB) tools that integrated nutrition-specific criteria into validated generic assessment tools to address RoB issues, including those specific to dietary exposure assessment. METHODS The Nutrition QUality Evaluation Strengthening Tools (NUQUEST) development and validation process included 8 steps. The first steps identified 1) a development strategy; 2) generic assessment tools with demonstrated validity; and 3) nutrition-specific appraisal issues. This was followed by 4) generation of nutrition-specific items and 5) development of guidance to aid users of NUQUEST. The final steps used established ratings of selected studies and feedback from independent raters to 6) assess reliability and validity; 7) assess formatting and usability; and 8) finalize NUQUEST. RESULTS NUQUEST is based on the Scottish Intercollegiate Guidelines Network checklists for randomized controlled trials, cohort studies, and case-control studies. Using a purposive sample of 45 studies representing the 3 study designs, interrater reliability was high (Cohen's κ: 0.73; 95% CI: 0.52, 0.93) across all tools and at least moderate for individual tools (range: 0.57-1.00). The use of a worksheet improved usability and consistency of overall interrater agreement across all study designs (40% without worksheet, 80%-100% with worksheet). When compared to published ratings, NUQUEST ratings for evaluated studies demonstrated high concurrent validity (93% perfect or near-perfect agreement). Where there was disagreement, the nutrition-specific component was a contributing factor in discerning exposure methodological issues. CONCLUSIONS NUQUEST integrates nutrition-specific criteria with generic criteria from assessment tools with demonstrated reliability and validity. NUQUEST represents a consistent and transparent approach for evaluating RoB issues related to dietary exposure assessment commonly encountered in human nutrition studies.
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Affiliation(s)
- Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Karima Benkhedda
- Bureau of Nutritional Sciences, Health Canada, Ottawa, Ontario, Canada
| | - Stephen P J Brooks
- Bureau of Nutritional Sciences, Health Canada, Ottawa, Ontario, Canada,Department of Biology, Carleton University, Ottawa, Ontario, Canada
| | - George A Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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12
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Howatt V, Prokop-Dorner A, Valli C, Zajac J, Bala MM, Alonso-Coello P, Guyatt GH, Johnston BC. Values and Preferences Related to Cancer Risk among Red and Processed Meat Eaters: A Pilot Cross-Sectional Study with Semi-Structured Interviews. Foods 2021; 10:foods10092182. [PMID: 34574291 PMCID: PMC8472466 DOI: 10.3390/foods10092182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/05/2021] [Accepted: 08/16/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction: Over the last decade, the possible impact of meat intake on overall cancer incidence and mortality has received considerable attention, and authorities have recommended decreasing consumption; however, the benefits of reducing meat consumption are small and uncertain. As such, individual decisions to reduce consumption are value- and preference-sensitive. Consequently, we undertook a pilot cross-sectional study to explore people’s values and preferences towards meat consumption in the face of cancer risk. Methods and analysis: The mixed-method pilot study included a quantitative questionnaire followed by qualitative evaluation to explore the dietary habits of 32 meat eaters, their reasons for eating meat, and willingness to change their meat consumption when faced with a potential risk reduction of cancer over a lifetime based on a systematic review and dose–response meta-analysis. We recruited a convenience sample of participants from two Canadian provinces: Nova Scotia and Prince Edward Island. This project was approved by the Research Ethics Board for Health Sciences research at Dalhousie University, Canada. Results: The average weekly consumption of red meat was 3.4 servings and the average weekly consumption of processed meat was 3 servings. The determinants that influenced meat intake were similar for both red and processed meat. Taste, cost, and family preferences were the three most commonly cited factors impacting red meat intake. Taste, cost, and (lack of) cooking time were the three most commonly cited factors impacting processed meat intake. None of the participants were willing to eliminate red or processed meat from their diet. About half of participants were willing to potentially reduce their meat consumption, with one third definitely willing to reduce their consumption. Strengths and limitations: This study is the first that we are aware of to share data with participants on the association of red meat and processed meat consumption and the risk of cancer mortality and cancer incidence, including the certainty of evidence for the risk reduction. The limitations of this study include its small sample size and its limited geographic sampling. Conclusions: When presented explicit information about the small uncertain cancer risk associated with red and processed meat consumption, study participants were unwilling to eliminate meat, while about one-third were willing to reduce their meat intake.
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Affiliation(s)
- Victoria Howatt
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Anna Prokop-Dorner
- Chair of Epidemiology and Preventive Medicine, Department of Medical Sociology, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Claudia Valli
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, 08193 Bellaterra, Spain;
- Iberoamerican Cochrane Centre Barcelona, Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain;
| | - Joanna Zajac
- Department of Hygiene and Dietetics, Epidemiology and Preventive Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Malgorzata M. Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, 31-008 Krakow, Poland;
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), 08041 Barcelona, Spain;
- CIBER de Epidemiología y Salud Pública (CIBERESP), 08023 Barcelona, Spain
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada;
- Department of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Bradley C. Johnston
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS B3H 4R2, Canada;
- Departments of Nutrition, Epidemiology and Biostatistics, Texas A&M University, College Station, TX 77843, USA
- Correspondence:
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13
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Food-based dietary guidelines in Spain: an assessment of their methodological quality. Eur J Clin Nutr 2021; 76:350-359. [PMID: 34282294 DOI: 10.1038/s41430-021-00972-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND & OBJECTIVES Food-based dietary guidelines (FBDGs) have been developed to promote healthy diets and prevent chronic diseases. However, the methodological quality of Spanish FBDGs has not been systematically assessed yet. The objective of this review is to identify and assess the methodological quality of Spanish FBDGs, as well as to describe their food guides and key recommendations. METHODS We conducted a systematic search to identify Spanish FBDGs targeted at the general population using multiple sources. Two authors independently screened the references, extracted data, and assessed the quality of the FBDGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Recommendation Excellence (AGREE-REX) instruments. We performed a descriptive analysis of the FBDGs. RESULTS We included 19 FBDGs, published between 2007 and 2019. The median scores for each AGREE II domain were: "scope and purpose" 44% (Q1-Q3: 33-61%); "Stakeholder involvement" 31% (11-44%), "rigor of development" 3% (1-14%); "clarity of presentation" 42% (33-47%), "applicability" 0% (0-6%); and "editorial independence" 0% (0-8%). Six FBDGs (32%; 6/19) were categorized as "recommended with modifications", and the rest (68%; 13/19) as "not recommended". None of the FBDGs scored ≥60% in three or more domains, including the "rigor of development" domain. FBDGs indexed in literature databases scored significantly higher in overall rating than those not indexed (P = 0.023). The majority of FBDGs (74%; 14/19) used the pyramid as a food guide representation with a larger number of food levels (3-7 levels). The majority of FBDGs recommended a daily intake of cereals and grains, vegetables, fruits, olive oil and dairy products; a weekly intake of vegetable and animal proteins; and the occasional and limited intake of other food groups (e.g., ultraprocessed foods). CONCLUSIONS Overall, the methodological quality of FBDGs is poor showing that only 32% of FBDGs are "recommended for use with modifications". Our results highlight the need to revise, systematize and improve FBDG development processes in Spain.
