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Low-carbohydrate, high animal fat and protein diets have been promoted for weight loss and diabetes treatment. We therefore tested the effect of a low-carbohydrate vegan diet in diabetes as a potentially healthier and more ecologically sustainable low-carbohydrate option.We sought to compare the effectiveness of a low-carbohydrate vegan diet with a moderate-carbohydrate vegetarian diet on weight loss and metabolic measures in diabetes.One hundred and sixty-four male and female participants with type 2 diabetes were randomly assigned to advice on either a low-carbohydrate vegan diet, high in canola oil and plant proteins, or a vegetarian therapeutic diet, for 3 mo, with both diets recommended at 60% of calorie requirements. Body weight, fasting blood, blood pressure, and 7-d food records, to estimate potential greenhouse gas emissions, were obtained throughout the study with tests of cholesterol absorption undertaken at baseline and end of study on 50 participants.Both low-carbohydrate vegan and vegetarian diets similarly but markedly reduced body weight (-5.9 kg; 95% CI: -6.5, -5.28 kg; and -5.23 kg; 95% CI: -5.84, -4.62 kg), glycated hemoglobin (-0.99%; 95% CI: -1.07, -0.9%; and -0.88%; 95% CI: -0.97, -0.8%), systolic blood pressure (-4 mmHg; 95% CI: -7, -2 mmHg; and -6 mmHg; 95% CI: -8, -3 mmHg), and potential greenhouse gas emissions, but only for potential greenhouse gas emissions was there a significant treatment difference of -0.63 kgCO2/d (95% CI: -0.99, -0.27 kgCO2/d) favoring the low-carbohydrate vegan diet.Low-carbohydrate vegan and vegetarian diets reduced body weight, improved glycemic control and blood pressure, but the more plant-based diet had greater potential reduction in greenhouse gas emissions.Trial registration number: clinicaltrials.gov identifier NCT02245399.

Postprandial hypotension (PPH) has been reported to be associated with syncope, falls, adverse cardiovascular outcomes, and increased all-cause mortality. It has been reported to have an incidence as high as 30% in the elderly and persons with diabetes. We therefore performed a meta-analysis to determine the relation of PPH with cardiovascular disease (CVD) events and all-cause mortality.Our objective was to conduct a systematic review and meta-analysis of cohort and cross-sectional studies to determine the association of PPH with CVD and all-cause mortality.We searched the databases MEDLINE, EMBASE, and Cochrane library up to 13 April 2022 for prospective cohort and cross-sectional studies that examined the association of PPH with CVD outcomes and all-cause mortality. Data were analyzed using the generic inverse variance method with a random-effects model. Grading of Recommendations, Assessment, Development, and Evaluation approach assessed the certainty of evidence.Seven studies that included 2389 participants met our inclusion criteria. PPH was associated with each outcome individually, including increased all-cause mortality, total CVD, CVD mortality, and stroke. CVD outcomes and all-cause mortality combined were also associated with PPH (RR: 1.52; 95% CI: 1.05, 2.18; P = 0.03; I2 = 77%). The certainty of evidence was graded as very low due to significant heterogeneity and the limited number of studies.This assessment indicates an association of PPH with CVD and all-cause mortality. Further studies are required to improve CVD and mortality estimates, but the potential seriousness of CVD and all-cause mortality as outcomes of PPH justifies more screening, diagnosis, and research.

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%, pQpp<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%, pQp<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. Graphical abstract

In many non-Asian countries, soy is consumed via soy-based meat and dairy alternatives, in addition to the traditional Asian soyfoods, such as tofu and miso. Meat alternatives are typically made using concentrated sources of soy protein, such as soy protein isolate (SPI) and soy protein concentrate (SPC). Therefore, these products are classified as ultra-processed foods (UPFs; group 4) according to NOVA, an increasingly widely used food-classification system that classifies all foods into 1 of 4 groups according to the processing they undergo. Furthermore, most soymilks, even those made from whole soybeans, are also classified as UPFs because of the addition of sugars and emulsifiers. Increasingly, recommendations are being made to restrict the consumption of UPFs because their intake is associated with a variety of adverse health outcomes. Critics of UPFs argue these foods are unhealthful for a wide assortment of reasons. Explanations for the proposed adverse effects of UPFs include their high energy density, high glycemic index (GI), hyper-palatability, and low satiety potential. Claims have also been made that UPFs are not sustainably produced. However, this perspective argues that none of the criticisms of UPFs apply to soy-based meat and dairy alternatives when compared with their animal-based counterparts, beef and cow milk, which are classified as unprocessed or minimally processed foods (group 1). Classifying soy-based meat and dairy alternatives as UPFs may hinder their public acceptance, which could detrimentally affect personal and planetary health. In conclusion, the NOVA classification system is simplistic and does not adequately evaluate the nutritional attributes of meat and dairy alternatives based on soy.

Background: Health authorities are near universal in their recommendation to replace sugar-sweetened beverages (SSBs) with water. Non-nutritive sweetened beverages (NSBs) are not as widely recommended as a replacement strategy due to a lack of established benefits and concerns they may induce glucose intolerance through changes in the gut microbiome. The STOP Sugars NOW trial aims to assess the effect of the substitution of NSBs (the “intended substitution”) versus water (the “standard of care substitution”) for SSBs on glucose tolerance and microbiota diversity. Design and Methods: The STOP Sugars NOW trial (NCT03543644) is a pragmatic, “head-to-head”, open-label, crossover, randomized controlled trial conducted in an outpatient setting. Participants were overweight or obese adults with a high waist circumference who regularly consumed ≥1 SSBs daily. Each participant completed three 4-week treatment phases (usual SSBs, matched NSBs, or water) in random order, which were separated by ≥4-week washout. Blocked randomization was performed centrally by computer with allocation concealment. Outcome assessment was blinded; however, blinding of participants and trial personnel was not possible. The two primary outcomes are oral glucose tolerance (incremental area under the curve) and gut microbiota beta-diversity (weighted UniFrac distance). Secondary outcomes include related markers of adiposity and glucose and insulin regulation. Adherence was assessed by objective biomarkers of added sugars and non-nutritive sweeteners and self-report intake. A subset of participants was included in an Ectopic Fat sub-study in which the primary outcome is intrahepatocellular lipid (IHCL) by 1H-MRS. Analyses will be according to the intention to treat principle. Baseline results: Recruitment began on 1 June 2018, and the last participant completed the trial on 15 October 2020. We screened 1086 participants, of whom 80 were enrolled and randomized in the main trial and 32 of these were enrolled and randomized in the Ectopic Fat sub-study. The participants were predominantly middle-aged (mean age 41.8 ± SD 13.0 y) and had obesity (BMI of 33.7 ± 6.8 kg/m2) with a near equal ratio of female: male (51%:49%). The average baseline SSB intake was 1.9 servings/day. SSBs were replaced with matched NSB brands, sweetened with either a blend of aspartame and acesulfame-potassium (95%) or sucralose (5%). Conclusions: Baseline characteristics for both the main and Ectopic Fat sub-study meet our inclusion criteria and represent a group with overweight or obesity, with characteristics putting them at risk for type 2 diabetes. Findings will be published in peer-reviewed open-access medical journals and provide high-level evidence to inform clinical practice guidelines and public health policy for the use NSBs in sugars reduction strategies. Trial registration: ClinicalTrials.gov identifier, NCT03543644.

