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Cardiovascular disease and its concurrent risk factors are prevalent after liver transplant (LT). Most of these risk factors are modifiable by diet. We aimed to synthesise the literature reporting the nutritional intake of liver transplant recipients (LTR) and the potential determinants of intake. We performed a systematic review and meta-analyses of studies published up until July 2021 reporting the nutritional intake of LTR. The pooled daily mean intakes were recorded as 1998 (95% CI 1889, 2108) kcal, 17 (17, 18)% energy from protein, 49 (48, 51)% energy from carbohydrates, 34 (33, 35)% energy from total fat, 10 (7, 13)% energy from saturated fat, and 20 (18, 21) g of fibre. The average fruit and vegetable intake ranged from 105 to 418 g/day. The length of time post-LT and the age and sex of the cohorts, as well as the continent and year of publication of each study, were sources of heterogeneity. Nine studies investigated the potential determinants of intake, time post-LT, gender and immunosuppression medication, with inconclusive results. Energy and protein requirements were not met in the first month post-transplant. After this point, energy intake was significantly higher and remained stable over time, with a high fat intake and low intake of fibre, fruits and vegetables. This suggests that LTR consume a high-energy, low-quality diet in the long term and do not adhere to the dietary guidelines for cardiovascular disease prevention.

Peer reviewed: True, Funder: Imperial College Junior Research Fellowship, Low fruit and vegetable consumption is a major modifiable risk factor for raised blood pressure (BP), but it is unknown how heterogeneity in national supply has contributed to BP trends. To address this, we characterised supply trends from 1975 to 2015 and whether it met WHO recommendations. We then examined associations with three metrics: systolic, diastolic and raised BP. We used ecological data on fruit and vegetable supply and on BP for 159 countries. We examined trends in fruit and vegetable supply from 1975 to 2015 by country and World Bank income region. Multivariable linear regression was used to examine cross-sectional associations with BP. Global fruit and vegetable supply increased from 1975 to 2015, but with heterogeneous national and regional trends. While WHO recommendations were met globally, this target was not met in almost half the countries, of which many were low-income countries. Significant associations between combined fruit and vegetable supply and raised BP were observed. Over the past four decades, combined fruit and vegetable supply has been consistently and strongly associated with lower prevalence of raised BP globally. However, the heterogeneous regional trends in fruit and vegetable supply underpin the need for international organisations and individual governments to introduce or strengthen policies for increased fruit and vegetable supply to reduce the burden of non-communicable diseases at national and global levels.

Summary Background and aims Previous studies have reported associations between higher potato intake and higher blood pressure (BP) and/or risk of hypertension and obesity. These studies rarely considered preparation methods of potatoes, overall dietary pattern or the nutrient quality of the meals. These factors may affect the association of potato intake with BP and body mass index (BMI). This study investigated potato consumption by amount, type of processing, overall dietary pattern, and nutrient quality of the meals in relation to BP and BMI. Methods Cross-sectional analyses were conducted among 2696 participants aged 40–59 y in the US and UK samples of the International Study of Macro- and Micro-Nutrients and Blood Pressure (INTERMAP). Nutrient quality of individual food items and the overall diet was assessed with the Nutrient-Rich Foods (NRF) index. Results No associations with BP or BMI were found for total potato intake nor for boiled, mashed, or baked potatoes or potato-based mixed dishes. In US women, higher intake of fried potato was associated with 2.29 mmHg (95% CI: 0.55, 3.83) higher systolic BP and with 1.14 mmHg (95% CI: 0.10, 2.17) higher diastolic BP, independent of BMI. Higher fried potato consumption was directly associated with a +0.86 kg/m2 difference in BMI (95% CI: 0.24, 1.58) in US women. These associations were not found in men. Higher intakes of fried potato meals with a lower nutritional quality (NRF index≤ 2) were positively associated with systolic (3.88 mmHg; 95% CI: 2.63, 5.53) and diastolic BP (1.62 mmHg; 95% CI: 0.48, 2.95) in US women. No associations with BP were observed for fried potato meals with a higher nutritional quality (NRF index> 2). Conclusions Fried potato was directly related to BP and BMI in women, but non-fried potato was not. Poor-nutrient quality meals were associated with intake of fried potatoes and higher BP, suggesting that accompanied dietary choices are key mediators of these associations.

In a cross-sectional analysis of a population-based cohort (United Kingdom, N = 21,318, 1993–1998), we studied how associations between meal patterns and non-fasting triglyceride and glucose concentrations were influenced by the hour of day at which the blood sample was collected to ascertain face validity of reported meal patterns, as well as the influence of reporting bias (assessed using formula of energy expenditure) on this association. Meal size (i.e., reported energy content), mealtime and meal frequency were reported using pre-structured 7-day diet diaries. In ANCOVA, sex-specific means of biomarker concentrations were calculated by hour of blood sample collection for quartiles of reported energy intake at breakfast, lunch and dinner (meal size). Significant interactions were observed between breakfast size, sampling time and triglyceride concentrations and between lunch size, sampling time and triglyceride, as well as glucose concentrations. Those skipping breakfast had the lowest triglyceride concentrations in the morning and those skipping lunch had the lowest triglyceride and glucose concentrations in the afternoon, especially among acceptable energy reporters. Eating and drinking occasion frequency was weakly associated with glucose concentrations in women and positively associated with triglyceride concentrations in both sexes; stronger associations were observed for larger vs. smaller meals and among acceptable energy reporters. Associations between meal patterns and concentration biomarkers can be observed when accounting for diurnal variation and underreporting. These findings support the use of 7-day diet diaries for studying associations between meal patterns and health.

