Effect of Nuts on Anthropometric and Glycemic Indexes and Blood Pressure in Secondary Cardiovascular Prevention: A Systematic Review and Meta-analysis of Randomized Controlled Trials

CONTEXT

Nut-enriched diets have a positive impact on cardiovascular risk factors, such as body mass, blood pressure, and fasting blood glucose. However, studies in individuals undergoing secondary cardiovascular prevention show controversial results.

OBJECTIVE

This systematic review with meta-analysis assessed the effect of nut supplementation on anthropometric, glycemic, and blood pressure indices in patients with atherosclerotic cardiovascular disease, as well as the frequency of adverse events.

DATA SOURCES

Six databases were used for the search-PubMed, Cochrane Library, EMBASE, BVS (Biblioteca Virtual da Saude), Web of Science, and ClinicalTrials.gov-until February 2023, with no language restrictions.

DATA EXTRACTION

The Cochrane Handbook for Systematic Reviews of Interventions methodology and the PICOS (Population, Intervention, Comparison, Outcome, Setting/design) strategy were used. Seven independent reviewers were involved in data extraction and resolution of disagreements. Certainty of the evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

DATA ANALYSIS

From 5187 records identified, 6 publications containing data referring to 5 randomized clinical trials (n = 436) were included in the final analyses. The nuts evaluated were almonds, pecans, Brazil nuts, and mixed nuts, with portions that varied between 5 g and 85 g (median: 30 g/day). The intervention period varied between 6 and 12 weeks. The nuts had no effect on fasting glucose and anthropometric indices, although the certainty of the evidence for most of these outcomes was low or very low. They also had no effect on systolic (mean difference [MD]: -1.16 mmHg [95% CI, -5.68 to 3.35], I2 = 0%-moderate certainty of evidence) or diastolic (MD: 0.10 mmHg [95% CI, -2.30 to 2.51], I2 = 0%-high certainty of evidence) blood pressure. It was not possible to aggregate data on adverse events.

CONCLUSION

Nut supplementation had no effect on blood pressure, fasting glucose, or anthropometric profile in the context of atherosclerotic cardiovascular disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020163456.

Mindful eating questionnaire: Validation and reliability in Brazilian adults with type 2 diabetes mellitus

OBJECTIVE

The objective was to evaluate the psychometric properties of the Mindful Eating Questionnaire (MEQ) in Brazilian subjects with type 2 diabetes mellitus (T2DM) and validate a Brazilian version of the MEQ for adults with T2DM (MEQ-DM).

METHODOLOGY

Baseline data from the multicentre Nutritional Strategy for Glycaemic Control in Patients with Type 2 Diabetes Mellitus (NUGLIC) trial were used. Construct validity was assessed using exploratory factor analysis (EFA). The root mean square error of approximation (RMSEA), comparative fit index (CFI) and Tucker‒Lewis index (TLI) fit indices indicated the adequacy of the model. The reliability of the questionnaire was evaluated considering the different factor loadings. Criterion validity was tested by correlating the MEQ-DM with sociodemographic variables, body mass index (BMI) and physical activity levels.

RESULTS

A total of 370 participants were included, who were mostly female (60.8 %) and had a median age of 61 (54-67) years. The EFA results supported the two-factor structure of the 25-item MEQ-DM: disinhibition and awareness. The results of the fit indices (RMSEA = 0.04; CFI = 0.95 and TLI = 0.94) and composite reliability (disinhibition = 0.84 and awareness = 0.81) were consistent. The criterion validity analysis indicated a significant association between MEQ-DM scores and age, sex, civil status, education level, BMI and physical activity (p < 0.05).

CONCLUSION

When explored with Brazilian adults with T2DM, the MEQ-DM presented a factorial model with two dimensions: disinhibition and awareness. This model must be confirmed in future studies with Brazilians with T2DM.

Effectiveness of a two-component nutritional strategy for blood pressure control in individuals with hypertension users of a public health system: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effectiveness of a nutritional strategy based on two components and adapted for the public health system on blood pressure, cardiometabolic features, self-care, qualify of life and diet quality in individuals with hypertension.

METHODS

NUPRESS was an open-label, parallel-group, superiority randomized controlled clinical trial in which participants at least 21 years with hypertension and poorly controlled blood pressure were randomly assigned (1 : 1 allocation ratio) to either an individualized dietary prescription according to nutritional guidelines (control group, n = 205); or a two-component nutrition strategy, including a goal-directed nutritional counseling and mindfulness techniques (NUPRESS [intervention] group, n = 205). Primary outcomes were SBP (mmHg) after 24 weeks of follow up and blood pressure control, defined as either having SBP more than 140 mmHg at baseline and achieving 140 mmHg or less after follow-up or having SBP 140 mmHg or less at baseline and reducing the frequency of antihypertensive drugs in use after follow-up.