Context Excess calories from free sugars are implicated in the epidemics of obesity and type 2 diabetes. Honey is a free sugar but is generally regarded as healthy. Objective The effect of honey on cardiometabolic risk factors was assessed via a systematic review and meta-analysis of controlled trials using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Data Sources MEDLINE, Embase, and the Cochrane Library databases were searched up to January 4, 2021, for controlled trials ≥1 week in duration that assessed the effect of oral honey intake on adiposity, glycemic control, lipids, blood pressure, uric acid, inflammatory markers, and markers of nonalcoholic fatty liver disease. Data Extraction Independent reviewers extracted data and assessed risk of bias. Data were pooled using the inverse variance method and expressed as mean differences (MDs) with 95%CIs. Certainty of evidence was assessed using GRADE. Data Analysis A total of 18 controlled trials (33 trial comparisons, N = 1105 participants) were included. Overall, honey reduced fasting glucose (MD = −0.20 mmol/L, 95%CI, −0.37 to −0.04 mmol/L; low certainty of evidence), total cholesterol (MD = −0.18 mmol/L, 95%CI, −0.33 to −0.04 mmol/L; low certainty), low-density lipoprotein cholesterol (MD = −0.16 mmol/L, 95%CI, −0.30 to −0.02 mmol/L; low certainty), fasting triglycerides (MD = −0.13 mmol/L, 95%CI, −0.20 to −0.07 mmol/L; low certainty), and alanine aminotransferase (MD = −9.75 U/L, 95%CI, −18.29 to −1.21 U/L; low certainty) and increased high-density lipoprotein cholesterol (MD = 0.07 mmol/L, 95%CI, 0.04–0.10 mmol/L; high certainty). There were significant subgroup differences by floral source and by honey processing, with robinia honey, clover honey, and raw honey showing beneficial effects on fasting glucose and total cholesterol. Conclusion Honey, especially robinia, clover, and unprocessed raw honey, may improve glycemic control and lipid levels when consumed within a healthy dietary pattern. More studies focusing on the floral source and the processing of honey are required to increase certainty of the evidence. Systematic Review Registration PROSPERO registration number CRD42015023580.

Background Although fructose as a source of excess calories increases uric acid, the effect of the food matrix is unclear. Objectives To assess the effects of fructose-containing sugars by food source at different levels of energy control on uric acid, we conducted a systematic review and meta-analysis of controlled trials. Methods MEDLINE, Embase, and the Cochrane Library were searched (through 11 January 2021) for trials ≥ 7 days. We prespecified 4 trial designs by energy control: substitution (energy-matched replacement of sugars in diets); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced in diets) designs. Independent reviewers (≥2) extracted data and assessed the risk of bias. Grading of Recommendations, Assessment, Development, and Evaluation was used to assess the certainty of evidence. Results We included 47 trials (85 comparisons; N = 2763) assessing 9 food sources [sugar-sweetened beverages (SSBs), sweetened dairy, fruit drinks, 100% fruit juice, fruit, dried fruit, sweets and desserts, added nutritive sweetener, and mixed sources] across 4 energy control levels in predominantly healthy, mixed-weight adults. Total fructose-containing sugars increased uric acid levels in substitution trials (mean difference, 0.16 mg/dL; 95% CI: 0.06-0.27 mg/dL; P = 0.003), with no effect across the other energy control levels. There was evidence of an interaction by food source: SSBs and sweets and desserts increased uric acid levels in the substitution design, while SSBs increased and 100% fruit juice decreased uric acid levels in addition trials. The certainty of evidence was high for the increasing effect of SSBs in substitution and addition trials and the decreasing effect of 100% fruit juice in addition trials and was moderate to very low for all other comparisons. Conclusions Food source more than energy control appears to mediate the effects of fructose-containing sugars on uric acid. The available evidence provides reliable indications that SSBs increase and 100% fruit juice decreases uric acid levels. More high-quality trials of different food sources are needed. This trial was registered at clinicaltrials.gov as NCT02716870.

In the extended UNICEF framework of early childhood nutrition, parents' stress is associated with parental feeding style. However, no comprehensive review has examined the association between parents' stress and feeding styles and practices. The objective of our review was to synthesise the current literature examining the association between parents' stress and their feeding practices and/or styles, among parents of children ≤ 5 years old. We searched; MEDLINE, EMBASE, PSYCHINFO and CINAHL from 2019 to 2021. Two investigators independently extracted relevant data and assessed the study quality and the certainty of evidence. Data were pooled using generic inverse variance with fixed effects (5 comparisons) or random effects (≥5 comparisons) and expressed as correlation coefficients with 95% confidence intervals (CI). Between study heterogeneity was assessed using Cochran's Q and quantified with I

[Background & aims]: The Portfolio and Dietary Approaches to Stop Hypertension (DASH) diets have been shown to lower cardiometabolic risk factors in randomized controlled trials (RCTs). However, the Portfolio diet has only been assessed in RCTs of hyperlipidemic patients. Therefore, to assess the Portfolio diet in a population with metabolic syndrome (MetS), we conducted a longitudinal analysis of one-year data of changes in the Portfolio and DASH diet scores and their association with cardiometabolic risk factors in Prevención con Dieta Mediterránea (PREDIMED)-Plus trial. [Methods]: PREDIMED-Plus is an ongoing clinical trial (Trial registration: ISRCTN89898) conducted in Spain that includes 6874 older participants (mean age 65 y, 48% women) with overweight/obesity fulfilling at least three criteria for MetS. Data for this analysis were collected at baseline, six months and one year. Adherence to the Portfolio and DASH diet scores were derived from a validated 143-item food frequency questionnaire. We used linear mixed models to examine the associations of 1-SD increase and quartile changes in the diet scores with concomitant changes in cardiometabolic risk factors. [Results]: After adjusting for several potential confounders, a 1-SD increase in the Portfolio diet score was significantly associated with lower HbA1c (β [95% CI]: −0.02% [−0.02, −0.01], P < 0.001), fasting glucose (−0.47 mg/dL [−0.83, −0.11], P = 0.01), triglycerides (−1.29 mg/dL [−2.31, −0.28], P = 0.01), waist circumference (WC) (−0.51 cm [−0.59, −0.43], P < 0.001), and body mass index (BMI) (−0.17 kg/m2 [−0.19, −0.15], P < 0.001). A 1-SD increase in the DASH diet score was significantly associated with lower HbA1c (−0.03% [−0.04, −0.02], P < 0.001), glucose (−0.84 mg/dL [−1.18, −0.51], P < 0.001), triglycerides (−3.38 mg/dL [−4.37, −2.38], P < 0.001), non-HDL-cholesterol (−0.47 mg/dL [−0.91, −0.04], P = 0.03), WC (−0.69 cm [−0.76, −0.60 cm], P < 0.001), BMI (−0.25 kg/m2 [−0.28, −0.26 kg/m2], P < 0.001), systolic blood pressure (−0.57 mmHg [−0.81, −0.32 mmHg], P < 0.001), diastolic blood pressure (−0.15 mmHg [−0.29, −0.01 mmHg], P = 0.03), and with higher HDL-cholesterol (0.21 mg/dL [0.09, 0.34 mg/dL, P = 0.001]). Similar associations were seen when both diet scores were assessed as quartiles, comparing extreme categories of adherence. [Conclusions]: Among older adults at high cardiovascular risk with MetS, greater adherence to the Portfolio and DASH diets showed significant favourable prospective associations with several clinically relevant cardiometabolic risk factors. Both diets are likely beneficial for cardiometabolic risk reduction., The PREDIMED-Plus trial was supported by the Spanish government's official funding agency for biomedical research, ISCIII, through the Fondo de Investigación para la Salud (FIS) and co-funded by European Union ERDF/ESF, “A way to make Europe”/“Investing in your future” (five coordinated FIS projects led by JS-S and JVid, including the following projects: PI13/00673, PI13/00492, PI13/00272, PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728, PI13/01090, PI13/01056, PI14/01722, PI14/00636, PI14/00618, PI14/00696, PI14/01206, PI14/01919, PI14/00853, PI14/01374, PI14/00972, PI14/00728, PI14/01471, PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183,PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, PI17/01441, PI17/00508, PI17/01732, PI17/00926, PI19/00957, PI19/00386, PI19/00309, PI19/01032, PI19/00576, PI19/00017, PI19/01226, PI19/00781, PI19/01560, and PI19/01332), the Special Action Project entitled: Implementación y evaluación de una intervención intensiva sobre la actividad física Cohorte PREDIMED-Plus grant to JS-S, the European Research Council (Advanced Research Grant 2014–2019, 340918) to MÁM-G, the Recercaixa Grant to JS-S (2013ACUP00194), grants from the Consejería de Salud de la Junta de Andalucía (PI0458/2013, PS0358/2016, and PI0137/2018), a grant from the Generalitat Valenciana (PROMETEO/2017/017), a SEMERGEN grant, and funds from the European Regional Development Fund (CB06/03). This research was also partially funded by EU-H2020 Grant (EAT2BENICE/H2020-SFS-2016-2; Ref 728018). Study resulting from the SLT006/17/00246 grant, funded by the Department of Health of the Generalitat de Catalunya by the call “Acció instrumental de programes de recerca orientats en l'àmbit de la recerca i la innovació en salut”. We thank CERCA Programme/Generalitat de Catalunya for institutional support. This work is partially supported by ICREA under the ICREA Academia programme. IP-G receives a grant from the Spanish Ministry of Education, Culture and Sports (FPU 17/01925). MRBL was supported by “Miguel Servet Type I” program (CP15/00028) from the ISCIII-Madrid (Spain), cofinanced by the Fondo Europeo de Desarrollo Regional-FEDER. AJG was supported by the Nora Martin Fellowship in Nutritional Sciences, the Banting & Best Diabetes Centre Tamarack Graduate Award in Diabetes Research, the Peterborough K.M. Hunter Charitable Foundation Graduate Award and an Ontario Graduate Scholarship. PH-A was supported by a postdoctoral fellowship (Juan de la Cierva-Formación), FJCI-2017–32205, funded by the Ministry of Science and Innovation. RE group has been supported by the ‘Ajut 2017-2021 SGR 1717 from the Generalitat de Catalunya. DJAJ was funded by the Government of Canada through the Canada Research Chair Endowment. JK was supported by the ‘FOLIUM’ programme within the FUTURMed project from the Fundación Instituto de Investigación Sanitaria Illes Balears (financed by 2017 annual plan of the sustainable tourism tax and at 50% with charge to the ESF Operational Program 2014–2020 of the Balearic Islands). JLS was funded by a Diabetes Canada Clinician Scientist Award.