In a cross-sectional analysis of a population-based cohort (United Kingdom, N = 21,318, 1993–1998), we studied how associations between meal patterns and non-fasting triglyceride and glucose concentrations were influenced by the hour of day at which the blood sample was collected to ascertain face validity of reported meal patterns, as well as the influence of reporting bias (assessed using formula of energy expenditure) on this association. Meal size (i.e., reported energy content), mealtime and meal frequency were reported using pre-structured 7-day diet diaries. In ANCOVA, sex-specific means of biomarker concentrations were calculated by hour of blood sample collection for quartiles of reported energy intake at breakfast, lunch and dinner (meal size). Significant interactions were observed between breakfast size, sampling time and triglyceride concentrations and between lunch size, sampling time and triglyceride, as well as glucose concentrations. Those skipping breakfast had the lowest triglyceride concentrations in the morning and those skipping lunch had the lowest triglyceride and glucose concentrations in the afternoon, especially among acceptable energy reporters. Eating and drinking occasion frequency was weakly associated with glucose concentrations in women and positively associated with triglyceride concentrations in both sexes; stronger associations were observed for larger vs. smaller meals and among acceptable energy reporters. Associations between meal patterns and concentration biomarkers can be observed when accounting for diurnal variation and underreporting. These findings support the use of 7-day diet diaries for studying associations between meal patterns and health.

Childhood obesity is an area of intense concern internationally and is influenced by events during antenatal and postnatal life. Although pregnancy complications, such as gestational diabetes and large-for-gestational-age birthweight have been associated with increased obesity risk in offspring, very few successful interventions in pregnancy have been identified. We describe a study protocol to identify if a reduced calorie diet in pregnancy can reduce adiposity in children to 3 years of age. The dietary intervention in gestational diabetes (DiGest) study is a randomised, controlled trial of a reduced calorie diet provided by a whole-diet replacement in pregnant women with gestational diabetes. Women receive a weekly dietbox intervention from enrolment until delivery and are blinded to calorie allocation. This follow-up study will assess associations between a reduced calorie diet in pregnancy with offspring adiposity and maternal weight and glycaemia. Anthropometry will be performed in infants and mothers at 3 months, 1, 2 and 3 years post-birth. Glycaemia will be assessed using bloodspot C-peptide in infants and continuous glucose monitoring with HbA1c in mothers. Data regarding maternal glycaemia in pregnancy, maternal nutrition, infant birthweight, offspring feeding behaviour and milk composition will also be collected. The DiGest follow-up study is expected to take 5 years, with recruitment finishing in 2026.

BACKGROUND Saudi Arabian diets are transitioning to more Western dietary patterns that have been associated with higher levels of inflammation. Emerging evidence suggests plant-based diets are related to lower levels of inflammation; however, the definition of plant-based diets varies. OBJECTIVE The purpose of this study was to identify the extent to which an overall Plant-Based Diet Index (PDI), Healthy-PDI (hPDI), and Unhealthy-PDI (uPDI) vs Energy-Adjusted Dietary Inflammatory Index correlate with high-sensitivity C-reactive protein (hs-CRP) level. DESIGN This was a cross-sectional study carried out at King Saud University. Data on dietary intake, anthropometrics, and hs-CRP were collected. PARTICIPANTS/SETTING Female students aged 19 to 35 years (n = 401) were recruited from King Saud University, Riyadh, Saudi Arabia, between February and May 2019. MAIN OUTCOME MEASURES The main outcome was hs-CRP level. STATISTICAL ANALYSES PERFORMED Pearson correlation and multivariate linear regression analyses were used to examine the associations between hs-CRP, each PDI, and Energy-Adjusted Dietary Inflammatory Index (E-DII). RESULTS E-DII and uPDI scores had a moderate and a small positive correlation with hs-CRP levels (r = 0.46 and 0.22, respectively), whereas PDI and hPDI scores had a small and a moderate inverse correlation with hs-CRP levels (r = -0.13 and -0.31, respectively). A 1-standard deviation higher E-DII score was directly associated with a 1.05 mg/L higher hs-CRP level (95% confidence interval 0.72 to 1.38; P < 0.0001) after adjusting for body mass index. Overall PDI score was not associated with hs-CRP levels. A 6-point higher hPDI and uPDI score were associated with a 0.13 mg/L lower hs-CRP (95% confidence interval -0.08 to -0.28) and a 0.15 mg/L higher hs-CRP (95% confidence interval 0.03 to 0.31), respectively, after adjusting for lifestyle and dietary factors; however, results attenuated and were no longer statistically significant after body mass index adjustment. CONCLUSIONS Although all indexes had a small or moderate correlation with hs-CRP, only E-DII score was positively associated with hs-CRP level. Future research can examine PDI-based interventions for lowering inflammation.

BackgroundPlant-based diets are associated with a lower risk of cardiovascular diseases; however, little is known how the healthiness of the diet may be associated with blood pressure (BP). We aimed to modify three plant -based diet indices: overall plant-based diet index (PDI), healthy PDI (hPDI), and unhealthy PDI (uPDI) according to country-specific dietary guidelines to enable use across populations with diverse dietary patterns – and assessed their associations with BP.DesignWe used cross-sectional data including 4,680 men and women ages 40–59y in Japan, China, the United Kingdom, and the United States from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP). During four visits, eight BP measurements, and four 24-h dietary recalls were collected. Multivariable regression coefficients were estimated, pooled, weighted, and adjusted extensively for lifestyle/dietary confounders.ResultsModified PDI was not associated with BP. Consumption of hPDI higher by 1SD was inversely associated with systolic (-0.82 mm Hg;95% CI:-1.32,-0.49) and diastolic BP (-0.49 mm Hg; 95% CI:-0.91, -0.28). In contrast, consumption of an uPDI was directly associated with systolic (0.77 mm Hg;95% CI:0.30,1.20). Significant associations between hPDI with BP were attenuated with separate adjustment for vegetables and whole grains; associations between uPDI and BP were attenuated after adjustment for refined grains, sugar-sweetened beverages, and meat.ConclusionAn hPDI is associated with lower BP while a uPDI is adversely related to BP. Plant-based diets rich in vegetables and whole grains and limited in refined grains, sugar-sweetened beverages, and total meat may contribute to these associations. In addition to current guidelines, the nutritional quality of consumed plant foods is as important as limiting animal-based components.Trial registration numberThe observational INTERMAP study was registered at www.clinicaltrials.gov as NCT00005271.