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Vernooij R, Guyatt GH, Zeraatkar D, Han MA, Valli C, El Dib R, Alonso-Coello P, Bala MM, Johnston BC. Reconciling contrasting guideline recommendations on red and processed meat for health outcomes. J Clin Epidemiol 2021; 138:215-218. [PMID: 34273525 DOI: 10.1016/j.jclinepi.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Rwm Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G H Guyatt
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - D Zeraatkar
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - M A Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - C Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain; Department of Paediatrics, Obstetrics,Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona,Barcelona, Spain
| | - R El Dib
- Institute of Science and Technology, Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil
| | - P Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - M M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - B C Johnston
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; Departments of Nutrition, Epidemiology & Biostatistics, Texas A&M University, College Station, TX, USA.
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Musa-Veloso K, Racey M, MacFarlane A, Bier D, Lamarche B, Trumbo P, House J. Challenges in the design, interpretation, and reporting of randomized controlled clinical studies on the health effects of whole foods. Appl Physiol Nutr Metab 2021; 46:1152-1158. [PMID: 34048662 DOI: 10.1139/apnm-2021-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Given the challenges with nutrition research, the Canadian Nutrition Society and Intertek Health Sciences Inc held an expert consultation in late 2019 to discuss the development and implementation of best practices for clinical trials on whole foods. Key challenges in the design, interpretation, and reporting of clinical efficacy studies on whole foods and opportunities for the future development of best practices are reported. Novelty: Outlines existing tools, resources, and checklists for clinical nutrition trials and provides clear and tangible steps to develop best practices for studies on whole foods.
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Affiliation(s)
- Kathy Musa-Veloso
- Health Claims and Clinical Trials, Food and Nutrition Group, Intertek Health Sciences Inc., Suite 201, 2233 Argentia Road, Mississauga, ON L5N 2X7, Canada
| | - Megan Racey
- School of Nursing, Faculty of Health Sciences, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4L8, Canada
| | - Amanda MacFarlane
- Bureau of Nutritional Sciences, Health Canada, 251 Sir Frederick Banting Driveway, Ottawa, ON K1A 0K9, Canada
| | - Dennis Bier
- Pediatrics-Nutrition, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates St., Houston, TX 77030, USA
| | - Benoît Lamarche
- Centre Nutrition, santé et société (NUTRISS), Institute of Nutrition and Functional Foods (INAF), Laval University, 2440 Hochelaga Blvd., Quebec City, QC G1V 0A6, Canada
| | - Paula Trumbo
- Adjunct Faculty, Department of Food Science and Nutrition, University of Minnesota, 1334 Eckles Ave., St. Paul, MN 55108, USA
| | - James House
- Faculty of Agriculture and Food Sciences, University of Manitoba, 208A Human Ecology Building, 66 Chancellors Circle, Winnipeg, MB R3T 2N2, Canada
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Grammatikopoulou MG, Nigdelis MP, Theodoridis X, Gkiouras K, Tranidou A, Papamitsou T, Bogdanos DP, Goulis DG. How fragile are Mediterranean diet interventions? A research-on-research study of randomised controlled trials. BMJ Nutr Prev Health 2021; 4:115-131. [PMID: 34308119 PMCID: PMC8258081 DOI: 10.1136/bmjnph-2020-000188] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The Mediterranean diet (MD) is a traditional regional dietary pattern and a healthy diet recommended for the primary and secondary prevention of various diseases and health conditions. Results from the higher level of primary evidence, namely randomised controlled trials (RCTs), are often used to produce dietary recommendations; however, the robustness of RCTs with MD interventions is unknown. METHODS A systematic search was conducted and all MD RCTs with dichotomous primary outcomes were extracted from PubMed. The fragility (FI) and the reverse fragility index (RFI) were calculated for the trials with significant and non-significant comparisons, respectively. RESULTS Out of 27 RCTs of parallel design, the majority failed to present a significant primary outcome, exhibiting an FI equal to 0. The median FI of the significant comparisons was 5, ranging between 1 and 39. More than half of the comparisons had an FI <5, indicating that the addition of 1-4 events to the treatment arm eliminated the statistical significance. For the comparisons with an FI=0, the RFI ranged between 1 and 29 (Median RFI: 7). When the included RCTs were stratified according to masking, the use of a composite primary endpoint, sample size, outcome category, or dietary adherence assessment method, no differences were exhibited in the FI and RFI between groups, except for the RFI among different compliance assessment methods. CONCLUSIONS In essence, the present study shows that even in the top tiers of evidence hierarchy, research on the MD may lack robustness, setting concerns for the formulation of nutrition recommendations.