Background Previous meta-analyses, with some methodological controversies, have assessed the relation between nut consumption and type 2 diabetes (T2D) risk and pointed to contradictory results, making desirable the performance of an updated meta-analysis. Objectives We aimed to systematically review and meta-analyze all the published studies investigating the relations of total nuts and different types of nuts-i.e., walnuts, peanuts, peanut butter, and total tree nuts-with the prevalence and incidence of T2D. Methods A systematic search was conducted in the PubMed and Cochrane databases through 12 August, 2020. The inverse variance method with fixed-effect models was used to pool data across studies, expressed as risk ratios (RRs) or ORs and 95% CIs for prospective cohort and cross-sectional studies, respectively. The Cochran Q test and I2 statistics were used to test and quantify heterogeneity, respectively. Dose-response meta-analysis was also conducted. Results Eight studies (5 prospective and 3 cross-sectional) were included in the quantitative synthesis. Meta-analyses of cross-sectional studies and prospective cohort studies, comparing the highest with the lowest categories, revealed a nonsignificant association between total nut consumption and T2D. Meta-analyses of prospective cohort studies showed an inverse association between peanut butter consumption and T2D incidence (RR: 0.87; 95% CI: 0.77, 0.98; I2 = 50.6%; Pheterogeneity = 0.16), whereas no association was observed between peanuts or tree nuts and T2D. There was no evidence of a linear dose-response or nonlinear dose-response gradient for total nut and peanut consumption in prospective cohort studies. The certainty of the evidence using NutriGrade was very low for all the exposures. Conclusions Current results do not demonstrate an association of total nut, peanut, or tree nut consumption with T2D. Peanut butter consumption may be inversely associated with this disease.This review protocol was registered at www.crd.york.ac.uk/prospero/ as CRD42020149756.

To determine the effect of oat β‑glucan (OBG) on acute glucose and insulin responses and identify significant effect modifiers we searched the MEDLINE, EMBASE, and Cochrane databases through October 27, 2020 for acute, crossover, controlled feeding trials investigating the effect of adding OBG (concentrate or oat-bran) to carbohydrate-containing test-meals compared to comparable or different carbohydrate-matched control-meals in humans regardless of health status. The primary outcome was glucose incremental area-under-the-curve (iAUC). Secondary outcomes were insulin iAUC, and glucose and insulin incremental peak-rise (iPeak). Two reviewers extracted the data and assessed risk-of-bias and certainty-of-evidence (GRADE). Data were pooled using generic inverse-variance with random-effects model and expressed as ratio-of-means with [95% CIs]. We included 103 trial comparisons (N = 538). OBG reduced glucose iAUC and iPeak by 23% (0.77 [0.74, 0.81]) and 28% (0.72 [0.64, 0.76]) and insulin by 22% (0.78 [0.72, 0.85]) and 24% (0.76 [0.65, 0.88]), respectively. Dose, molecular-weight, and comparator were significant effect modifiers of glucose iAUC and iPeak. Significant linear dose-response relationships were observed for all outcomes. OBG molecular-weight >300 kg/mol significantly reduced glucose iAUC and iPeak, whereas molecular-weight p = 0.03) and iPeak (39 vs 25%, p

Background: There has been an emerging concern that non-nutritive sweeteners (NNS) can increase the risk of cardiometabolic disease. Much of the attention has focused on acute metabolic and endocrine responses to NNS. To examine whether these mechanisms are operational under real-world scenarios, we conducted a systematic review and network meta-analysis of acute trials comparing the effects of non-nutritive sweetened beverages (NNS beverages) with water and sugar-sweetened beverages (SSBs) in humans. Methods: MEDLINE, EMBASE, and The Cochrane Library were searched through to January 15, 2022. We included acute, single-exposure, randomized, and non-randomized, clinical trials in humans, regardless of health status. Three patterns of intake were examined: (1) uncoupling interventions, where NNS beverages were consumed alone without added energy or nutrients; (2) coupling interventions, where NNS beverages were consumed together with added energy and nutrients as carbohydrates; and (3) delayed coupling interventions, where NNS beverages were consumed as a preload prior to added energy and nutrients as carbohydrates. The primary outcome was a 2 h incremental area under the curve (iAUC) for blood glucose concentration. Secondary outcomes included 2 h iAUC for insulin, glucagon-like peptide 1 (GLP-1), gastric inhibitory polypeptide (GIP), peptide YY (PYY), ghrelin, leptin, and glucagon concentrations. Network meta-analysis and confidence in the network meta-analysis (CINeMA) were conducted in R-studio and CINeMA, respectively. Results: Thirty-six trials involving 472 predominantly healthy participants were included. Trials examined a variety of single NNS (acesulfame potassium, aspartame, cyclamate, saccharin, stevia, and sucralose) and NNS blends (acesulfame potassium + aspartame, acesulfame potassium + sucralose, acesulfame potassium + aspartame + cyclamate, and acesulfame potassium + aspartame + sucralose), along with matched water/unsweetened controls and SSBs sweetened with various caloric sugars (glucose, sucrose, and fructose). In uncoupling interventions, NNS beverages (single or blends) had no effect on postprandial glucose, insulin, GLP-1, GIP, PYY, ghrelin, and glucagon responses similar to water controls (generally, low to moderate confidence), whereas SSBs sweetened with caloric sugars (glucose and sucrose) increased postprandial glucose, insulin, GLP-1, and GIP responses with no differences in postprandial ghrelin and glucagon responses (generally, low to moderate confidence). In coupling and delayed coupling interventions, NNS beverages had no postprandial glucose and endocrine effects similar to controls (generally, low to moderate confidence). Conclusions: The available evidence suggests that NNS beverages sweetened with single or blends of NNS have no acute metabolic and endocrine effects, similar to water. These findings provide support for NNS beverages as an alternative replacement strategy for SSBs in the acute postprandial setting.

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

Diabetes is a continuously growing global concern affecting >10% of adults, which may be mitigated by modifiable lifestyle factors. Consumption of nuts and their inclusion in dietary patterns has been associated with a range of beneficial health outcomes. Diabetes guidelines recommend dietary patterns that incorporate nuts; however, specific recommendations related to nuts have been limited. This review considers the epidemiological and clinical evidence to date for the role of nut consumption as a dietary strategy for the prevention and management of type 2 diabetes (T2D) and related complications. Findings suggest nut consumption may have a potential role in the prevention and management of T2D, with mechanistic studies assessing nuts and individual nut-related nutritional constituents supporting this possibility. However, limited definitive evidence is available to date, and future studies are needed to elucidate better the impact of nuts on the prevention and management of T2D.