Funder: Wellcome Trust, Gestational diabetes mellitus (GDM) annually affects 35,000 pregnancies in the United Kingdom, causing suboptimal health outcomes to the mother and child. Obesity and excessive gestational weight gain are risk factors for GDM. The Institute of Medicine recommends weight targets for women that are overweight and obese, however, there are no clear guidelines for women with GDM. Observational data suggest that modest weight loss (0.6-2 kg) after 28 weeks may reduce risk of caesarean section, large-for-gestational-age (LGA), and maternal postnatal glycaemia. This protocol for a multicentre randomised double-blind controlled trial aims to identify if a fully controlled reduced energy diet in GDM pregnancy improves infant birthweight and reduces maternal weight gain (primary outcomes). A total of 500 women with GDM (National Institute of Health and Care Excellence (NICE) 2015 criteria) and body mass index (BMI) ≥25 kg/m2 will be randomised to receive a standard (2000 kcal/day) or reduced energy (1200 kcal/day) diet box containing all meals and snacks from 28 weeks to delivery. Women and caregivers will be blinded to the allocations. Food diaries, continuous glucose monitoring, and anthropometry will measure dietary compliance, glucose levels, and weight changes. Women will receive standard antenatal GDM management (insulin/metformin) according to NICE guidelines. The secondary endpoints include caesarean section rates, LGA, and maternal postnatal glucose concentrations.

Background: Epidemiological evidence links blood pressure (BP) -lowering effects with fruit, vegetables, pulses, nuts but results are inconsistent and often rely on self-administered dietary assessment methods prone to random and systematic errors and potential under- or overestimation of relationships. Objective: To characterize urinary metabolic signatures of plant food intake (fruit, vegetables, pulses, and nuts) and subsequently to assess their associations with BP, validated across cohorts. Methods: We used untargeted metabolic profiling obtained by proton nuclear magnetic resonance spectroscopy ( 1 H NMR) of two timed repeated 24-hour urine collections derived from 2,032 free-living US participants, and replicated among 449 UK participants, all part of the cross-sectional International Study of Macro- and Micronutrients and Blood Pressure (INTERMAP) study. Associations of plant foods intakes from four 24-hour dietary recalls with 7,100 NMR features were evlauted using univariate linear regression analyses. Significant metabolites were structurally identified using analytical and statistical approaches. We compared extensively adjusted associations of plant food intake and urinary metabolites with BP in the total population (N=2,481). All analyses were extensively adjusted for potential confounders and accounted for multiple testing. Results: We found consistent, reproducible relationships of NMR signatures with plant food intake across repeated urine collections and between populations. Eleven urinary metabolites were identified and two remained unknown (1: δ 2.80 (s); 2: δ 1.16(s), 1.67 (s)). Twelve metabolites were directly correlated with plant foods ranging from 0.15 (P≤1x10 -11 ) to 0.49 (P≤5x10 -119 ), and phenylacetylglutamine was inversely associated (r=-0.18, P≤1x10 -5 ). In adjusted analyses, plant food intake was inversely associated with systolic BP (-1.29 mmHg; 95%CI: -2.38,-0.19), but not with diastolic BP. Metabolites inversely associated with systolic BP were hippurate (-2.67 mmHg;-3.71,-1.63), citrate (-2.50 mmHg; -3.55,-1.44), phenylacetylglutamine (-2.26 mmHg; -3.29,-1.23), unknown1 (-2.05 mmHg; -3.06,-1.04), 4-hydroxyhippurate (-1.45 mmHg; -2.44,-0.45), and unknown2 (-1.09 mmHg; -2.09,-0.09); with diastolic BP were phenylacetylglutamine (-1.12 mmHg; -1.84,-0.40), citrate (-1.02 mmHg; -1.76,-0.28), and unknown1 (-1.18 mmHg; -1.88,-0.47). Plant food-systolic BP associations were attenuated by further adjustment for citrate, hippurate, and unknown1, while hydroxyproline, proline and phenylacetylglutamine were potential effect modifiers. Conclusion: Urinary metabolites were consistently associated with plant food intake. Urinary metabolites that may underlie the plant food-BP association were gut-microbial co-metabolites and tricarboxylic acid cycle intermediates.

Healthy dietary habits are the cornerstone of cardiovascular disease (CVD) prevention. Numerous researchers have developed diet quality indices to help evaluate and compare diet quality across and within various populations. The availability of these new indices raises questions regarding the best selection relevant to a given population. In this perspective, we critically evaluate a priori–defined dietary indices commonly applied in epidemiological studies of CVD risk and mortality. A systematic literature search identified 59 observational studies that applied a priori–defined diet quality indices to CVD risk factors and/or CVD incidence and/or CVD mortality. Among 31 different indices, these scores were categorized as follows: 1) those based on country-specific dietary patterns, 2) those adapted from distinct dietary guidelines, and 3) novel scores specific to key diet-related factors associated with CVD risk. The strengths and limitations of these indices are described according to index components, calculation methods, and the application of these indices to different population groups. Also, the importance of identifying methodological challenges faced by researchers when applying an index are considered, such as selection and weighting of food groups within a score, since food groups are not necessarily equivalent in their associations with CVD. The lack of absolute cutoff values, emphasis on increasing healthy food without limiting unhealthy food intake, and absence of validation of scores with biomarkers or other objective diet assessment methods further complicate decisions regarding the best indices to use. Future research should address these limitations, consider cross-cultural and other differences between population groups, and identify translational challenges inherent in attempting to apply a relevant diet quality index for use in CVD prevention at a population level.

The authors would like to correct an error in a recent published paper [...]