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Affiliation(s)
- Maria G Grammatikopoulou
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
- Rheumatology and Clinical Immunology, Faculty of Health Sciences, University of Thessaly, Larissa, Greece
- Nutritional Sciences & Dietetics, Faculty of Health Sciences, International Hellenic University, Thessaloniki, Greece
| | - Meletios P Nigdelis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Xenophon Theodoridis
- Rheumatology and Clinical Immunology, Faculty of Health Sciences, University of Thessaly, Larissa, Greece
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Konstantinos Gkiouras
- Rheumatology and Clinical Immunology, Faculty of Health Sciences, University of Thessaly, Larissa, Greece
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Antigoni Tranidou
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
- Department of Endocrinology, Diabetes and Metabolism, Hippokration General Hospital of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Theodora Papamitsou
- Laboratory of Histology and Embryology, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Dimitrios P Bogdanos
- Rheumatology and Clinical Immunology, Faculty of Health Sciences, University of Thessaly, Larissa, Greece
- Division of Transplantation, Immunology and Mucosal Biology, MRC Centre for Transplantation, School of Medical Education, King's College London, London, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
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Maruvada P, Stover PJ, Mason JB, Bailey RL, Davis CD, Field MS, Finnell RH, Garza C, Green R, Gueant JL, Jacques PF, Klurfeld DM, Lamers Y, MacFarlane AJ, Miller JW, Molloy AM, O'Connor DL, Pfeiffer CM, Potischman NA, Rodricks JV, Rosenberg IH, Ross SA, Shane B, Selhub J, Stabler SP, Trasler J, Yamini S, Zappalà G. Knowledge gaps in understanding the metabolic and clinical effects of excess folates/folic acid: a summary, and perspectives, from an NIH workshop. Am J Clin Nutr 2020; 112:1390-1403. [PMID: 33022704 PMCID: PMC7657327 DOI: 10.1093/ajcn/nqaa259] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/20/2020] [Indexed: 12/21/2022] Open
Abstract
Folate, an essential nutrient found naturally in foods in a reduced form, is present in dietary supplements and fortified foods in an oxidized synthetic form (folic acid). There is widespread agreement that maintaining adequate folate status is critical to prevent diseases due to folate inadequacy (e.g., anemia, birth defects, and cancer). However, there are concerns of potential adverse effects of excess folic acid intake and/or elevated folate status, with the original concern focused on exacerbation of clinical effects of vitamin B-12 deficiency and its role in neurocognitive health. More recently, animal and observational studies have suggested potential adverse effects on cancer risk, birth outcomes, and other diseases. Observations indicating adverse effects from excess folic acid intake, elevated folate status, and unmetabolized folic acid (UMFA) remain inconclusive; the data do not provide the evidence needed to affect public health recommendations. Moreover, strong biological and mechanistic premises connecting elevated folic acid intake, UMFA, and/or high folate status to adverse health outcomes are lacking. However, the body of evidence on potential adverse health outcomes indicates the need for comprehensive research to clarify these issues and bridge knowledge gaps. Three key research questions encompass the additional research needed to establish whether high folic acid or total folate intake contributes to disease risk. 1) Does UMFA affect biological pathways leading to adverse health effects? 2) Does elevated folate status resulting from any form of folate intake affect vitamin B-12 function and its roles in sustaining health? 3) Does elevated folate intake, regardless of form, affect biological pathways leading to adverse health effects other than those linked to vitamin B-12 function? This article summarizes the proceedings of an August 2019 NIH expert workshop focused on addressing these research areas.
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Affiliation(s)
- Padma Maruvada
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Patrick J Stover
- Texas A&M University College of Agriculture and Life Sciences, Texas A&M University AgriLife, College Station, TX, USA
| | - Joel B Mason
- Jean Mayer USDA Human Nutrition Research Center on Aging, Friedman School of Nutrition Science and Policy, and School of Medicine, Tufts University, Boston, MA, USA
| | - Regan L Bailey
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Cindy D Davis
- Office of Dietary Supplements, NIH, Bethesda, MD, USA
| | - Martha S Field
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Richard H Finnell
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Cutberto Garza
- Professor Emeritus, Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jean-Louis Gueant
- University of Lorraine and University Regional Hospital Centre of Nancy, Nancy, France
| | - Paul F Jacques
- Tufts University Friedman School of Nutritional Science and Policy and the Jean Mayer USDA Human Nutrition Research Center, Boston, MA, USA
| | - David M Klurfeld
- Department of Nutrition, Food Safety, and Quality, USDA Agricultural Research Service, Beltsville, MD, USA
| | - Yvonne Lamers
- Food, Nutrition and Health Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Anne M Molloy
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Irwin H Rosenberg
- Jean Mayer USDA Human Nutrition Research Center on Aging, Friedman School of Nutrition Science and Policy, and School of Medicine, Tufts University, Boston, MA, USA
| | | | - Barry Shane
- Department of Nutritional Sciences & Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Jacob Selhub
- Tufts University Friedman School of Nutritional Science and Policy and the Jean Mayer USDA Human Nutrition Research Center, Boston, MA, USA
| | | | | | - Sedigheh Yamini
- Office of Nutrition and Food Labeling, Center for Food Safety and Applied Nutrition, US FDA, College Park, MD, USA
| | - Giovanna Zappalà
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
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Valli C, Howatt V, Prokop-Dorner A, Rabassa M, Johnston BC, Zajac J, Han MA, Kenji Nampo F, Guyatt GH, Bala MM, Alonso-Coello P. Evaluating adults' health-related values and preferences about unprocessed red meat and processed meat consumption: protocol for a cross-sectional mixed-methods study. F1000Res 2020; 9:346. [PMID: 34136136 PMCID: PMC8176263 DOI: 10.12688/f1000research.23593.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 11/26/2022] Open
Abstract
Background: People need to choose from a wide range of foods, and in addition to availability and accessibility, people's values and preferences largely determine their daily food choices. Given the potential adverse health consequences of red and processed meat and the limited knowledge on individuals' health-related values and preferences on the topic, such data would be useful in the development of recommendations regarding meat consumption. Methods and analysis: We will perform a cross-sectional mixed methods study. The study population will consist of adult omnivores currently consuming a minimum of three weekly servings of either unprocessed red meat or processed meat. We will explore participants' willingness to stop or reduce their unprocessed red meat, or their processed meat consumption through a direct-choice exercise. This exercise will consist of presenting a scenario tailored to each individual's average weekly consumption. That is, based on a systematic review and meta-analysis of the best estimate of the risk reduction in overall cancer incidence and cancer mortality, we will ask participants if they would stop their consumption, and/or reduce their average consumption. We will also present the corresponding certainty of the evidence for the potential risk reductions. Finally, we will measure their meat consumption three months after the interview and determine if they have made any changes to their average consumption. Ethics and dissemination: The research protocol was approved by the ethics committees in Canada (Research Ethics Board, Dalhousie University), Spain (Comitè Ètic d'Investigació Clínica de l'IDIAP Jordi Gol), Poland (The Bioethics Committee of the Jagiellonian University), and Brazil (National Research Ethics Commission). The study is based on voluntary participation and informed written consent. Results from this project will be disseminated through publications and presentations.