Viscous dietary fiber, functional seeds and ginseng roots have individually been proposed for the management of diabetes. We explored whether their co-administration would improve glycemic control in type 2 diabetes beyond conventional therapy. In a randomized, double-blind, controlled trial conducted at two academic centers (Toronto, Canada and Zagreb, Croatia), individuals with type 2 diabetes were assigned to either an active intervention (10 g viscous fiber, 60 g white chia seeds, 1.5 g American and 0.75 g Korean red ginseng extracts), or energy and fiber-matched control (53 g oat bran, 25 g inulin, 25 g maltodextrose and 2.25 g wheat bran) intervention for 24 weeks, while on conventional standard of care. The prespecified primary endpoint was end difference at week 24 in HbA1c, following an intent-to-treat analysis adjusted for center and baseline. Between January 2016 and April 2018, 104 participants (60M:44F; mean ± SEM age 59 ± 0.8 years; BMI 29.0 ± 0.4 kg/m2; HbA1c 7.0 ± 0.6%) managed with antihyperglycemic agent(s) (n = 98) or lifestyle (n = 6), were randomized (n = 52 test; n = 52 control). At week 24, HbA1c levels were 0.27 ± 0.1% lower on test compared to control (p = 0.03). There was a tendency towards an interaction by baseline HbA1c (p = 0.07), in which a greater reduction was seen in participants with baseline HbA1c > 7% vs ≤ 7% (− 0.56 ± 0.2% vs 0.03 ± 0.2%). Diet and body weight remained unchanged. The interventions were well tolerated with no related adverse events and with high retention rate of 84%. Co-administration of selected dietary and herbal therapies was well-tolerated and may provide greater glycemic control as add-on therapy in type 2 diabetes. Registration: Clinicaltrials.gov NCT02553382 (registered on September 17, 2015).

碳水化合物日益与肥胖、糖尿病及其下游心血管代谢疾病的流行 有关。已有学者提出了” 碳水化合物-胰岛素模型” 来解释碳水化合物 的这种作用。推测碳水化合物的高摄入诱导了以高胰岛素血症为特征 的内分泌失调，改变能量分配——脂肪组织中能量储存的增加，从而 导致食物摄入的适应性增加和能量消耗的降低。是否所有碳水化合物 食物在真实的摄入条件下直接导致体重增加及其并发症，或该模型是 否能解释这些临床现象，还需要经过严格查验。本综述的目的是评估 碳水化合物的数量与质量在心脏代谢健康作用的证据。尽管” 碳水化 合物-胰岛素模型” 的临床研究已经表明胰岛素分泌减少并且脂肪氧化 增加，但是在低碳水化合物摄入下并没有实现预期的脂肪减少。现有 最佳证据的系统评价和网络荟萃分析未能表明低碳水化合物膳食在长 期临床减重方面具有优势，或所有来源的碳水化合物的作用相同。强 调含有重要营养素和物质的食物的高碳水化合物膳食，如全谷类(特 别是燕麦和大麦)、豆类或水果；低血糖指数和负荷；或高纤维(特别 是粘性纤维源) 在随机试验中降低了心脏代谢中间危险因素，并且在 前瞻性队列研究中与体重减轻、糖尿病、心血管疾病的发病率和心血 管死亡率的降低相关。糖作为碳水化合物质量标志的证据似乎高度依 赖于能量控制和食物来源，提供过多的能量的含糖饮料已显示出危害，含糖的高质量碳水化合物食物源(如，水果、100% 果汁、酸奶和早餐 谷物)显示出在能量供给上相匹配的替代精制淀粉(低质碳水化合物 食物源)的益处。这些数据反映了当前膳食指南的变化——允许膳食 中宏量营养素(包括碳水化合物)比例更加灵活，重点关注“质量”胜 过“数量”以及膳食模式，而非单一营养素的影响

We applied the Framingham risk equation in healthy, metabolic syndrome, and diabetes populations, following treatment with viscous fibre from konjac-based blend (KBB). KBB yielded reduction in estimated risk score by 16% (1.04 ± 0.03 vs. 0.87 ± 0.04, p < 0.01) in type 2 diabetes, 24% (1.08 ± 0.01 vs. 0.82 ± 0.02, p < 0.01) in metabolic syndrome, and 25% (1.09 ± 0.05 vs. 0.82 ± 0.06, p < 0.01) in healthy individuals. Drivers for decreased risk were improvements in blood cholesterol and systolic blood pressure. The composite coronary heart disease risk across populations was reduced 22% (p < 0.01). Novelty Viscous fibre from konjac-xanthan reduced 10-year relative coronary heart disease using Framingham Risk Score across the glycemic status spectrum.

Dietary fiber has played a consistent role in weight management, with efficacy potentially attributed to increased viscous fiber consumption. To summarize the effects of viscous fiber on body weight and other anthropometric parameters, along with a calorie-deficient diet, through a systematic review and meta-analysis. MEDLINE, EMBASE, and the Cochrane library were searched through July 24, 2019 for randomized controlled trials that assessed the effect of viscous fiber supplementation as part of a restricted calorie diet for ≥ 4 weeks relative to comparator diets. Data were pooled using the generic inverse-variance method with random-effects models and expressed as mean differences with 95% confidence intervals. Inter-study heterogeneity was assessed using Cochran’s Q and quantified with I2. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the overall certainty of evidence. Findings from 15 studies (n = 1347) showed viscous fiber supplementation significantly decreased body weight (− 0.81 kg [− 1.20, − 0.41]; p

Background: The role of dietary fiber in obesity management remains debatable. Evidence suggests that intake of viscous fiber may have the potential to facilitate weight loss. Objective: We aimed to summarize and quantify the effects of viscous fiber on body weight, BMI, waist circumference, and body fat, independent of calorie restriction, through a systematic review and meta-analysis of randomized controlled trials. Methods: Trials ≥4 wk in duration that assessed the effect of viscous fiber supplemented to an ad libitum diet along with comparator diets were included. MEDLINE, EMBASE, and the Cochrane library were searched through 24 July, 2019. Two independent reviewers extracted relevant data. Data were pooled using the generic inverse variance method and random-effects models and expressed as mean differences with 95% CIs. Interstudy heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). The overall certainty of evidence was explored using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: Findings from 62 trials (n = 3877) showed that viscous fiber reduced mean body weight (-0.33 kg ; 95% CI: -0.51, -0.14 kg ; P = 0.004), BMI (in kg/m2) (-0.28 ; 95% CI: -0.42, -0.14 ; P = 0.0001), and waist circumference (-0.63 cm ; 95% CI: -1.11, -0.16 cm ; P = 0.008), with no change in body fat (-0.78% ; 95% CI: -1.56%, 0.00% ; P = 0.05) when consumed with an ad libitum diet. Greater reductions in body weight were observed in overweight individuals and those with diabetes and metabolic syndrome. The certainty of evidence was graded moderate for body weight, high for waist circumference and body fat, and low for BMI. Conclusions: Dietary viscous fiber modestly yet significantly improved body weight and other parameters of adiposity independently of calorie restriction. Future trials are warranted to address the inconsistency and imprecision identified through GRADE and to determine long- term weight-loss sustainability.This systematic review and meta-analysis was registered at clinicaltrials.gov as NCT03257449.

Dietary carbohydrates are our main source of energy. Traditionally, they are classified based on the polymer length between simple and complex carbohydrates, which does not necessarily reflect their impact on health. Simple sugars, such as fructose, glucose and lactose, despite having a similar energy efficiency and caloric content have very distinct metabolic effects, leading to increased risk for various chronic diseases when consumed in excess. In addition, beyond the absolute amount of carbohydrate consumed, recent data point out that the food form or processing level can modulate both the energy efficiency and the cardiometabolic risk associated with specific carbohydrates. In order to account for both of these aspects - the quality of carbohydrates as well as its food form - several metrics can be proposed to help identifying carbohydrate-rich food sources and distinguish between those that would favor the development of chronic diseases, of those that may contribute to prevent these. This review summarizes the findings presented during the American Society of Nutrition Satellite symposium on 'Carbohydrates Quality', where these different aspects were presented.