Background: Epidemiologic evidence suggests that low-fat dairy consumption may lower risk of hypertension. Dairy products may be distinctly linked to health, because of differences in nutritional composition, but little is known about specific nutrients that contribute to the dairy-blood pressure (BP) association, nor to underlying kidney function. Methods: We examined cross-sectional associations to BP of dairy product intakes, total and by type, from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP) including 2694 participants aged 40–59 years from the UK and the USA. Eight BP, four 24-h dietary recalls and two 24-h urine samples were collected during four visits. Linear regression models adjusted for lifestyle/dietary factors to estimate BP differences per 2SD higher intakes of total-and-individual-types of dairy were calculated. Results: Multivariable linear regression coefficients were estimated and pooled. In contrast to total and whole-fat dairy, each 195 g/1000 kcal (2SD) greater low-fat dairy intake was associated with a lower SBP −2.31 mmHg and DBP −2.27 mmHg. Significant associations attenuated with adjustment for dietary phosphorus, calcium, and lactose, but strengthened with urinary calcium adjustment. Stratification by median albumin–creatinine ratio (ACR; high ACR indicates impaired kidney function) showed strong associations between low-fat dairy and BP in participants with low ACR (SBP: −3.66; DBP: −2.15 mmHg), with no association in participants with high ACR. Conclusion: Low-fat dairy consumption was associated with lower BP, especially among participants with low ACR. Dairy-rich nutrients including phosphorus and calcium may have contributed to the beneficial associations with BP.

Adverse blood pressure (BP) is a major independent risk factor for epidemic cardiovascular diseases affecting almost one-quarter of the adult population worldwide. Dietary intake is a major determinant in the development and progression of high BP. Lifestyle modifications, including recommended dietary guidelines, are advocated by the American Society of Hypertension, the International Society of Hypertension, the Japanese Society of Hypertension, and many other organisations for treating all hypertensive people, prior to initiating drug therapy and as an adjunct to medication in persons already on drug therapy. Lifestyle modification can also reduce high BP and prevent development of hypertension. This review synthesizes results from the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP), a cross-sectional epidemiological study of 4,680 men and women aged 40–59 years from Japan, the People’s Republic of China the United Kingdom, and the United States, published over the past few years on cross cultural BP differences. INTERMAP has previously reported that intakes of vegetable protein, glutamic acid, total and insoluble fibre, total polyunsaturated fatty acid and linoleic acid, total n-3 fatty acid and linolenic acid, phosphorus, calcium, magnesium, and non-heme iron were inversely related to BP. Direct associations of sugars (fructose, glucose and sucrose) and sugar-sweetened beverages, (especially combined with high sodium intake) cholesterol, glycine and alanine, and oleic acid from animal sources with BP were also reported by the INTERMAP Study.

Chronic kidney disease (CKD) is highly prevalent among older post-myocardial infarction (MI) patients. It is not known whether CKD is an independent risk factor for mortality in older post-MI patients with optimal cardiovascular drug-treatment. Therefore, we studied the relation between kidney function and all-cause and specific mortality among older post-MI patients, without severe heart failure, who are treated with state-of-the-art pharmacotherapy. From 2002–2006, 4,561 Dutch post-MI patients were enrolled and followed until death or January 2012. We estimated Glomerular Filtration Rate (eGFR) with cystatin C (cysC) and creatinine (cr) using the CKD-EPI equations and analyzed the relation with any and major causes of death using Cox models and restricted cubic splines. Mean (SD) for age was 69 years (5.6), 79% were men, 17% smoked, 21% had diabetes, 90% used antihypertensive drugs, 98% used antithrombotic drugs and 85% used statins. Patients were divided into four categories of baseline eGFRcysC: ≥90 (33%; reference), 60–89 (47%), 30–59 (18%), and

Background: Epidemiologic evidence suggests that fruit consumption may lower the risk of cardiovascular diseases through blood pressure (BP)–lowering effects; little is known on the independent effect of raw fruit and fruit juice on BP. Objective: The objective was to quantify associations of raw fruit and fruit juice consumption with BP by using cross-sectional data from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP) of 4680 men and women aged 40–59 y from Japan, China, the United Kingdom, and the United States. Design: During 4 visits, 8 BP, four 24-h dietary recalls, and two 24-h urine samples were collected. Country-specific multivariate-controlled linear regression coefficients, including adjustment for urinary sodium excretion, were estimated and pooled weighted by inverse of their variance. Results: The average total raw fruit consumption varied from a mean 6 SD 52 6 65 g/1000 kcal in the United States to 68 6 70 g/1000 kcal in China. Individual raw fruit intake was not associated with BP in pooled analyses for all countries or in participants from Western countries, although a positive association with diastolic BP was observed in East Asian participants (per 50 g/1000 kcal; 0.37 mm Hg; 95% CI: 0.02, 0.71). Positive relationships with diastolic BP were found for citrus fruit intake in Western consumers (per 25 g/1000 kcal; 0.47 mm Hg; 95% CI: 0.12, 0.81) and for apple intake in East Asian consumers (0.40 mm Hg; 95% CI: 0.03, 0.78). Among East Asian banana consumers, banana intake was inversely associated with diastolic BP (21.01 mm Hg; 95% CI: 21.88, 20.02). Fruit juice intake, which was negligible in Asia, was not related to BP in Western countries. Conclusion: Consistent associations were not found between raw fruit and fruit juice consumption of individuals and BP. This observational study was registered at www.clinicaltrials.gov as NCT00005271. Am J Clin Nutr doi: 10.3945/ajcn.112.046300.

Atherosclerosis is one of the most important contributors to the global burden of cardiovascular diseases. With the recognition of atherosclerosis as an inflammatory disease, nutrition research interest has expanded toward the role of dietary patterns in the prevention of atherosclerosis primarily focused on associations with early inflammatory markers. This review summarizes the latest evidence from January 2010 until January 2013 of eight observational studies on the associations between empirically derived dietary patterns and diet quality scores with markers of inflammation and endothelial function. Overall, results of recently published cohort studies support those of previously published cross-sectional studies suggesting that consuming a healthy type of diet characteristically abundant in fruits and vegetables is associated with lower concentrations of C-reactive protein and other inflammatory markers. Unfavorable associations were found between eating a western dietary pattern high in meat and inflammatory markers. Different statistical approaches of deriving dietary patterns were applied in these studies and most of them lacked in reporting types and absolute intakes of foods and/or food groups. Future prospective cohort studies are needed to evaluate long-term associations between dietary patterns and changes in inflammatory markers by comparing various approaches of dietary pattern derivation within a population. Reporting types and absolute intakes of foods and/or food groups may facilitate the identification of a typical dietary pattern that may beneficially influence inflammation.