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Affiliation(s)
- Claudia Valli
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Victoria Howatt
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anna Prokop-Dorner
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Bradley C. Johnston
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Nutrition, Texas A&M University, College Station, Texas, USA
| | - Joanna Zajac
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Fernando Kenji Nampo
- Latin-American Institute of Life and Nature Sciences, Federal University of Latin-American Integration, Evidence-Based Public Health Research Group, Foz do Iguassu, Brazil
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Malgorzata M. Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, (CIBERESP), Barcelona, Spain
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19
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Valli C, Howatt V, Prokop-Dorner A, Rabassa M, Johnston BC, Zajac J, Han MA, Kenji Nampo F, Guyatt GH, Bala MM, Alonso-Coello P. Evaluating adults' health-related values and preferences about unprocessed red meat and processed meat consumption: protocol for a cross-sectional mixed-methods study. F1000Res 2020; 9:346. [PMID: 34136136 PMCID: PMC8176263 DOI: 10.12688/f1000research.23593.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 04/03/2024] Open
Abstract
Background: People need to choose from a wide range of foods, and in addition to availability and accessibility, people's values and preferences largely determine their daily food choices. Given the potential adverse health consequences of red and processed meat and the limited knowledge on individuals' health-related values and preferences on the topic, such data would be useful in the development of recommendations regarding meat consumption. Methods and analysis: We will perform an international cross-sectional mixed methods study in four countries across two continents. The study population will consist of adult omnivores currently consuming a minimum of three weekly servings of either unprocessed red meat or processed meat. We will explore participants' willingness to stop or reduce their unprocessed red meat, or their processed meat consumption through a direct-choice exercise. This exercise will consist of presenting a scenario tailored to each individual's average weekly consumption. That is, based on a systematic review and meta-analysis of the best estimate of the risk reduction in overall cancer mortality and cancer incidence, we will ask participants if they would stop their consumption, and/or reduce their average consumption. We will also present the corresponding certainty of the evidence for the potential risk reductions. Finally, for all included participants, we will measure their meat consumption three months after the interview and determine if they have made any changes to their average consumption. Ethics and dissemination: The research protocol was approved by the ethics committees in Canada (Research Ethics Board, Dalhousie University), Spain (Comitè Ètic d'Investigació Clínica de l'IDIAP Jordi Gol), Poland (The Bioethics Committee of the Jagiellonian University), and Brazil (National Research Ethics Commission). The study is based on voluntary participation and informed written consent. Results from this project will be disseminated through publications and presentations.
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Affiliation(s)
- Claudia Valli
- Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Victoria Howatt
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anna Prokop-Dorner
- Department of Medical Sociology, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Bradley C. Johnston
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Nutrition, Texas A&M University, College Station, Texas, USA
| | - Joanna Zajac
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, South Korea
| | - Fernando Kenji Nampo
- Latin-American Institute of Life and Nature Sciences, Federal University of Latin-American Integration, Evidence-Based Public Health Research Group, Foz do Iguassu, Brazil
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Malgorzata M. Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, (CIBERESP), Barcelona, Spain
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20
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Johnston BC, Zeraatkar D, Vernooij RWM, Rabassa M, El Dib R, Valli C, Han MA, Alonso-Coello P, Bala MM, Guyatt GH. Unprocessed Red Meat and Processed Meat Consumption. Ann Intern Med 2020; 172:639-640. [PMID: 32365371 DOI: 10.7326/l20-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G.)
| | - Robin W M Vernooij
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands (R.W.V.)
| | - Montserrat Rabassa
- Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (M.R.)
| | - Regina El Dib
- Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil (R.E.)
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., P.A.)
| | - Mi Ah Han
- Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., P.A.)
| | | | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G.)
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21
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Johnston BC, Alonso-Coello P, Bala MM, Zeraatkar D, Rabassa M, Valli C, Marshall C, El Dib R, Vernooij RWM, Vandvik PO, Guyatt GH. Correction to: Methods for trustworthy nutritional recommendations NutriRECS (Nutritional Recommendations and accessible Evidence summaries Composed of Systematic reviews): a protocol. BMC Med Res Methodol 2019; 19:240. [PMID: 31847819 PMCID: PMC6918667 DOI: 10.1186/s12874-019-0888-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Following publication of the original article [1], the authors reported a change in the 'Competing interests' section as described below.
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Affiliation(s)
- Bradley C Johnston
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Pablo Alonso-Coello
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Catherine Marshall
- Cochrane Consumer and Honorary Patron of the Guidelines International Network, Wellington, New Zealand
| | - Regina El Dib
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Institute of Science and Technology, Unesp - Univ Estadual Paulista, São José dos Campos, Brazil
| | - Robin W M Vernooij
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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22
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Intake of red and processed meat on the incidence of cancer: Are the risks really relevant? Food Chem Toxicol 2019; 134:110884. [DOI: 10.1016/j.fct.2019.110884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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23
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Vernooij RWM, Zeraatkar D, Han MA, El Dib R, Zworth M, Milio K, Sit D, Lee Y, Gomaa H, Valli C, Swierz MJ, Chang Y, Hanna SE, Brauer PM, Sievenpiper J, de Souza R, Alonso-Coello P, Bala MM, Guyatt GH, Johnston BC. Patterns of Red and Processed Meat Consumption and Risk for Cardiometabolic and Cancer Outcomes: A Systematic Review and Meta-analysis of Cohort Studies. Ann Intern Med 2019; 171:732-741. [PMID: 31569217 DOI: 10.7326/m19-1583] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article has been corrected. The original version (PDF) is appended to this article as a Supplement. BACKGROUND Studying dietary patterns may provide insights into the potential effects of red and processed meat on health outcomes. PURPOSE To evaluate the effect of dietary patterns, including different amounts of red or processed meat, on all-cause mortality, cardiometabolic outcomes, and cancer incidence and mortality. DATA SOURCES Systematic search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and ProQuest Dissertations & Theses Global from inception to April 2019 with no restrictions on year or language. STUDY SELECTION Teams of 2 reviewers independently screened search results and included prospective cohort studies with 1000 or more participants that reported on the association between dietary patterns and health outcomes. DATA EXTRACTION Two reviewers independently extracted data, assessed risk of bias, and evaluated the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. DATA SYNTHESIS Eligible studies that followed patients for 2 to 34 years revealed low- to very-low-certainty evidence that dietary patterns lower in red and processed meat intake result in very small or possibly small decreases in all-cause mortality, cancer mortality and incidence, cardiovascular mortality, nonfatal coronary heart disease, fatal and nonfatal myocardial infarction, and type 2 diabetes. For all-cause, cancer, and cardiovascular mortality and incidence of some types of cancer, the total sample included more than 400 000 patients; for other outcomes, total samples included 4000 to more than 300 000 patients. LIMITATION Observational studies are prone to residual confounding, and these studies provide low- or very-low-certainty evidence according to the GRADE criteria. CONCLUSION Low- or very-low-certainty evidence suggests that dietary patterns with less red and processed meat intake may result in very small reductions in adverse cardiometabolic and cancer outcomes. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42017074074).
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Affiliation(s)
- Robin W M Vernooij
- Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands, and Dalhousie University, Halifax, Nova Scotia, Canada (R.W.V.)
| | - Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Mi Ah Han
- Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Regina El Dib
- Dalhousie University, Halifax, Nova Scotia, Canada, and Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil (R.E.)
| | - Max Zworth
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Kirolos Milio
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Daegan Sit
- University of British Columbia, Vancouver, British Columbia, Canada (D.S.)
| | - Yung Lee
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Huda Gomaa
- Alexandria University, Alexandria, Egypt, and Tanta Chest Hospital, Ministry of Health, Tanta, Egypt (H.G.)