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

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

Background: Fructose-containing sugars as sugar-sweetened beverages (SSBs) may increase inflammatory biomarkers. Whether this effect is mediated by the food matrix at different levels of energy is unknown. To investigate the role of food source and energy, we conducted a systematic review and meta-analysis of controlled trials on the effect of different food sources of fructose-containing sugars on inflammatory markers at different levels of energy control. Methods: MEDLINE, Embase, and the Cochrane Library were searched through March 2022 for controlled feeding trials ≥ 7 days. Four trial designs were prespecified by energy control: substitution (energy matched replacement of sugars); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced). The primary outcome was C-reactive protein (CRP). Secondary outcomes were tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). Independent reviewers extracted data and assessed risk of bias. GRADE assessed certainty of evidence. Results: We identified 64 controlled trials (91 trial comparisons, n = 4094) assessing 12 food sources (SSB; sweetened dairy; sweetened dairy alternative [soy]; 100% fruit juice; fruit; dried fruit; mixed fruit forms; sweetened cereal grains and bars; sweets and desserts; added nutritive [caloric] sweetener; mixed sources [with SSBs]; and mixed sources [without SSBs]) at 4 levels of energy control over a median 6-weeks in predominantly healthy mixed weight or overweight/obese adults. Total fructose-containing sugars decreased CRP in addition trials and had no effect in substitution, subtraction or ad libitum trials. No effect was observed on other outcomes at any level of energy control. There was evidence of interaction/influence by food source: substitution trials (sweetened dairy alternative (soy) and 100% fruit juice decreased, and mixed sources (with SSBs) increased CRP); and addition trials (fruit decreased CRP and TNF-α; sweets and desserts (dark chocolate) decreased IL-6). The certainty of evidence was moderate-to-low for the majority of analyses. Conclusions: Food source appears to mediate the effect of fructose-containing sugars on inflammatory markers over the short-to-medium term. The evidence provides good indication that mixed sources that contain SSBs increase CRP, while most other food sources have no effect with some sources (fruit, 100% fruit juice, sweetened soy beverage or dark chocolate) showing decreases, which may be dependent on energy control. Clinicaltrials.gov: (NCT02716870).

OBJECTIVES: Fructose as a source of excess calories increases uric acid. Whether this effect is mediated by the food matrix at different levels of energy is unknown. We aim to conduct a systematic review and meta-analysis of controlled feeding trials on the effect of food sources of fructose-containing sugars at different energy levels on uric acid (NCT02716870). METHODS: MEDLINE, Embase and the Cochrane Library were searched through January 27, 2020 for controlled trials ≥7-days assessing the effect of food sources of fructose-containing sugars on uric acid. Trial designs were prespecified based on energy control: substitution (energy matched replacement of sugars by other macronutrients); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced by other macronutrients) trials. Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed using the GRADE approach. RESULTS: Eligibility was met by 41 trials (72 trial comparisons, N = 2109) assessing the effect of 9 food sources (sugar-sweetened beverages [SSBs], sweetened dairy, fruit drink [lemonade], 100% fruit juice, fruit, dried fruit [raisins], baked goods desserts and sweets, added nutritive [caloric] sweetener and mixed sources) across the 4 energy levels. Total fructose-containing sugars increased uric acid in substitution trials (mean difference, 0.15 mg/dL [95% confidence interval, 0.03 to 0.27 mg/dL], P = 0.012) with no effect in addition, subtraction or ad libitum trials. There was evidence of interaction by food source with SSBs and baked goods, desserts and sweets increasing uric acid in substitution and SSBs increasing and 100% fruit juice decreasing uric acid in addition trials. The overall certainty of evidence was moderate for the increasing effect of SSBs in substitution and addition trials and low to very low for all other comparisons. CONCLUSIONS: Food source more than energy control mediate the effect of fructose-containing sugars on uric acid. SSBs and baked goods, desserts and sweets appear to increase, and 100% fruit juice appear to decrease uric acid. More high-quality trials of different food sources of fructose-containing sugars are needed to improve our estimates. FUNDING SOURCES: Diabetes Canada.

OBJECTIVES: The association between body mass index (BMI) and total body adiposity differs across ethnic groups. For instance, South Asians (SA) and East Asians (EA) have lower body fat for a given BMI level than Europeans, while the opposite is true for African-Caribbeans (AC). This suggests that the relationship between BMI and type 2 diabetes (T2D) risk may also vary depending on ethnicity. We conducted a meta-analysis to investigate whether the association between BMI and the risk of T2D differs across ethnic groups. METHODS: MEDLINE, EMBASE and Web of Science were searched up to July 2020. We included prospective cohort studies of >2 years, which investigated the association between BMI and T2D incidence among adults of a specified ethnicity. Linear and non-linear dose-response meta-analyses were performed using random effects models, with subgroup analyses by ethnicity. The heterogeneity among studies was estimated using the Cochran Q test and I(2) statistic. Study quality was assessed with the Newcastle-Ottawa Scale. RESULTS: 54 studies were included. Cohorts were stratified into the following ethnic subgroups: AC (N = 67,453), EA (N = 1,012,135), European (N = 206,424), Indigenous (N = 10,533), Latin American (LA) (N = 4,669), SA (N = 9,395), and Southeast Asian (SEA) (N = 51,129). Linear dose-response associations between 1 kg/m(2) increase in BMI and T2D were observed for the SEA (RR = 1.26; 95% CI, 1.10, 1.30) and SA (RR = 1.11; 95% CI: 1.04, 1.19) subgroups with no evidence of departure from linearity. Associations departed from linearity for all other subgroups. At a BMI level of 30 kg/m(2), the non-linear dose-response curves for each of the other subgroups displayed the following risk ratios; AC: RR = 3.13 (95% CI, 1.95, 5.02), EA: RR = 2.39 (95% CI, 1.96, 2.92), European: RR = 7.41 (95% CI, 3.88, 14.18), Indigenous: RR = 8.15 (95% CI, 6.07; 10.95), and LA: RR = 12.82 (95% CI, 5.50, 29.92). For all subgroups, there was a high degree of interstudy heterogeneity (I(2 )> 75%). CONCLUSIONS: Our findings indicated that the association between BMI and the risk of T2D differs across ethnic groups, suggesting that ethnic-specific BMI cut-offs could be helpful in identifying cardiometabolic risk profiles across different populations. FUNDING SOURCES: Canadian Institutes for Health Research.

OBJECTIVES: Sugar-sweetened beverages (SSBs) have been linked to weight gain. It is unclear if other food sources of fructose-containing sugars behave similarly. We conducted a systematic review and meta-analysis of controlled feeding trials to assess the effect of different food sources of fructose-containing sugars on body weight and markers of adiposity. METHODS: MEDLINE, Embase, and the Cochrane Library were searched through January 2020 for controlled feeding trials ≥2 weeks on the effect of fructose-containing sugars. Trial designs were prespecified by energy control: substitution (energy matched replacement of sugars in diets); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced in diets). The primary outcome was body weight. Secondary outcomes were body mass index, body fat and waist circumference. Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed using GRADE. (NCT02558920) RESULTS: We identified 119 controlled trials (368 trial comparisons, N = 5263) assessing the effect of 10 food sources (SSBs, sweetened dairy alternative (soy), fruit juice, fruit drink, fruit, dried fruit, sweetened cereal grains/bars, sweets, added sweeteners and mixed sources). Total fructose-containing sugars increased body weight (mean difference, 0.29 kg [95% confidence interval, 0.05 to 0.53 kg], P = 0.017) and body fat in addition trials with no effect in other analyses or outcomes. There was evidence of interaction by food source in substitution trials with fruit reducing and mixed sources increasing some outcomes and in addition trials with 100% fruit juice reducing and SSBs and mixed sources increasing some outcomes. The overall certainty of evidence was moderate for the decreasing effect of fruit and fruit juice and the increasing effect of SSBs and mixed sources and high-to-very low for other comparisons. CONCLUSIONS: Energy control and food source may mediate the effect of fructose-containing sugars on adiposity. The evidence provides good indication that fruit and 100% fruit juice decrease and SSBs and mixed sources increase markers of adiposity. More high-quality randomized trials of different foods are needed to improve our estimates. FUNDING SOURCES: American Society for Nutrition, Diabetes Canada, CIHR, Mitacs.