ObjectiveConsuming a variety of fruit and vegetables provides many different micronutrients and bioactive compounds. Whether this contributes to the beneficial association between fruit and vegetables and incident CHD and stroke is unknown.DesignProspective population-based cohort study.SettingThe Netherlands.SubjectsMen and women (n 20 069) aged 20–65 years. Participants completed a validated 178-item FFQ, including nine fruit and thirteen vegetable items. Variety in fruit and vegetables was defined as the sum of different items consumed at least once per 2 weeks over the previous year. Hazard ratios (HR) for variety in relation to incident CHD and stroke were calculated using multivariable Cox proportional hazards models additionally adjusted for quantity of fruit and vegetables.ResultsVariety and quantity in fruit and vegetables were highly correlated (r = 0·81). Variety was not associated with total energy intake (r = −0·01) and positively associated with nutrient intakes, particularly vitamin C (r = 0·70). During 10 years of follow-up, 245 cases of CHD and 233 cases of stroke occurred. Variety in vegetables (HR per 2 items = 1·05; 95 % CI 0·94, 1·17) and in fruit (HR per 2 items = 1·00; 95 % CI 0·87, 1·15) were not related to incident CHD. Variety in vegetables (HR per 2 items = 0·93; 95 % CI 0·83, 1·04) and in fruit (HR per 2 items = 1·03; 95 % CI 0·89, 1·18) were also not related to incident stroke.ConclusionsMore variety in fruit and vegetable consumption was associated with higher intakes of fruit and vegetables and micronutrients. Independently of quantity, variety in fruit and vegetables was related neither to incident CHD nor to incident stroke.

The colours of the edible part of fruit and vegetables indicate the presence of specific micronutrients and phytochemicals. The extent to which fruit and vegetable colour groups contribute to CHD protection is unknown. We therefore examined the associations between fruit and vegetables of different colours and their subgroups and 10-year CHD incidence. We used data from a prospective population-based cohort including 20 069 men and women aged 20–65 years who were enrolled between 1993 and 1997. Participants were free of CVD at baseline and completed a validated 178-item FFQ. Hazard ratios (HR) for the association between green, orange/yellow, red/purple, white fruit and vegetables and their subgroups with CHD were calculated using multivariable Cox proportional hazards models. During 10 years of follow-up, 245 incident cases of CHD were documented. For each 25 g/d increase in the intake of the sum of all four colours of fruit and vegetables, a borderline significant association with incident CHD was found (HR 0·98; 95 % CI 0·97, 1·01). No clear associations were found for the colour groups separately. However, each 25 g/d increase in the intake of deep orange fruit and vegetables was inversely associated with CHD (HR 0·74; 95 % CI 0·55, 1·00). Carrots, their largest contributor (60 %), were associated with a 32 % lower risk of CHD (HR 0·68; 95 % CI 0·48, 0·98). In conclusion, though no clear associations were found for the four colour groups with CHD, a higher intake of deep orange fruit and vegetables and especially carrots may protect against CHD.

OBJECTIVE We carried out a secondary analysis in high-risk patients with a previous myocardial infarction (MI) and diabetes in the Alpha Omega Trial. We tested the hypothesis that in these patients an increased intake of the n-3 fatty acids eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and α-linolenic acid (ALA) will reduce the incidence of ventricular arrhythmias and fatal MI. RESEARCH DESIGN AND METHODS A subgroup of 1,014 post-MI patients with diabetes aged 60–80 years was randomly allocated to receive one of four trial margarines, three with an additional amount of n-3 fatty acids and one placebo for 40 months. The end points were ventricular arrhythmia–related events and fatal MI. The data were analyzed according to the intention-to-treat principle, using multivariable Cox proportional hazards models. RESULTS The patients consumed on average 18.6 g of margarine per day, which resulted in an additional intake of 223 mg EPA plus 149 mg DHA and/or 1.9 g ALA in the active treatment groups. During follow-up, 29 patients developed a ventricular arrhythmia–related events and 27 had a fatal MI. Compared with placebo patients, the EPA-DHA plus ALA group experienced less ventricular arrhythmia–related events (hazard ratio 0.16; 95% CI 0.04–0.69). These n-3 fatty acids also reduced the combined end-point ventricular arrhythmia–related events and fatal MI (0.28; 0.11–0.71). CONCLUSIONS Our results suggest that low-dose supplementation of n-3 fatty acids exerts a protective effect against ventricular arrhythmia–related events in post-MI patients with diabetes.

Background Weekly fish consumption has been related to a lower risk of fatal coronary heart disease (CHD) and incident stroke in populations with a low fish intake. This relation has mainly been attributed to n-3 fatty acids in fish, that is, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). It is at present unclear whether alpha-linolenic acid (ALA), a n-3 fatty acid from vegetable origin, could also be protective against cardiovascular diseases (CVDs). There is a need for food-based trials to establish the efficacy of low doses of n-3 fatty acids in CVD prevention. Objectives The aim of the study was to evaluate the effect of an additional daily intake of 400 mg of EPA + DHA and 2 g of ALA on CVD morbidity and mortality in free-living subjects with a history of myocardial infarction. Design The multicenter Alpha Omega Trial is a randomized, double-blind, placebo-controlled trial with a 2 x 2 factorial design. Between May 2002 and December 2006, we enrolled a total of 4,837 men and women aged 60 through 80 who experienced a myocardial infarction within 10 years before entering the study. Subjects were randomized to 1 of 4 margarine spreads that were enriched with EPA + DHA and/or ALA, or placebo. Compliance was monitored via tub counts and assessment of n-3 fatty acids in plasma. Subjects were observed for 40 months for the occurrence of fatal and nonfatal CVD. Results The cohort was on average 69 years old at the start of the study and comprised 22% women. Subjects had their (last) myocardial infarction approximately 4 years before enrolment. Mean body mass index was 27.7 kg/m(2), and 17% smoked. Average serum total and high-density lipoprotein cholesterol were 4.7 and 1.3 mmol/L, respectively, and 85% used statins. Mean blood pressure was 142/80 mm Hg, and most subjects were on antihypertensive medication (88%). Diabetes mellitus was reported by 17% of the subjects, and 7% reported a history of stroke. The overall mortality rate during the trial period was 23 per 1,000 person-years, with approximately 40% due to CVD. Current status Follow-up of the patients was completed in November 2009, and findings will be reported in the second part of 2010. (Am Heart J 2010; 159: 539-546. e2.)