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau, Barcelona, Spain (C.V.)
| | - Mateusz J Swierz
- Jagiellonian University Medical College, Krakow, Poland (M.J.S., M.M.B.)
| | - Yaping Chang
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Steven E Hanna
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | | | - John Sievenpiper
- University of Toronto and St. Michael's Hospital, Toronto, Ontario, Canada (J.S.)
| | - Russell de Souza
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), and CIBER de Epidemiología y Salud Publicá (CIBERESP), Barcelona, Spain (P.A.)
| | - Malgorzata M Bala
- Jagiellonian University Medical College, Krakow, Poland (M.J.S., M.M.B.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., M.Z., K.M., Y.L., Y.C., S.E.H., R.D., G.H.G.)
| | - Bradley C Johnston
- Dalhousie University, Halifax, Nova Scotia, and McMaster University, Hamilton, Ontario, Canada (B.C.J.)
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Johnston BC, Zeraatkar D, Han MA, Vernooij RWM, Valli C, El Dib R, Marshall C, Stover PJ, Fairweather-Taitt S, Wójcik G, Bhatia F, de Souza R, Brotons C, Meerpohl JJ, Patel CJ, Djulbegovic B, Alonso-Coello P, Bala MM, Guyatt GH. Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations From the Nutritional Recommendations (NutriRECS) Consortium. Ann Intern Med 2019; 171:756-764. [PMID: 31569235 DOI: 10.7326/m19-1621] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article has been corrected. The original version (PDF) is appended to this article as a Supplement. DESCRIPTION Dietary guideline recommendations require consideration of the certainty in the evidence, the magnitude of potential benefits and harms, and explicit consideration of people's values and preferences. A set of recommendations on red meat and processed meat consumption was developed on the basis of 5 de novo systematic reviews that considered all of these issues. METHODS The recommendations were developed by using the Nutritional Recommendations (NutriRECS) guideline development process, which includes rigorous systematic review methodology, and GRADE methods to rate the certainty of evidence for each outcome and to move from evidence to recommendations. A panel of 14 members, including 3 community members, from 7 countries voted on the final recommendations. Strict criteria limited the conflicts of interest among panel members. Considerations of environmental impact or animal welfare did not bear on the recommendations. Four systematic reviews addressed the health effects associated with red meat and processed meat consumption, and 1 systematic review addressed people's health-related values and preferences regarding meat consumption. RECOMMENDATIONS The panel suggests that adults continue current unprocessed red meat consumption (weak recommendation, low-certainty evidence). Similarly, the panel suggests adults continue current processed meat consumption (weak recommendation, low-certainty evidence). PRIMARY FUNDING SOURCE None. (PROSPERO 2017: CRD42017074074; PROSPERO 2018: CRD42018088854).
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Affiliation(s)
- Bradley C Johnston
- Dalhousie University, Halifax, Nova Scotia, Canada, McMaster University, Hamilton, Ontario, Canada, and Texas A&M University, College Station, Texas (B.C.J.)
| | - Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G.)
| | - Mi Ah Han
- Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Robin W M Vernooij
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands, and Dalhousie University, Halifax, Nova Scotia, Canada (R.W.V.)
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., P.A.)
| | - Regina El Dib
- Institute of Science and Technology, Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil, and Dalhousie University, Halifax, Nova Scotia, Canada (R.E.)
| | | | - Patrick J Stover
- Texas A&M AgriLife Research, College of Agriculture and Life Sciences, Texas A&M University, College Station, Texas (P.J.S.)
| | | | - Grzegorz Wójcik
- Jagiellonian University Medical College, Kraków, Poland (G.W., M.M.B.)
| | | | - Russell de Souza
- Population Health Research Institute, Hamilton, Ontario, Canada (R.D.)
| | - Carlos Brotons
- Sardenya Primary Health Care Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain (C.B.)
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Centre, University of Freiburg, Freiburg, Germany (J.J.M.)
| | | | | | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., P.A.)
| | - Malgorzata M Bala
- Jagiellonian University Medical College, Kraków, Poland (G.W., M.M.B.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G.)
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25
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Zeraatkar D, Han MA, Guyatt GH, Vernooij RWM, El Dib R, Cheung K, Milio K, Zworth M, Bartoszko JJ, Valli C, Rabassa M, Lee Y, Zajac J, Prokop-Dorner A, Lo C, Bala MM, Alonso-Coello P, Hanna SE, Johnston BC. Red and Processed Meat Consumption and Risk for All-Cause Mortality and Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Cohort Studies. Ann Intern Med 2019; 171:703-710. [PMID: 31569213 DOI: 10.7326/m19-0655] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article has been corrected. The original version (PDF) is appended to this article as a Supplement. BACKGROUND Dietary guidelines generally recommend limiting intake of red and processed meat. However, the quality of evidence implicating red and processed meat in adverse health outcomes remains unclear. PURPOSE To evaluate the association between red and processed meat consumption and all-cause mortality, cardiometabolic outcomes, quality of life, and satisfaction with diet among adults. DATA SOURCES EMBASE (Elsevier), Cochrane Central Register of Controlled Trials (Wiley), Web of Science (Clarivate Analytics), CINAHL (EBSCO), and ProQuest from inception until July 2018 and MEDLINE from inception until April 2019, without language restrictions, as well as bibliographies of relevant articles. STUDY SELECTION Cohort studies with at least 1000 participants that reported an association between unprocessed red or processed meat intake and outcomes of interest. DATA EXTRACTION Teams of 2 reviewers independently extracted data and assessed risk of bias. One investigator assessed certainty of evidence, and the senior investigator confirmed the assessments. DATA SYNTHESIS Of 61 articles reporting on 55 cohorts with more than 4 million participants, none addressed quality of life or satisfaction with diet. Low-certainty evidence was found that a reduction in unprocessed red meat intake of 3 servings per week is associated with a very small reduction in risk for cardiovascular mortality, stroke, myocardial infarction (MI), and type 2 diabetes. Likewise, low-certainty evidence was found that a reduction in processed meat intake of 3 servings per week is associated with a very small decrease in risk for all-cause mortality, cardiovascular mortality, stroke, MI, and type 2 diabetes. LIMITATION Inadequate adjustment for known confounders, residual confounding due to observational design, and recall bias associated with dietary measurement. CONCLUSION The magnitude of association between red and processed meat consumption and all-cause mortality and adverse cardiometabolic outcomes is very small, and the evidence is of low certainty. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42017074074).
