Paraskevi Massara1, Andreea Zurbau1,2,3, Andrea J Glenn1,2,3,4, Laura Chiavaroli1,2,3, Tauseef A Khan1,2,3, Effie Viguiliouk1,5, Sonia Blanco Mejia1,2,3, Elena M Comelli1,6, Victoria Chen1, Ursula Schwab7,8, Ulf Risérus9, Matti Uusitupa10, Anne-Marie Aas11, Kjeld Hermansen12,13, Inga Thorsdottir14,15, Dario Rahelić16,17,18, Hana Kahleová19,20, Jordi Salas-Salvadó21,22, Cyril W C Kendall1,2,3,23, John L Sievenpiper24,25,26,27,28,29,30. 1. Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 2. Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada. 3. Clinical Nutrition and Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada. 4. Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA. 5. Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada. 6. Joannah and Brian Lawson Centre for Child Nutrition, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 7. Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland. ursula.schwab@uef.fi. 8. Department of Medicine, Endocrinology and Clinical Nutrition, Kuopio University Hospital, Kuopio, Finland. ursula.schwab@uef.fi. 9. Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden. 10. Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland. 11. Division of Medicine, Department of Clinical Service, Section of Nutrition and Dietetics, Oslo University Hospital, Oslo, Norway. 12. Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark. 13. Department of Clinical Medicine, Aarhus University, Aarhus, Denmark. 14. Unit for Nutrition Research, Health Science Institute, University of Iceland, Reykjavík, Iceland. 15. Landspitali - University Hospital of Iceland, Reykjavík, Iceland. 16. Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Zagreb, Croatia. 17. Croatian Catholic University School of Medicine, Zagreb, Croatia. 18. Josip Juraj Strossmayer University School of Medicine, Osijek, Croatia. 19. Institute for Clinical and Experimental Medicine, Diabetes Centre, Prague, Czech Republic. 20. Physicians Committee for Responsible Medicine, Washington, DC, USA. 21. Centro de Investigacion Biomedica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain. 22. Human Nutrition Department, IISPV, Universitat Rovira i Virgili, Reus, Spain. 23. College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada. 24. Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca. 25. Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada. john.sievenpiper@utoronto.ca. 26. Clinical Nutrition and Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada. john.sievenpiper@utoronto.ca. 27. Joannah and Brian Lawson Centre for Child Nutrition, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca. 28. Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada. john.sievenpiper@utoronto.ca. 29. Division of Endocrinology and Metabolism, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada. john.sievenpiper@utoronto.ca. 30. Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. john.sievenpiper@utoronto.ca.
Abstract
AIMS/HYPOTHESIS: Nordic dietary patterns that are high in healthy traditional Nordic foods may have a role in the prevention and management of diabetes. To inform the update of the EASD clinical practice guidelines for nutrition therapy, we conducted a systematic review and meta-analysis of Nordic dietary patterns and cardiometabolic outcomes. METHODS: We searched MEDLINE, EMBASE and The Cochrane Library from inception to 9 March 2021. We included prospective cohort studies and RCTs with a follow-up of ≥1 year and ≥3 weeks, respectively. Two independent reviewers extracted relevant data and assessed the risk of bias (Newcastle-Ottawa Scale and Cochrane risk of bias tool). The primary outcome was total CVD incidence in the prospective cohort studies and LDL-cholesterol in the RCTs. Secondary outcomes in the prospective cohort studies were CVD mortality, CHD incidence and mortality, stroke incidence and mortality, and type 2 diabetes incidence; in the RCTs, secondary outcomes were other established lipid targets (non-HDL-cholesterol, apolipoprotein B, HDL-cholesterol, triglycerides), markers of glycaemic control (HbA1c, fasting glucose, fasting insulin), adiposity (body weight, BMI, waist circumference) and inflammation (C-reactive protein), and blood pressure (systolic and diastolic blood pressure). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of the evidence. RESULTS: We included 15 unique prospective cohort studies (n=1,057,176, with 41,708 cardiovascular events and 13,121 diabetes cases) of people with diabetes for the assessment of cardiovascular outcomes or people without diabetes for the assessment of diabetes incidence, and six RCTs (n=717) in people with one or more risk factor for diabetes. In the prospective cohort studies, higher adherence to Nordic dietary patterns was associated with 'small important' reductions in the primary outcome, total CVD incidence (RR for highest vs lowest adherence: 0.93 [95% CI 0.88, 0.99], p=0.01; substantial heterogeneity: I2=88%, pQ<0.001), and similar or greater reductions in the secondary outcomes of CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). Inverse dose-response gradients were seen for total CVD incidence, CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). No studies assessed CHD or stroke mortality. In the RCTs, there were small important reductions in LDL-cholesterol (mean difference [MD] -0.26 mmol/l [95% CI -0.52, -0.00], pMD=0.05; substantial heterogeneity: I2=89%, pQ<0.01), and 'small important' or greater reductions in the secondary outcomes of non-HDL-cholesterol, apolipoprotein B, insulin, body weight, BMI and systolic blood pressure (p<0.05). For the other outcomes there were 'trivial' reductions or no effect. The certainty of the evidence was low for total CVD incidence and LDL-cholesterol; moderate to high for CVD mortality, established lipid targets, adiposity markers, glycaemic control, blood pressure and inflammation; and low for all other outcomes, with evidence being downgraded mainly because of imprecision and inconsistency. CONCLUSIONS/ INTERPRETATION: Adherence to Nordic dietary patterns is associated with generally small important reductions in the risk of major CVD outcomes and diabetes, which are supported by similar reductions in LDL-cholesterol and other intermediate cardiometabolic risk factors. The available evidence provides a generally good indication of the likely benefits of Nordic dietary patterns in people with or at risk for diabetes. REGISTRATION: ClinicalTrials.gov NCT04094194. FUNDING: Diabetes and Nutrition Study Group of the EASD Clinical Practice.