Item does not contain fulltext BACKGROUND: Little is known about dietary scores and mortality risk in cardiac patients who are well treated with drugs with attendant relatively low risk of cardiovascular diseases (CVDs). OBJECTIVE: We assessed whether healthy eating lowers the risk of CVD and all-cause mortality in cardiac patients. DESIGN: We included 4307 patients from the Alpha Omega Trial aged 60-80 y with a clinically diagnosed myocardial infarction and monitored mortality for 10 y. Diet was assessed at baseline (2002-2006) with a validated 203-item food-frequency questionnaire. We created 2 dietary scores on the basis of nonoverlapping sets of foods: the Dutch Healthy Nutrient and Food Score (DHNaFS) and the Dutch Undesirable Nutrient and Food Score (DUNaFS). The associations of both dietary scores with CVD and all-cause mortality were assessed by using multivariable-adjusted Cox regression models. RESULTS: The median time after myocardial infarction at baseline was 3.7 y (IQR: 1.7-6.3 y). During a median of 6.5 y of follow-up (IQR: 5.3-7.6 y), 801 patients died; 342 of those died of CVD. One patient was lost to follow-up. A substantially higher average amount of DHNaFS foods ( approximately 1750 g/d) than DUNaFS foods ( approximately 650 g/d) was consumed. Almost all patients received drug treatment: 86% used statins, 90% used antihypertensive medication, and 98% used antithrombotic medication. Patients in the fifth quintile of the DHNaFS had a 30% (HR: 0.70; 95% CI: 0.55, 0.91) lower CVD risk and a 32% (HR: 0.68; 95% CI: 0.47, 0.99) lower all-cause mortality risk than did patients in the first quintile. The DUNaFS was unrelated to both CVD and all-cause mortality. CONCLUSION: Beyond state-of-the-art drug treatment, healthy eating was associated with a lower risk of CVD and all-cause mortality in cardiac patients. This trial was registered at clinicaltrials.gov as NCT00127452.

Prospective cohort studies have shown inverse associations between fibre intake and CVD, possibly mediated by blood pressure (BP). However, little is known about the impact of types of fibre on BP. We examined cross-sectional associations with BP of total, insoluble and soluble fibre intakes. Data were used from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP) study, including 2195 men and women aged between 40 and 59 years from the USA. During four visits, eight BP, four 24 h dietary recalls and two 24 h urine samples were collected. Linear regression models adjusted for lifestyle and dietary confounders to estimate BP differences per 2 sd higher intakes of total and individual types of fibre were calculated. After multivariable adjustment, total fibre intake higher by 6·8 g/4184 kJ (6·8 g/1000 kcal) was associated with a 1·69 mmHg lower systolic blood pressure (SBP; 95% CI -2·97, -0·41) and attenuated to -1·01 mmHg (95% CI -2·35, 0·34) after adjustment for urinary K. Insoluble fibre intake higher by 4·6 g/4184 kJ (4·6 g/1000 kcal) was associated with a 1·81 mmHg lower SBP (95% CI -3·65, 0·04), additionally adjusted for soluble fibre and urinary K excretion, whereas soluble fibre was not associated with BP. Raw fruit was the main source of total and insoluble fibre, followed by whole grains and vegetables. In conclusion, higher intakes of fibre, especially insoluble, may contribute to lower BP, independent of nutrients associated with higher intakes of fibre-rich foods.

Prospective cohort studies have shown inverse associations between fibre intake and CVD, possibly mediated by blood pressure (BP). However, little is known about the impact of types of fibre on BP. We examined cross-sectional associations with BP of total, insoluble and soluble fibre intakes. Data were used from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP) study, including 2195 men and women aged between 40 and 59 years from the USA. During four visits, eight BP, four 24 h dietary recalls and two 24 h urine samples were collected. Linear regression models adjusted for lifestyle and dietary confounders to estimate BP differences per 2 sd higher intakes of total and individual types of fibre were calculated. After multivariable adjustment, total fibre intake higher by 6·8 g/4184 kJ (6·8 g/1000 kcal) was associated with a 1·69 mmHg lower systolic blood pressure (SBP; 95 % CI −2·97, −0·41) and attenuated to −1·01 mmHg (95 % CI −2·35, 0·34) after adjustment for urinary K. Insoluble fibre intake higher by 4·6 g/4184 kJ (4·6 g/1000 kcal) was associated with a 1·81 mmHg lower SBP (95 % CI −3·65, 0·04), additionally adjusted for soluble fibre and urinary K excretion, whereas soluble fibre was not associated with BP. Raw fruit was the main source of total and insoluble fibre, followed by whole grains and vegetables. In conclusion, higher intakes of fibre, especially insoluble, may contribute to lower BP, independent of nutrients associated with higher intakes of fibre-rich foods.