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Affiliation(s)
- Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Mi Ah Han
- Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Robin W M Vernooij
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands, and Dalhousie University, Halifax, Nova Scotia, Canada (R.W.V.)
| | - Regina El Dib
- Science and Technology Institute, Universidade Estadual Paulista, São Paulo, Brazil, and Dalhousie University, Halifax, Nova Scotia, Canada (R.E.)
| | - Kevin Cheung
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Kirolos Milio
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Max Zworth
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Jessica J Bartoszko
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Claudia Valli
- Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., M.R.)
| | - Montserrat Rabassa
- Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., M.R.)
| | - Yung Lee
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Joanna Zajac
- Jagiellonian University Medical College, Krakow, Poland (J.Z., A.P., M.M.B.)
| | - Anna Prokop-Dorner
- Jagiellonian University Medical College, Krakow, Poland (J.Z., A.P., M.M.B.)
| | - Calvin Lo
- University of British Columbia, Vancouver, British Columbia, Canada (C.L.)
| | - Malgorzata M Bala
- Jagiellonian University Medical College, Krakow, Poland (J.Z., A.P., M.M.B.)
| | - Pablo Alonso-Coello
- Biomedical Research Institute San Pau (IIB Sant Pau) and CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (P.A.)
| | - Steven E Hanna
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., K.C., K.M., M.Z., J.J.B., Y.L., S.E.H.)
| | - Bradley C Johnston
- Dalhousie University, Halifax, Nova Scotia, Canada, and McMaster University, Hamilton, Ontario, Canada (B.C.J.)
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Han MA, Zeraatkar D, Guyatt GH, Vernooij RWM, El Dib R, Zhang Y, Algarni A, Leung G, Storman D, Valli C, Rabassa M, Rehman N, Parvizian MK, Zworth M, Bartoszko JJ, Lopes LC, Sit D, Bala MM, Alonso-Coello P, Johnston BC. Reduction of Red and Processed Meat Intake and Cancer Mortality and Incidence: A Systematic Review and Meta-analysis of Cohort Studies. Ann Intern Med 2019; 171:711-720. [PMID: 31569214 DOI: 10.7326/m19-0699] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article has been corrected. The original version (PDF) is appended to this article as a Supplement. BACKGROUND Cancer incidence has continuously increased over the past few centuries and represents a major health burden worldwide. PURPOSE To evaluate the possible causal relationship between intake of red and processed meat and cancer mortality and incidence. DATA SOURCES Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, and ProQuest from inception until July 2018 and MEDLINE from inception until April 2019 without language restrictions. STUDY SELECTION Cohort studies that included more than 1000 adults and reported the association between consumption of unprocessed red and processed meat and cancer mortality and incidence. DATA EXTRACTION Teams of 2 reviewers independently extracted data and assessed risk of bias; 1 reviewer evaluated the certainty of evidence, which was confirmed or revised by the senior reviewer. DATA SYNTHESIS Of 118 articles (56 cohorts) with more than 6 million participants, 73 articles were eligible for the dose-response meta-analyses, 30 addressed cancer mortality, and 80 reported cancer incidence. Low-certainty evidence suggested that an intake reduction of 3 servings of unprocessed meat per week was associated with a very small reduction in overall cancer mortality over a lifetime. Evidence of low to very low certainty suggested that each intake reduction of 3 servings of processed meat per week was associated with very small decreases in overall cancer mortality over a lifetime; prostate cancer mortality; and incidence of esophageal, colorectal, and breast cancer. LIMITATION Limited causal inferences due to residual confounding in observational studies, risk of bias due to limitations in diet assessment and adjustment for confounders, recall bias in dietary assessment, and insufficient data for planned subgroup analyses. CONCLUSION The possible absolute effects of red and processed meat consumption on cancer mortality and incidence are very small, and the certainty of evidence is low to very low. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42017074074).
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Affiliation(s)
- Mi Ah Han
- Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | - Robin W M Vernooij
- Dalhousie University, Halifax, Nova Scotia, Canada, and Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands (R.W.V.)
| | - Regina El Dib
- Science and Technology Institute, Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil, and Dalhousie University, Halifax, Nova Scotia, Canada (R.E.)
| | - Ying Zhang
- Beijing University of Chinese Medicine, Beijing, China (Y.Z.)
| | | | - Gareth Leung
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | - Dawid Storman
- Jagiellonian University Medical College, Kraków, Poland (D.S.)
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute Sant Pau, and CIBER de Epidemiología y Salud Pública, Barcelona, Spain (C.V., M.R.)
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute Sant Pau, and CIBER de Epidemiología y Salud Pública, Barcelona, Spain (C.V., M.R.)
| | - Nadia Rehman
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | - Michael K Parvizian
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | - Max Zworth
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | - Jessica J Bartoszko
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G., G.L., N.R., M.K.P., M.Z., J.J.B.)
| | | | - Daegan Sit
- University of British Columbia, Vancouver, British Columbia, Canada (D.S.)
| | | | - Pablo Alonso-Coello
- McMaster University, Hamilton, Ontario, Canada, and Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute Sant Pau, and CIBER de Epidemiología y Salud Pública, Barcelona, Spain (P.A.)
| | - Bradley C Johnston
- Dalhousie University, Halifax, Nova Scotia, and McMaster University, Hamilton, Ontario, Canada (B.C.J.)
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Zeraatkar D, Johnston BC, Bartoszko J, Cheung K, Bala MM, Valli C, Rabassa M, Sit D, Milio K, Sadeghirad B, Agarwal A, Zea AM, Lee Y, Han MA, Vernooij RWM, Alonso-Coello P, Guyatt GH, El Dib R. Effect of Lower Versus Higher Red Meat Intake on Cardiometabolic and Cancer Outcomes: A Systematic Review of Randomized Trials. Ann Intern Med 2019; 171:721-731. [PMID: 31569236 DOI: 10.7326/m19-0622] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article has been corrected. The original version (PDF) is appended to this article as a Supplement. BACKGROUND Few randomized trials have evaluated the effect of reducing red meat intake on clinically important outcomes. PURPOSE To summarize the effect of lower versus higher red meat intake on the incidence of cardiometabolic and cancer outcomes in adults. DATA SOURCES EMBASE, CENTRAL, CINAHL, Web of Science, and ProQuest from inception to July 2018 and MEDLINE from inception to April 2019, without language restrictions. STUDY SELECTION Randomized trials (published in any language) comparing diets lower in red meat with diets higher in red meat that differed by a gradient of at least 1 serving per week for 6 months or more. DATA EXTRACTION Teams of 2 reviewers independently extracted data and assessed the risk of bias and the certainty of the evidence. DATA SYNTHESIS Of 12 eligible trials, a single trial enrolling 48 835 women provided the most credible, though still low-certainty, evidence that diets lower in red meat may have little or no effect on all-cause mortality (hazard ratio [HR], 0.99 [95% CI, 0.95 to 1.03]), cardiovascular mortality (HR, 0.98 [CI, 0.91 to 1.06]), and cardiovascular disease (HR, 0.99 [CI, 0.94 to 1.05]). That trial also provided low- to very-low-certainty evidence that diets lower in red meat may have little or no effect on total cancer mortality (HR, 0.95 [CI, 0.89 to 1.01]) and the incidence of cancer, including colorectal cancer (HR, 1.04 [CI, 0.90 to 1.20]) and breast cancer (HR, 0.97 [0.90 to 1.04]). LIMITATIONS There were few trials, most addressing only surrogate outcomes, with heterogeneous comparators and small gradients in red meat consumption between lower versus higher intake groups. CONCLUSION Low- to very-low-certainty evidence suggests that diets restricted in red meat may have little or no effect on major cardiometabolic outcomes and cancer mortality and incidence. PRIMARY FUNDING SOURCE None (PROSPERO: CRD42017074074).