OBJECTIVES: Intermittent fasting (IF) is a popular trending diet, yet there is limited evidence-based support considering its clinical impact on cardiometabolic outcomes. In an effort to inform the European Association for the Study of Diabetes (EASD) clinical practice guidelines for nutrition therapy, we conducted a network meta-analysis of randomized controlled trials (RCTs) comparing IF strategies and continuous energy restriction (CER) on cardiometabolic outcomes using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched through Nov 2020. We included RCTs assessing the effect of IF strategies (alternate-day fasting (ADF), whole-day periodic fasting (WDF), time-restricted feeding (TRF)), CER, and ad libitum diet. Outcomes included body weight, fasting glucose and LDL-cholesterol. Two independent researchers extracted data and assessed risk of bias. A network meta-analysis was performed and data were expressed as mean differences (MD) with 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE. RESULTS: We identified 19 RCTs (n = 590) including adults of varying health backgrounds. ADF and CER both showed a benefit for body weight reduction compared to ad libitum diet (18 trials, n = 520; MD −3.95 kg [95% CI −6.09, −1.81] and MD −2.85 kg [95% CI −4.99, −0.71], respectively). For fasting glucose (17 trials, n = 590), TRF showed a benefit compared to ad libitum diet (MD −0.39 mmol/L [95% CI −0.59, −0.20]), to CER (MD −0.25 mmol/L [95% CI, −0.45 to −0.06]) and to WDF (MD −0.20 mmol/L [95% CI, −0.45, −0.05]). Furthermore, ADF showed a benefit in reducing LDL-cholesterol (17 trials, n = 590) compared to ad libitum diet (MD −0.21 mmol/L [95% CI −0.40, −0.1]), and to CER (MD −0.15 mmol/L [95% CI −0.31, −0.01]). The certainty of the evidence ranged from high to moderate due to variable downgrades for imprecision. CONCLUSIONS: Current evidence provides a good indication that IF strategies have similar benefits to CER for weight loss but may have additional benefits for fasting glucose and LDL-cholesterol. Long-term high quality RCTs are needed to clarify the effect of different IF strategies on cardiometabolic outcomes. FUNDING SOURCES: Diabetes and Nutrition Study Group of the EASD, Canadian Institutes of Health Research (CIHR), Diabetes Canada.

OBJECTIVES: The efficacy of oat beta-glucan (OBG), a viscous soluble fibre, on postprandial glycemic outcomes may depend on the nature of the control and the dose and molecular weight (MW) utilized. We undertook a systematic review and meta-analysis of acute clinical trials to determine whether these features mediate the glycemic and insulinaemic responses to OBG. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through October 27, 2020. We included acute, single-meal feeding, controlled trials investigating the effect of OBG (concentrate or oat bran) added to a carbohydrate-containing meal compared to a comparable meal (matched control) or a different carbohydrate-containing meal (unmatched control). Two reviewers extracted the data and assessed the risk of bias and certainty of evidence (GRADE). The primary outcome was incremental area under the curve (iAUC) for blood glucose. Data were pooled using the generic-inverse variance method with random effects model and expressed as ratio of means with [95% Cis]. RESULTS: One hundred and three trial comparisons (N = 538) were included. OBG reduced glucose iAUC and iPeak by 23% (0.77 [0.74, 0.81]) and 28% (0.72 [0.64, 0.76]) and insulin by 22% (0.78 [0.72, 0.85]) and 24% (0.76 [0.65, 0.88]), respectively. Dose, molecular-weight and comparator were significant effect modifiers of glucose iAUC and iPeak. Significant linear dose-response relationships were observed for all outcomes. OBG molecular-weight > 300 kg/mol significantly reduced glucose iAUC and iPeak, whereas, molecular-weight

OBJECTIVES: Sugars have been implicated in the epidemic of obesity. It is unclear whether food sources of fructose-containing sugars other than sugar-sweetened beverages (SSBs) are associated with increased risk of obesity. To assess the evidence of the relation of food sources of fructose-containing sugars with incident overweight or obesity, we undertook a systematic review and meta-analysis of prospective cohort studies. METHODS: We searched MEDLINE, EMBASE and Cochrane Library through Aug 2019. We included prospective cohort studies of ≥1 year. Two reviewers extracted data and assessed the risk of bias. The primary outcome was incident overweight/obesity. Data were pooled using generic-inverse variance method (random effects) and expressed as relative risks (RR) for incident outcomes and ß-coefficients for WC with 95% confidence intervals (CI). GRADE assessed the certainty of evidence RESULTS: We included 12 and 8 prospective cohorts involving 181,295 adults and 31,717 children, respectively. Four food sources of fructose-containing sugars were identified: SSBs, 100% fruit juice, fruit and yogurt. There was no data available in children for yogurt or WC. SSBs were associated with increased incident overweight/obesity in children (RR, 1.22 [95% CI, 1.03 to 1.44] but not in adults and increased incident abdominal obesity in both children (3.78 [1.08 to 13.25]) and adults (1.51 [1.11 to 2.06]), but there was no association with change in WC in adults. Fruit juice was associated with increased incident overweight/obesity in children (1.28 [1.07 to 1.53]) but not in adults, and there was no association with incident abdominal obesity in either children or adults or WC in adults. Fruit was associated with decreased incident overweight/obesity (0.87 [0.82 to 0.92]) and decreased WC (ß, −0.23 cm [−0.33 to −0.13]) in adults. Yogurt was associated with decreased incident abdominal obesity (0.65 [0.47 to 0.90]) in adults with no data available on WC. The certainty of the evidence was graded as “very low” to “moderate”. CONCLUSIONS: Current evidence indicates that the relation between fructose-containing sugars and obesity outcomes differs by food sources. More research of more food sources of sugars is needed to improve our certainty in the evidence. (ClinicalTrials.gov, NCT02558920) FUNDING SOURCES: ASN, Diabetes Canada, Banting and Best Diabetes Centre.

Context Previous meta-analyses evaluating the association between nut consumption and the risk of cardiovascular disease (CVD) had substantial methodological limitations and lacked recently published large prospective studies; hence, making an updated meta-analysis highly desirable. Objective To update the clinical guidelines for nutrition therapy in relation to the European Association for the Study of Diabetes (EASD), a systematic review and meta-analysis of prospective studies was conducted using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to summarize the evidence of the association between total nuts, specific types of nuts, and the incidence of, and mortality from, CVD outcomes. Data sources Relevant articles were identified by searching the PubMed and Cochrane databases. Data extraction Two independent researchers screened the articles to identify those that met the inclusion criteria. Data analysis The inverse variance method with fixed-effect or random-effects models was used to pool data across studies (expressed as risk ratio [RR] and 95% confidence interval [CI]). Heterogeneity was tested and quantified using the Cochrane Q test and I2-statistic, respectively. The GRADE system was used to assess the quality of the evidence. Results Nineteen studies were included in the analyses. The results revealed an inverse association between total nut consumption (comparing highest vs lowest categories) and CVD incidence (RR, 0.85; 95%CI, 0.800.91; I2, 0%), CVD mortality (RR, 0.77; 95%CI, 0.72–0.82; I2, 3%), coronary heart disease (CHD) incidence (RR, 0.82; 95%CI, 0.69–0.96; I2, 74%), CHD mortality (RR, 0.76; 95%CI, 0.67–0.86; I2, 46%), stroke mortality (RR, 0.83; 95%CI, 0.75–0.93; I2, 0%), and atrial fibrillation (RR, 0.85; 95%CI, 0.73–0.99; I2, 0%). No association was observed with stroke incidence and heart failure. The certainty of the evidence ranged from moderate to very low. Conclusions This systematic review and meta-analysis revealed a beneficial role of nut consumption in reducing the incidence of, and mortality from, different CVD outcomes.

Summary Background & aims To update the European Association for the Study of Diabetes (EASD) clinical practice guidelines for nutrition therapy, we conducted a systematic review and meta-analysis of randomized controlled trials to summarize the evidence for the effect of vegetarian dietary patterns on glycemic control and other established cardiometabolic risk factors in individuals with diabetes. Methods We searched MEDLINE, EMBASE, and Cochrane databases through February 26, 2018 for randomized controlled trials ≥3 weeks assessing the effect of vegetarian dietary patterns in individuals with diabetes. The primary outcome was HbA1c. Secondary outcomes included other markers of glycemic control, blood lipids, body weight/adiposity, and blood pressure. Two independent reviewers extracted data and assessed risk of bias. Data were pooled by the generic inverse variance method and expressed as mean differences (MD) with 95% CIs. Heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). The overall certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results Nine trials (n = 664 participants) met the eligibility criteria. Vegetarian dietary patterns significantly lowered HbA1c (MD = −0.29% [95% CI: −0.45, −0.12%]), fasting glucose (MD = −0.56 mmol/L [95% CI: −0.99, −0.13 mmol/L]), LDL-C (MD = −0.12 mmol/L [95% CI: −0.20, −0.04 mmol/L]), non-HDL-C (MD = −0.13 mmol/L [95% CI: −0.26, −0.01 mmol/L]), body weight (MD = −2.15 kg [95% CI: −2.95, −1.34 kg]), BMI (MD = −0.74 kg/m2 [95% CI: −1.09, −0.39 kg/m2]) and waist circumference (MD = −2.86 cm [95% CI: −3.76, −1.96 cm]). There was no significant effect on fasting insulin, HDL-C, triglycerides or blood pressure. The overall certainty of evidence was moderate but was low for fasting insulin, triglycerides and waist circumference. Conclusion Vegetarian dietary patterns improve glycemic control, LDL-C, non-HDL-C, and body weight/adiposity in individuals with diabetes, supporting their inclusion for diabetes management. More research is needed to improve our confidence in the estimates. ClinicalTrials.gov identifier NCT02600377 .