RESULTS

In total, 410 participants were randomized and submitted to an intention-to-treat analysis regarding primary outcomes. Both groups decreased blood pressure, but after adjusting for baseline values, there was no significant difference between them on SBP [intervention-control difference: -0.03 (-3.01; 2.94); P = 0.98] nor blood pressure control [odds ratio 1.27 (0.82; 1.97); P = 0.28]. No differences between groups were also detected regarding secondary and tertiary outcomes.

CONCLUSION

There was no difference between a two-component nutritional strategy and an established dietary intervention on blood pressure in participants with hypertension.

Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years

BACKGROUND

Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality.

OBJECTIVES

The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission.

METHODS

We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle.

RESULTS

A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%).

CONCLUSIONS

Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Maternal Feeding Practices among Children with Feeding Difficulties-Cross-sectional Study in a Brazilian Reference Center

BACKGROUND

Given the positive influence of responsive caregiving on dietary habits in childhood, to raise awareness of caregivers regarding their behavior is crucial in multidisciplinary care on infant feeding.

OBJECTIVES

To identify the most common responsive and non-responsive feeding practices in mothers of children with feeding complaints, as well as to seek associations between practices and caregivers' profile.

METHODS

Cross-sectional study with 77 children under 18 years old, with complaints of feeding difficulties. Data were collected during interviews with mothers: child age, gender, duration of exclusive breastfeeding, presence of organic disease, dynamics of bottle use, self-feeding practices and posture at meals, use of appropriate feeding equipment; basic information about the mothers (parity and level of education), caregiver feeding style, presence of coercive feeding, frequency and characteristics of family meals. Statistical analysis considered significance level at 5%.

RESULTS

The non-responsive profile predominated among mothers (76.2%, with the Authoritarian style being the most prevalent-39.7%). The responsive profile was characterized by absence of coercive feeding, stimulation of self-feeding practices, use of appropriate feeding equipment and meal environment, with interaction at meals. Non-responsive profile consisted of both inadequate environment and posture at meals, use of distraction and coercive feeding, lack of shared meals, and disregard for children's hunger signals. Only the habit of sharing meals with children was associated with mothers' profile, and considered a protection factor against non-responsive care (OR 0.23; 95% CI 0.06-0.88). Both Authoritarian (p = 0.000) and indulgent mothers (p = 0.007) breastfed exclusively for longer time than negligent ones. There was a higher level of interaction with children in "responsive" parental style (OR 0.056; p = 0.01) compared to other feeding styles.

CONCLUSION

Results highlight the need for educational interventions focused on caregivers' behaviors.

Delayed Development of Feeding Skills in Children with Feeding Difficulties-Cross-sectional Study in a Brazilian Reference Center

BACKGROUND

Delays in gross motor development, sensory processing issues, and organic and behavioral problems are known to interfere in the development of feeding skills (FS); and-therefore-in the success of the process of feeding a child. Children with feeding difficulties (FD) commonly present inadequacy of FS.

OBJECTIVES

Assessment of five FS in Brazilian children with FD, and search of associations with types of FD.

METHODS

Cross-sectional study with 70 children below 10 years old. Data were obtained from medical records: age, gender, age at texture transitions, feeding phase (breastfeeding, weaning to solids or full solids) at first complaint; characteristics of the meal (duration, environment, and shared meals with adults), self-feeding practices, use of feeding equipment and bottle, mouthing, feeding position and FD diagnosis. Skills were categorized according to standards for age. Chi-Square, Anova Test (or non-parametric equivalent) and Multinomial logistic regression tests were used, with a significance level of 5%.

RESULTS

There was no difference in FS (p > 0.05) or in the number of FS inadequateness (p = 0.84) according to FD diagnosis. The majority (94%) of children presented at least one delayed development of FS; 1/3 presented delays in more than half of the FS. The most prevalent inadequacies in FS were inadequate feeding position (73.5%), prolonged bottle feeding (56.9%), and inadequate self-feeding practices (37.9%). Feeding complaints first appeared at 10.9 ± 11.4 months, and picky eating was the most prevalent type of FD (37.1%). Most children were fed in inadequate environments (55.2%), without the company of adults (78%). Transition to solid foods occurred at 16 ± 5.6 months. Multinomial logistic regression showed no difference in likelihood of presenting any type of FD compared to picky eating, according to FS. Age at texture transition both from breastfeeding to complementary feeding (p = 0.95), and from complementary feeding to solid foods (p = 0.43) did not vary according to FD diagnosis.

CONCLUSION

FS development or number of FS inadequateness did not vary according to FD diagnosis. Identification of these inadequacies could help the discussion for multi-professional treatment of patients with FD.