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Affiliation(s)
- Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Bradley C Johnston
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Jessica Bartoszko
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Kevin Cheung
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | | | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., M.R., P.A.)
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., M.R., P.A.)
| | - Daegen Sit
- University of British Columbia, Vancouver, British Columbia, Canada (D.S.)
| | - Kirolos Milio
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Behnam Sadeghirad
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Arnav Agarwal
- University of Toronto, Toronto, Ontario, Canada (A.A.)
| | - Adriana M Zea
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Yung Lee
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Mi Ah Han
- Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Robin W M Vernooij
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands (R.W.V.)
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (C.V., M.R., P.A.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., B.C.J., J.B., K.C., K.M., B.S., A.M.Z., Y.L., G.H.G.)
| | - Regina El Dib
- Institute of Science and Technology, Universidade Estadual Paulista, São José dos Campos, São Paulo, Brazil (R.E.)
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Valli C, Rabassa M, Johnston BC, Kuijpers R, Prokop-Dorner A, Zajac J, Storman D, Storman M, Bala MM, Solà I, Zeraatkar D, Han MA, Vernooij RWM, Guyatt GH, Alonso-Coello P. Health-Related Values and Preferences Regarding Meat Consumption: A Mixed-Methods Systematic Review. Ann Intern Med 2019; 171:742-755. [PMID: 31569219 DOI: 10.7326/m19-1326] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article has been corrected. The original version (PDF) is appended to this article as a Supplement. BACKGROUND A person's meat consumption is often determined by their values and preferences. PURPOSE To identify and evaluate evidence addressing health-related values and preferences regarding meat consumption. DATA SOURCES MEDLINE, EMBASE, Web of Science, Centre for Agriculture and Biosciences Abstracts, International System for Agricultural Science and Technology, and Food Science and Technology Abstracts were searched from inception to July 2018 without language restrictions. STUDY SELECTION Pairs of reviewers independently screened search results and included quantitative and qualitative studies reporting adults' health-related values and preferences regarding meat consumption. DATA EXTRACTION Pairs of reviewers independently extracted data and assessed risk of bias. DATA SYNTHESIS Data were synthesized into narrative form, and summaries were tabulated and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Of 19 172 initial citations, 41 quantitative studies (38 addressed reasons for meat consumption and 5 addressed willingness to reduce meat consumption) and 13 qualitative studies (10 addressed reasons for meat consumption and 4 addressed willingness to reduce meat consumption) were eligible for inclusion. Thirteen studies reported that omnivores enjoy eating meat, 18 reported that these persons consider meat an essential component of a healthy diet, and 7 reported that they believe they lack the skills needed to prepare satisfactory meals without meat. Omnivores are generally unwilling to change their meat consumption. The certainty of evidence was low for both "reasons for meat consumption" and "willingness to reduce meat consumption in the face of undesirable health effects." LIMITATION Limited generalizability of findings to lower-income countries, low-certainty evidence for willingness to reduce meat consumption, and limited applicability to specific types of meat (red and processed meat). CONCLUSION Low-certainty evidence suggests that omnivores are attached to meat and are unwilling to change this behavior when faced with potentially undesirable health effects. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42018088854).
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Affiliation(s)
- Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), and Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Auto` noma de Barcelona, Barcelona, Spain (C.V.)
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain (M.R.)
| | - Bradley C Johnston
- McMaster University, Hamilton, Ontario, and Dalhousie University, Halifax, Nova Scotia, Canada (B.C.J.)
| | - Ruben Kuijpers
- Wageningen University, Wageningen, the Netherlands (R.K.)
| | - Anna Prokop-Dorner
- Jagiellonian University Medical College, Krakow, Poland (A.P., J.Z., D.S., M.M.B.)
| | - Joanna Zajac
- Jagiellonian University Medical College, Krakow, Poland (A.P., J.Z., D.S., M.M.B.)
| | - Dawid Storman
- Jagiellonian University Medical College, Krakow, Poland (A.P., J.Z., D.S., M.M.B.)
| | - Monika Storman
- Medical University of Warsaw, Warsaw, and Jagiellonian University Medical College, Krakow, Poland (M.S.)
| | - Malgorzata M Bala
- Jagiellonian University Medical College, Krakow, Poland (A.P., J.Z., D.S., M.M.B.)
| | - Ivan Solà
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), and CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain (I.S.)
| | - Dena Zeraatkar
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G.)
| | - Mi Ah Han
- School of Medicine, Chosun University, Gwangju, Republic of Korea (M.A.H.)
| | - Robin W M Vernooij
- Dalhousie University, Halifax, Nova Scotia, Canada, and Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands (R.W.V.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (D.Z., G.H.G.)
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), and CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain, and McMaster University, Hamilton, Ontario, Canada (P.A.)
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Aranceta-Bartrina J, Partearroyo T, López-Sobaler AM, Ortega RM, Varela-Moreiras G, Serra-Majem L, Pérez-Rodrigo C. Updating the Food-Based Dietary Guidelines for the Spanish Population: The Spanish Society of Community Nutrition (SENC) Proposal. Nutrients 2019; 11:E2675. [PMID: 31694249 PMCID: PMC6893611 DOI: 10.3390/nu11112675] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
Diet-related risk factors and physical inactivity are among the leading risk factors for disability and are responsible for a large proportion of the burden of chronic non-communicable diseases. Food-based dietary guidelines (FBDGs) are useful tools for nutrition policies and public health strategies to promote healthier eating and physical activity. In this paper, we discuss the process followed in developing the dietary guidelines for the Spanish population by the Spanish Society of Community Nutrition (SENC) and further explain the collaboration with primary healthcare practitioners as presented in the context of the NUTRIMAD 2018 international congress of SENC. From a health in all policies approach, SENC convened a group of experts in nutrition and public health to review the evidence on diet-health, nutrient intake and food consumption in the Spanish population, as well as food preparation, determinants and impact of diet on environmental sustainability. The collaborative group drafted the document and designed the graphic icon, which was then subject to a consultation process, discussion, and qualitative evaluation. Next, a collaborative group was established to plan a dissemination strategy, involving delegates from all the primary healthcare scientific societies in Spain. A product of this collaboration was the release of an attractive, easy-to-understand publication.