Background: Evidence from prospective cohort studies indicates that consumption of processed meats is associated with higher incidence of CHD. Processed meats are high in saturated fatty acids, cholesterol, and preservatives including sodium that may unfavorably influence blood pressure (BP), but evidence is limited. We therefore investigated associations with BP of unprocessed and processed meat consumption, including types of processed meats. Methods: We used cross-sectional data from the INTERMAP Study on 4,680 men and women aged 40-59 years from Japan, China, UK, and US. During four visits, eight BPs and four 24-hr dietary recalls were collected. Processed meats included preserved meats; fresh processed meats (ready-made, salted, and/or spiced, no curing), bacon, ham (cured and cooked), cold cuts and sausages, and canned meat products. Country-specific linear regression coefficients were estimated and pooled, weighted by inverse of their variance. Adjustments were made for demographic (age, gender, sample), lifestyle (total energy, alcohol, smoking, education, supplement use, adherence to special diet, low-fat dairy, fruit, vegetables, fiber-rich grain products, fish and shellfish), and clinical confounders (history of cardiovascular diseases or diabetes, family history of hypertension, use of anti-hypertensive, cardiovascular, or diabetes medication, BMI). The influence of adjustment for urinary sodium, total cholesterol, and total saturated fatty acids was additionally investigated. Results: Average daily unprocessed/processed meat consumption (g/1000 kcal) was 41/10 in Asian participants and 82/47 in Western participants. In Western participants, processed meats comprised fresh processed meat (36%), cold cuts and sausages (34%), ham (16%), and bacon (7%). Meat consumption was not associated with BP in Asian participants. After adjustment for demographic and lifestyle factors, significant associations with systolic BP were observed per each 50 g/1000 kcal higher intake of unprocessed (+1.19 mm Hg, P=0.02) and processed (+2.00 mm Hg, P=0.01) meat consumption in Western participants. However, these associations attenuated and did not remain significant after adjustment for BMI. We further examined types of processed meat in Western participants. Consumption of cold cuts and sausages higher by 12,5 g/1000 kcal was associated with a systolic BP difference of +0.72 mm Hg (P=0.02). Consumption of ham higher by 12,5 g/1000 kcal was associated with a systolic BP difference of -0.92 mm Hg (P=0.03). These associations prevailed after adjustment for urinary sodium excretion, intakes of saturated fatty acids, and total cholesterol. Conclusion: Unprocessed and processed meat consumption was not associated with BP, however, some types of processed meat may influence BP in opposite directions.

Background: According to recent national health surveys (2010-2013), diabetes mellitus (DM) is more prevalent in East Asian populations (11.6% in China, 11.3% in Japan) compared with Western populations (4.5% in UK and 8.3% in US), even though body weight and body mass index (BMI) are much lower in East Asian populations (mean ≈ 22-23 kg/m2 in China/Japan vs. ≈ 27-28 kg/m2 in UK/US, WHO 2008 report). Consumption of total available carbohydrate (CHO) (%kcal) in Eastern countries is higher than in Western countries. The patterns of CHO intake, dietary glycaemic Index (GI)/glycaemic Load (GL), may be important in accounting for these differences and their metabolic effects. Data on GI/GL of Asian foods are, however, limited. Objectives: To develop systematic methodology for assigning GI values to East Asian foods, and to identify East Asian foods contributing most to total GL, using data from the International Collaborative Study on Macro-/Micronutrients and Blood Pressure (INTERMAP). Methods: The INTERMAP Study is a cross-sectional epidemiologic investigation with standardized quality-controlled methods; it accrued four in-depth 24-hour dietary recalls, 2 timed 24-hour urine collections, 8 BP measurements and questionnaire data. National and International GI databases were used to develop a standardized algorithm for assigning GI values to the INTERMAP data on East Asian foods. “GL contribution of a food”, defined as the GI value of this food multiplied by total amount of available CHO contained in this food as consumed on average by all participants, was used to estimate total influence of each food on blood glucose, including absolute levels and relative percentages. Results: GI values of total of 2,928 East Asian individual food codes (2,030 Japanese food codes and 898 Chinese food codes) were assigned using this newly developed algorithm. Foods assigned with GI>0 using this algorithm contributed 92% (Japan) and 98% (China) of total CHO intake per day. Among Japanese foods, high GI foods were sweet red bean paste (Monaka, GI=91), rice cookie (GI=91), and rice cracker (GI=91). Among Chinese foods, high GI foods were flour and flour products (e.g., Mantou, steamed bread, fried dough sticks, and noodles, GI=88) and glutinous rice (GI=87). Foods contributing most to GL in Japan were white rice (54%), white bread (5%), sugar, syrup and preserves (3%); for Chinese foods: flour and flour products (25%), white rice (21%), and baked products (10%). Conclusion: With the algorithm we developed, it was feasible to assign GI values to East Asian foods. The composition of top GL contributors is different between China and Japan.

Background: Epidemiological evidence is limited and inconclusive on the separate contributions of soluble, insoluble fiber and dietary sugars to blood pressure (BP). This population based study examines relations to systolic and diastolic BP (SBP/DBP) of total dietary fiber and sugar and their individual components. Methods: Cross-sectional data were analysed from the population-based INTERMAP study, including 2,195 participants ages 40 to 59 from the United States. During 4 visits, eight BP readings were recorded and dietary intake was assessed by four in-depth 24-hour dietary recalls. Intakes of fiber and sugars (g/1000 kcal) were averaged over 4 days. In successive models, BP regression coefficients per 2 SD higher intake were estimated using isocaloric, multivariable linear regression with adjustment for multiple possible confounders (non-dietary and dietary), including each of the other individual dietary fiber or sugars. Results: Average intake (SD; g/1000 kcal) of total fiber was 8.8(3.3); soluble fiber 2.8(1.0); insoluble fiber 5.3(2.2). Average intake (SD; %kcal) of total sugar was 26.7(7.9) and of sucrose, the largest component, 10.8 (5.1). Partial Pearson correlation coefficients were low between total fiber and total sugar ( r =0.02), and high between soluble and insoluble fiber ( r =0.80). Correlations between fructose and other individual sugars were high only for glucose ( r =0.93), low ( r Conclusions: Higher intakes of dietary fiber, especially insoluble fiber, may contribute to lower BP, possibly driven by potassium present in high fiber foods. Total sugar intake was not associated with blood pressure; however, intakes of galactose and lactose may favorably influence blood pressure.