AIMS/HYPOTHESIS: Nordic dietary patterns that are high in healthy traditional Nordic foods may have a role in the prevention and management of diabetes. To inform the update of the EASD clinical practice guidelines for nutrition therapy, we conducted a systematic review and meta-analysis of Nordic dietary patterns and cardiometabolic outcomes. METHODS: We searched MEDLINE, EMBASE and The Cochrane Library from inception to 9 March 2021. We included prospective cohort studies and RCTs with a follow-up of ≥1 year and ≥3 weeks, respectively. Two independent reviewers extracted relevant data and assessed the risk of bias (Newcastle-Ottawa Scale and Cochrane risk of bias tool). The primary outcome was total CVD incidence in the prospective cohort studies and LDL-cholesterol in the RCTs. Secondary outcomes in the prospective cohort studies were CVD mortality, CHD incidence and mortality, stroke incidence and mortality, and type 2 diabetes incidence; in the RCTs, secondary outcomes were other established lipid targets (non-HDL-cholesterol, apolipoprotein B, HDL-cholesterol, triglycerides), markers of glycaemic control (HbA1c, fasting glucose, fasting insulin), adiposity (body weight, BMI, waist circumference) and inflammation (C-reactive protein), and blood pressure (systolic and diastolic blood pressure). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of the evidence. RESULTS: We included 15 unique prospective cohort studies (n=1,057,176, with 41,708 cardiovascular events and 13,121 diabetes cases) of people with diabetes for the assessment of cardiovascular outcomes or people without diabetes for the assessment of diabetes incidence, and six RCTs (n=717) in people with one or more risk factor for diabetes. In the prospective cohort studies, higher adherence to Nordic dietary patterns was associated with 'small important' reductions in the primary outcome, total CVD incidence (RR for highest vs lowest adherence: 0.93 [95% CI 0.88, 0.99], p=0.01; substantial heterogeneity: I2=88%, pQ<0.001), and similar or greater reductions in the secondary outcomes of CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). Inverse dose-response gradients were seen for total CVD incidence, CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). No studies assessed CHD or stroke mortality. In the RCTs, there were small important reductions in LDL-cholesterol (mean difference [MD] -0.26 mmol/l [95% CI -0.52, -0.00], pMD=0.05; substantial heterogeneity: I2=89%, pQ<0.01), and 'small important' or greater reductions in the secondary outcomes of non-HDL-cholesterol, apolipoprotein B, insulin, body weight, BMI and systolic blood pressure (p<0.05). For the other outcomes there were 'trivial' reductions or no effect. The certainty of the evidence was low for total CVD incidence and LDL-cholesterol; moderate to high for CVD mortality, established lipid targets, adiposity markers, glycaemic control, blood pressure and inflammation; and low for all other outcomes, with evidence being downgraded mainly because of imprecision and inconsistency. CONCLUSIONS/ INTERPRETATION: Adherence to Nordic dietary patterns is associated with generally small important reductions in the risk of major CVD outcomes and diabetes, which are supported by similar reductions in LDL-cholesterol and other intermediate cardiometabolic risk factors. The available evidence provides a generally good indication of the likely benefits of Nordic dietary patterns in people with or at risk for diabetes. REGISTRATION: ClinicalTrials.gov NCT04094194. FUNDING: Diabetes and Nutrition Study Group of the EASD Clinical Practice.
Authors: Laura Chiavaroli; Stephanie K Nishi; Tauseef A Khan; Catherine R Braunstein; Andrea J Glenn; Sonia Blanco Mejia; Dario Rahelić; Hana Kahleová; Jordi Salas-Salvadó; David J A Jenkins; Cyril W C Kendall; John L Sievenpiper Journal: Prog Cardiovasc Dis Date: 2018-05-26 Impact factor: 8.194
Authors: Katherine Esposito; Maria Ida Maiorino; Miryam Ciotola; Carmen Di Palo; Paola Scognamiglio; Maurizio Gicchino; Michela Petrizzo; Franco Saccomanno; Flora Beneduce; Antonio Ceriello; Dario Giugliano Journal: Ann Intern Med Date: 2009-09-01 Impact factor: 25.391