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Affiliation(s)
- Javier Aranceta-Bartrina
- Department of Food Sciences and Physiology, University of Navarra, Pamplona, 31009 Navarra, Spain
- CIBEROBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, 28029 Madrid, Spain
- Research Institute of Biomedical and Health Sciences (IUIBS), University of Las Palmas de Gran Canaria, 35016 Las Palmas, Spain
- Department of Physiology, Faculty of Medicine, University of the Basque Country (UPV/EHU), 48940 Leioa, Vizcaya, Spain
| | - Teresa Partearroyo
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, 28925 Alcorcón, Madrid, Spain
| | - Ana M. López-Sobaler
- Departamento de Nutrición y Ciencia de los Alimentos, Facultad de Farmacia, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Rosa M. Ortega
- Departamento de Nutrición y Ciencia de los Alimentos, Facultad de Farmacia, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Gregorio Varela-Moreiras
- Departamento de Ciencias Farmacéuticas y de la Salud, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, 28925 Alcorcón, Madrid, Spain
- Spanish Nutrition Foundation (FEN), 28010 Madrid, Spain
| | - Lluis Serra-Majem
- CIBEROBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, 28029 Madrid, Spain
- Research Institute of Biomedical and Health Sciences (IUIBS), University of Las Palmas de Gran Canaria, 35016 Las Palmas, Spain
- Fundación para la Investigación Nutricional (FIN), 08029 Barcelona, Spain
| | - Carmen Pérez-Rodrigo
- Department of Physiology, Faculty of Medicine, University of the Basque Country (UPV/EHU), 48940 Leioa, Vizcaya, Spain
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Zeraatkar D, Johnston BC, Guyatt G. Evidence Collection and Evaluation for the Development of Dietary Guidelines and Public Policy on Nutrition. Annu Rev Nutr 2019; 39:227-247. [DOI: 10.1146/annurev-nutr-082018-124610] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Dietary guidelines and recommendations, usually developed by government bodies or large authoritative organizations, have major downstream effects on public policy. A growing body of evidence supports the notion that there are serious deficiencies in the methods used to develop dietary guidelines. Such deficiencies include the failure to access or conduct comprehensive systematic reviews, a lack of systematic or rigorous evaluation of the quality of the evidence, a failure to acknowledge the limitations of the evidence base underlying recommendations, and insufficiently stringent management of conflicts of interest. These issues may be addressed by adhering to international standards for guideline development, including adopting systematic review methodology and using rigorous systems to evaluate the certainty of the evidence and to move from evidence to recommendations, of which the GRADE approach (Grading of Recommendations Assessment,Development and Evaluation) is the most rigorous and fully developed. Improving the methods by which dietary guidelines are produced has considerable potential to substantially improve public policy decision-making.
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Affiliation(s)
- Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Bradley C. Johnston
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1, Canada
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario L8S 4K1, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario L8S 4K1, Canada
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Theodoridis X, Grammatikopoulou MG, Petalidou A, Kontonika SM, Potamianos SP, Bogdanos DP. A Systematic Review of Medical Nutrition Therapy Guidelines for Liver Cirrhosis: Do We Agree? Nutr Clin Pract 2019; 35:98-107. [DOI: 10.1002/ncp.10393] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Xenophon Theodoridis
- Department of Rheumatology and Clinical Immunology; Faculty of Medicine; School of Health Sciences; University of Thessaly; Larissa Greece
- School of Medicine; Faculty of Health Sciences; Aristotle University of Thessaloniki; Thessaloniki Greece
- Department of Nutritional Sciences & Dietetics; International Hellenic University; Thessaloniki Greece
| | - Maria G. Grammatikopoulou
- Department of Rheumatology and Clinical Immunology; Faculty of Medicine; School of Health Sciences; University of Thessaly; Larissa Greece
- School of Medicine; Faculty of Health Sciences; Aristotle University of Thessaloniki; Thessaloniki Greece
- Department of Nutritional Sciences & Dietetics; International Hellenic University; Thessaloniki Greece
| | - Arianna Petalidou
- Department of Rheumatology and Clinical Immunology; Faculty of Medicine; School of Health Sciences; University of Thessaly; Larissa Greece
| | - Stamatia-Maria Kontonika
- Department of Rheumatology and Clinical Immunology; Faculty of Medicine; School of Health Sciences; University of Thessaly; Larissa Greece
- Department of Nutritional Sciences & Dietetics; International Hellenic University; Thessaloniki Greece
| | - Spyros P. Potamianos
- Department of Gastroenterology; Faculty of Medicine; School of Health Sciences; University of Thessaly; Larissa Greece
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology; Faculty of Medicine; School of Health Sciences; University of Thessaly; Larissa Greece
- Division of Transplantation Immunology and Mucosal Biology; MRC Centre for Transplantation; King's College London Medical School; London United Kingdom
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Johnston BC, Seivenpiper JL, Vernooij RW, de Souza RJ, Jenkins DJ, Zeraatkar D, Bier DM, Guyatt GH. The Philosophy of Evidence-Based Principles and Practice in Nutrition. Mayo Clin Proc Innov Qual Outcomes 2019; 3:189-199. [PMID: 31193887 PMCID: PMC6543447 DOI: 10.1016/j.mayocpiqo.2019.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 01/26/2023] Open
Abstract
The practice of evidence-based nutrition involves using the best available nutrition evidence, together with clinical experience, to conscientiously work with patients' values and preferences to help them prevent (sometimes), resolve (sometimes), or cope with (often) problems related to their physical, mental, and social health. This article outlines the 3 fundamental principles of evidence-based practice as applied to the field of clinical nutrition. First, optimal clinical decision making requires awareness of the best available evidence, which ideally will come from unbiased systematic summaries of that evidence. Second, evidence-based nutrition provides guidance on how to decide which evidence is more or less trustworthy-that is, how certain can we be of our patients' prognosis, diagnosis, or of our therapeutic options? Third, evidence alone is never sufficient to make a clinical decision. Decision makers must always trade off the benefits with the risks, burden, and costs associated with alternative management strategies, and, in so doing, consider their patients' unique predicament, including their values and preferences.
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Affiliation(s)
- Bradley C. Johnston
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John L. Seivenpiper
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St Michael’s Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Robin W.M. Vernooij
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Russell J. de Souza
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St Michael’s Hospital, Toronto, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - David J.A. Jenkins
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St Michael’s Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, St Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Dennis M. Bier
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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