BACKGROUND: Certain plant foods (nuts and soy protein) and food components (viscous fibers and plant sterols) have been permitted by the FDA to carry a heart health claim based on their cholesterol-lowering ability. The FDA is currently considering revoking the heart health claim for soy protein due to a perceived lack of consistent LDL cholesterol reduction in randomized controlled trials. OBJECTIVE: We performed a meta-analysis of the 46 controlled trials on which the FDA will base its decision to revoke the heart health claim for soy protein. METHODS: We included the 46 trials on adult men and women, with baseline circulating LDL cholesterol concentrations ranging from 110 to 201 mg/dL, as identified by the FDA, that studied the effects of soy protein on LDL cholesterol and total cholesterol (TC) compared with non-soy protein. Two independent reviewers extracted relevant data. Data were pooled by the generic inverse variance method with a random effects model and expressed as mean differences with 95% CI. Heterogeneity was assessed and quantified. RESULTS: Of the 46 trials identified by the FDA, 43 provided data for meta-analyses. Of these, 41 provided data for LDL cholesterol, and all 43 provided data for TC. Soy protein at a median dose of 25 g/d during a median follow-up of 6 wk decreased LDL cholesterol by 4.76 mg/dL (95% CI: −6.71, −2.80 mg/dL, P

Background: Fructose providing excess calories in the form of sugar sweetened beverages (SSBs) increases markers of non-alcoholic fatty liver disease (NAFLD). Whether this effect holds for other important food sources of fructose-containing sugars is unclear. To investigate the role of food source and energy, we conducted a systematic review and meta-analysis of controlled trials of the effect of fructose-containing sugars by food source at different levels of energy control on non-alcoholic fatty liver disease (NAFLD) markers. Methods and Findings: MEDLINE, Embase, and the Cochrane Library were searched through 7 January 2022 for controlled trials ≥7-days. Four trial designs were prespecified: substitution (energy-matched substitution of sugars for other macronutrients); addition (excess energy from sugars added to diets); subtraction (excess energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced by other macronutrients). The primary outcome was intrahepatocellular lipid (IHCL). Secondary outcomes were alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Independent reviewers extracted data and assessed risk of bias. The certainty of evidence was assessed using GRADE. We included 51 trials (75 trial comparisons, n = 2059) of 10 food sources (sugar-sweetened beverages (SSBs); sweetened dairy alternative; 100% fruit juice; fruit; dried fruit; mixed fruit sources; sweets and desserts; added nutritive sweetener; honey; and mixed sources (with SSBs)) in predominantly healthy mixed weight or overweight/obese younger adults. Total fructose-containing sugars increased IHCL (standardized mean difference = 1.72 [95% CI, 1.08 to 2.36], p < 0.001) in addition trials and decreased AST in subtraction trials with no effect on any outcome in substitution or ad libitum trials. There was evidence of influence by food source with SSBs increasing IHCL and ALT in addition trials and mixed sources (with SSBs) decreasing AST in subtraction trials. The certainty of evidence was high for the effect on IHCL and moderate for the effect on ALT for SSBs in addition trials, low for the effect on AST for the removal of energy from mixed sources (with SSBs) in subtraction trials, and generally low to moderate for all other comparisons. Conclusions: Energy control and food source appear to mediate the effect of fructose-containing sugars on NAFLD markers. The evidence provides a good indication that the addition of excess energy from SSBs leads to large increases in liver fat and small important increases in ALT while there is less of an indication that the removal of energy from mixed sources (with SSBs) leads to moderate reductions in AST. Varying uncertainty remains for the lack of effect of other important food sources of fructose-containing sugars at different levels of energy control.

International audience; No abstract available

Background: Few studies have published mediation analyses to quantify the role concurrent BMI plays in the relationship between growth and cardiometabolic risk (CMR) outcomes. Methods: We used data...

ContextRare sugars are monosaccharides and disaccharides (found in small quantities in nature) that have slight differences in their chemical structure compared with traditional sugars. Little is known about their unique physiological and cardiometabolic effects in humans.ObjectiveThe objective of this study was to conduct a systematic review and synthesis of controlled intervention studies of rare sugars in humans, using PRISMA guidelines.Data SourcesMEDLINE and EMBASE were searched through October 1, 2020. Studies included both post-prandial (acute) and longer-term (≥1 week duration) human feeding studies that examined the effect of rare sugars (including allulose, arabinose, tagatose, trehalose, and isomaltulose) on cardiometabolic and physiological risk factors.Data extractionIn all, 50 studies in humans focusing on the 5 selected rare sugars were found. A narrative synthesis of the selected literature was conducted, without formal quality assessment or quantitative synthesis.Data synthesisThe narrative summary included the food source of each rare sugar, its effect in humans, and the possible mechanism of effect. Overall, these rare sugars were found to offer both short- and long-term benefits for glycemic control and weight loss, with effects differing between healthy individuals, overweight/obese individuals, and those with type 2 diabetes. Most studies were of small size and there was a lack of large randomized controlled trials that could confirm the beneficial effects of these rare sugars.ConclusionRare sugars could offer an opportunity for commercialization as an alternative sweetener, especially for those who are at high cardiometabolic risk.Systematic Review RegistrationOSF registration no. 10.17605/OSF.IO/FW43D.

International audience; Dietary fibre is a generic term describing non-absorbed plant carbohydrates and small amounts of associated non-carbohydrate components. The main contributors of fibre to the diet are the cell walls of plant tissues, which are supramolecular polymer networks containing variable proportions of cellulose, hemicelluloses, pectic substances, and non-carbohydrate components, such as lignin. Other contributors of fibre are the intracellular storage oligosaccharides, such as fructans. A distinction needs to be made between intrinsic sources of dietary fibre and purified forms of fibre, given that the three-dimensional matrix of the plant cell wall confers benefits beyond fibre isolates. Movement through the digestive tract modifies the cell wall structure and may affect the interactions with the colonic microbes (e.g., small intestinally non-absorbed carbohydrates are broken down by bacteria to short-chain fatty acids, absorbed by colonocytes). These aspects, combined with the fibre associated components (e.g., micronutrients, polyphenols, phytosterols, and phytoestrogens), may contribute to the health outcomes seen with the consumption of dietary fibre. Therefore, where possible, processing should minimise the degradation of the plant cell wall structures to preserve some of its benefits. Food labelling should include dietary fibre values and distinguish between intrinsic and added fibre. Labelling may also help achieve the recommended intake of 14 g/1000 kcal/day.

International audience; Recent data from randomized clinical trials (RCTs) suggest that DHA may have stronger anti-inflammatory effects than EPA. This body of evidence has not yet been quantitatively reviewed. The aim of this study was to compare the effect of DHA and EPA on several markers of systemic inflammation by pairwise and network meta-analyses of RCTs. MEDLINE, EMBASE, and The Cochrane Library were searched through to September 2019. We included RCTs of ≥7 d on adults regardless of health status that directly compared the effects of DHA with EPA and RCTs of indirect comparisons, in which the effects of DHA or EPA were compared individually to a control fatty acid. Differences in circulating concentrations of C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α) and adiponectin were the primary outcome measures. Data were pooled by pairwise and network meta-analysis and expressed as mean differences (MDs) with 95% CIs. Heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic) in the pairwise meta-analysis. Inconsistency and transitivity were evaluated in the network meta-analysis. The certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Eligibility criteria were met by 5 RCTs (N = 411) for the pairwise meta-analysis and 20 RCTs (N = 1231) for the network meta-analysis. In the pairwise meta-analysis, DHA and EPA had similar effects on plasma CRP [MDDHA versus EPA = 0.14 mg/L (95% CI: -0.57, 0.85); I2 = 61%], IL-6 [MDDHA versus EPA = 0.10 pg/mL (-0.15, 0.34); I2 = 40%], and TNF-α [MDDHA versus EPA = -0.10 pg/mL (-0.37, 0.18); I2 = 40%]. In the network meta-analysis, the effects of DHA and EPA on plasma CRP [MDDHA versus EPA = -0.33 mg/L (-0.75, 0.10)], IL-6 [MDDHA versus EPA = 0.09 pg/mL (-0.12, 0.30)], and TNF-α [MDDHA versus EPA = -0.02 pg/mL (-0.25, 0.20)] were also similar. DHA and EPA had similar effects on plasma adiponectin in the network meta-analysis. Results from pairwise and network meta-analyses suggest that supplementation with either DHA or EPA does not differentially modify systemic markers of subclinical inflammation.

Carbohydrates are increasingly being implicated in the epidemics of obesity, diabetes, and their downstream cardiometabolic diseases. The “carbohydrate-insulin model” has been proposed to explain this role of carbohydrates. It posits that a high intake of carbohydrate induces endocrine deregulation marked by hyperinsulinemia, leading to energy partitioning with increased storage of energy in adipose tissue resulting in adaptive increases in food intake and decreases in energy expenditure. Whether all carbohydrate foods under real-world feeding conditions directly contribute to weight gain and its complications or whether this model can explain these clinical phenomena requires close inspection. The aim of this review is to assess the evidence for the role of carbohydrate quantity vs quality in cardiometabolic health. Although the clinical investigations of the “carbohydrate-insulin model” have shown the requisite decreases in insulin secretion and increases in fat oxidation, there has been a failure to achieve the expected fat loss under low-carbohydrate feeding. Systematic reviews with pairwise and network meta-analyses of the best available evidence have failed to show the superiority of low-carbohydrate diets on long-term clinical weight loss outcomes or that all sources of carbohydrate behave equally. High-carbohydrate diets that emphasize foods containing important nutrients and substances, including high-quality carbohydrate such as whole grains (especially oats and barley), pulses, or fruit; low glycemic index and load; or high fiber (especially viscous fiber sources) decrease intermediate cardiometabolic risk factors in randomized trials and are associated with weight loss and decreased incidence of diabetes, cardiovascular disease, and cardiovascular mortality in prospective cohort studies. The evidence for sugars as a marker of carbohydrate quality appears to be highly dependent on energy control (comparator) and food source (matrix), with sugar-sweetened beverages providing excess energy showing evidence of harm, and with high-quality carbohydrate food sources containing sugars such as fruit, 100% fruit juice, yogurt, and breakfast cereals showing evidence of benefit in energy-matched substitutions for refined starches (low-quality carbohydrate food sources). These data reflect the current shift in dietary guidance that allows for flexibility in the proportion of macronutrients (including carbohydrates) in the diet, with a focus on quality over quantity and dietary patterns over single nutrients.

Dietary carbohydrates are components of healthy foods, but many carbohydrate foods have recently been stigmatized as primary causes of diet-related risk factors for chronic disease. There is an opportunity to enhance efforts within the food landscape to encourage the consumption of higher quality carbohydrate foods. The use of labelling is one strategy that permits consumers to identify healthy carbohydrate foods at the point-of-purchase. This review discusses the regulatory frameworks and examples of associated non-mandatory food labelling claims that are currently employed to highlight healthy carbohydrate foods to consumers. The existing labelling frameworks discussed here align with established measures of carbohydrate quality, such as 1. dietary fibre nutrient content claims and associated dietary fibre-based health claims; 2. the presence of whole carbohydrate foods and ingredients that are intact or reconstituted, such as whole grains; and 3. low glycemic index and glycemic response claims. Standards from Codex Alimentarius, and regulations from Australia and New Zealand, Canada, Europe, and the United States will be used to illustrate the means by which food labelling can be used by consumers to identify quality carbohydrate foods.

OBJECTIVES: Sugar-sweetened beverages (SSBs) have been linked to weight gain, and it is unclear if other food sources of fructose-containing sugars behave similarily. We conducted a systematic review and meta-analysis of controlled feeding trials to assess the effect of different food sources of fructose-containing sugars on body weight. METHODS: MEDLINE, EMBASE, and The Cochrane library were searched through January 2019. We included controlled feeding trials of ≥2 weeks investigating the effect of different food sources of sugars. Four levels of energy control were prespecified: substitution (energy-matched comparisons); addition (energy from sugars added to diet); subtraction (energy from sugars subtracted from diet); or ad libitum (energy from sugars freely replaced). The primary outcome was body weight. Two independent reviewers extracted data and assessed risk of bias. Data were pooled using random effects models and expressed as mean differences (MDs) with 95% confidence intervals (CIs). GRADE assessed the certainty of evidence. RESULTS: We identified 110 controlled trials (N = 5133) assessing the effect of 7 different food sources of fructose-containing sugars (SSBs, fruit, fruit juice, dried fruit; baked goods, sweets, & desserts; mixed sources; added caloric sweeteners). No effect on body weight was observed in substitution trials, whereas there was an increasing effect in addition trials (MD, 0.23 kg [95% CI, 0.06 to 0.40]) and ad libitum trials (1.43 kg [0.78 to 2.16]), and a decreasing effect in subtraction trials (–0.52 kg [–1.02 to −0.02]). There was evidence of interaction by food source with fruit showing weight loss in substitution trials and SSBs showing weight gain in addition trials. The certainty of evidence was moderate for the effects in the addition and subtraction trials and high for the effects in the substitution and ad libitum trials. CONCLUSIONS: Energy control and food source appear to mediate the effect of fructose-containing sugars on body weight. Food sources of fructose-containing sugars adding excess energy to diets (especially sugars-sweetened beverages) appear to lead to weight gain. There is low to moderate likelihood that more research will substantially alter our estimates (ClinicalTrials.gov Identifier, NCT02558920) FUNDING SOURCES: American Society for Nutrition Foundation (commissioned and funded), Diabetes Canada.

OBJECTIVES: Nordic dietary patterns may have a role in diabetes management. To inform the update of the European Association for the Study of Diabetes (EASD) clinical practice guidelines, we conducted a systematic review and meta-analysis of Nordic dietary patterns and cardiometabolic outcomes. METHODS: We searched Cochrane, MEDLINE, and EMBASE through Aug 2019. We included cohort studies of ≥1 y and RCTs of ≥3 wk. Two independent reviewers extracted data and assessed risk of bias. The primary outcome was CVD in cohort studies and LDL-C in RCTs. Secondary outcomes included CHD and stroke in cohort studies and markers of glycemic control, lipids, adiposity, BP and inflammation in RCTs. Data were expressed as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). GRADE assessed the certainty of evidence. RESULTS: We identified 10 cohort studies in people inclusive of diabetes and 6 RCTs in people with ≥1 risk factor (overweight/obesity, metabolic syndrome, dyslipidemia). Nordic dietary patterns were associated with lower risk of the primary outcome, total CVD (RR, 0.93 [95% CI, 0.88, 0.99]) and CVD mortality (0.83 [0.73, 0.94]), as well as stroke (0.88 [0.79, 0.98]) in cohort studies. Although Nordic dietary patterns did not reduce the primary outcome, LDL-C, in RCTs, there were reductions in other established lipid targets, non-HDL-C (MD, −0.49 mmol/L [95% CI, −0.67, −0.30]) and apo B (0.15 g/L [−0.19, −0.11]), as well as weight (2.10 kg [−3.58, −0.63]), BMI (−0.90 kg/m(2) [−1.11, −0.69]), waist circumference (2.22 cm [−3.36, −1.09], diastolic BP (1.78 mmHg [−3.21, −0.35]) and insulin (7.23 pmol/L [−11.88, −2.58]). The certainty of evidence was moderate for the reductions in CVD mortality, established lipid targets, adiposity markers, and insulin and low for all other outcomes. CONCLUSIONS: Nordic dietary patterns are associated with decreased CVD and reduce cardiometabolic risk factors in people inclusive of or at risk for diabetes. The available data indicate a benefit for people with diabetes with a moderate likelihood that more studies will alter our estimates. (clinicaltrials.gov identifier, NCT04094194) FUNDING SOURCES: Diabetes and Nutrition Study Group (DNSG) of the EASD, CIHR, Diabetes Canada, Joannah and Brian Lawson Center for Child Nutrition, Connaught Fund, Onassis Foundation.