Background: Previous population-based cross-sectional studies have reported modest inverse relations of dietary starch intake and blood pressure (BP). However, studies that have evaluated associations of BP with starchy foods, e.g., rice, potatoes, pasta, bread, are limited. Objective: Data from INTERMAP were used to assess relations between consumptions of starchy foods and BP. Methods: INTERMAP is a cross-sectional epidemiologic study of 4,680 persons ages 40 to 59 years from 17 random population samples in China, Japan, United Kingdom (UK), and United States of America (USA). BP was measured 8 times; data on food and supplement use were obtained from 4 standardized in-depth multi-pass 24-hour dietary recalls and 2 timed 24-hour urine collections. Differences in BP for each food intake higher by two standard deviations (SD) were estimated by multivariable linear regression (2 SD values: rice: 177, pasta: 56, potatoes: 65, bread: 40, sum of these four: 177 g/1,000 kcal). Adjustment for possible confounders was performed sequentially; for age, gender, sample; plus dietary and other lifestyle factors. Results: Rice intake higher by 2SD was associated with systolic/diastolic BP differences of -1.38 /-0.79 mm Hg (p Conclusions: Modest inverse associations were observed with BP and intake of rice and the sum of the four most common starchy foods in four countries. Higher consumption of these starchy foods may contribute modestly to lower blood pressure levels in other populations, and thereby potentially confer preventive benefits regarding hypertension and cardiovascular disease.

Background: The color of the edible portion of fruits and vegetables, reflecting the presence of pigmented phytochemicals, may be used as an indicator of their nutrient profile. Previous cohort and intervention studies have documented beneficial associations of fruits and vegetables with blood pressure (BP). However, whether the color of fruits and vegetables is associated with BP is unknown. Methods: We used cross-sectional data from the International Study of Macro-/Micronutrients and Blood Pressure (INTERMAP) on 4,680 men and women ages 40-59 years from Japan, China, United Kingdom, and United States. During four visits, eight BP measurements and four 24-hr dietary recalls were completed. Fruits and vegetables were categorized in 4 color groups: green, orange/yellow, red/purple, and white. BP regression coefficients per 2SD higher intake were estimated using multivariable linear regression models. To estimate overall associations, country-specific regression coefficients were pooled, weighted by inverse of their variance. Adjustments were for age, gender, sample, intake of total energy and alcohol, 24-hr urinary sodium excretion, smoking, education, dietary supplement use, adherence to any special diet, history of cardiovascular diseases or diabetes, family history of hypertension, use of medication (antihypertensive, cardiovascular or for diabetes), body mass index, and intake of low-fat dairy, fibre-rich grain products, red and processed meats, fish and shellfish, and mutually for other fruit and vegetable color groups. Results: Average daily fruit plus vegetable intakes (g/1000 kcal) was 183 in the total population, varying from 129 in the United Kingdom to 222 in China. White fruits and vegetables contributed 32% of total fruit and vegetable intake, orange/yellow 27%, green 26%, and red/purple 15%. Fruit and vegetable color groups were weakly related to each other, partial r values ranged from 0.08 for green with red/purple to 0.15 for white with orange/yellow. Fruit and vegetable color groups were highly correlated with dietary and urinary potassium; highest correlation coefficients were for white fruits and vegetables (r=0.46 for dietary and r=0.26 for urinary potassium). Green fruits and vegetables were also highly related to beta-carotene (r=0.40) and dietary fiber (r=0.40), orange fruits and vegetables to vitamin C (r=0.59), and white fruits and vegetables to dietary fibre (r=0.49). Green fruit and vegetable intake higher by 90 g/1000 kcal was associated with a systolic BP difference of -1.19 mm Hg (P Conclusion: Higher intake of green fruits and vegetables may contribute to lower systolic BP.

Background and Purpose— The color of the edible portion of fruits and vegetables reflects the presence of pigmented bioactive compounds, (eg, carotenoids, anthocyanidins, and flavonoids). Which fruit and vegetable color groups contribute most to the beneficial association of fruit and vegetables with stroke incidence is unknown. Therefore, we examined associations between consumption of fruit and vegetable color groups with 10-year stroke incidence. Methods— This was a prospective, population-based cohort study, including 20 069 men and women age 20 to 65 years and free of cardiovascular diseases at baseline. Participants completed a validated, 178-item food frequency questionnaire. Hazard ratios (HR) were calculated for stroke incidence using multivariate Cox proportional hazards models adjusting for age, sex, lifestyle, and dietary factors. Results— During 10 years of follow-up, 233 incident cases of stroke were documented. Fruits and vegetables were classified into 4 color groups. Medians of green, orange/yellow, red/purple, and white fruit and vegetable consumption were 62, 87, 57, and 118 g/d, respectively. Green, orange/yellow, and red/purple fruits and vegetables were not related to incident stroke. Higher intake of white fruits and vegetables was inversely associated with incident stroke (Q4, >171 g/d, versus Q1, ≤78 g/d; HR, 0.48; 95% CI, 0.29–0.77). Each 25-g/d increase in white fruit and vegetable consumption was associated with a 9% lower risk of stroke (HR, 0.91; 95% CI, 0.85–0.97). Apples and pears were the most commonly consumed white fruit and vegetables (55%). Conclusions— High intake of white fruits and vegetables may protect against stroke.

Individuals with CHD are at increased risk of poor mental well-being. Dietary intake of EPA and DHA, the main n-3 fatty acids from fish, may be beneficial to mental well-being. We examined the association of EPA+DHA and fish intake with mental well-being in 644 participants, aged 60–80 years, with a history of myocardial infarction. Habitual food intake was assessed with a 203-item FFQ. Depressive symptoms were assessed with the self-report geriatric depression scale, and dispositional optimism was assessed with the revised life orientation test (LOT-R) and a four-item questionnaire (4Q). In Cox-regression models modified for cross-sectional analyses, we adjusted for sex, age, energy intake, BMI, family history of depression, education, marital status, smoking, physical activity and intake of saturated fat, alcohol and fibre. Compared with the lower tertile, subjects in the higher tertile of EPA+DHA intake had a lower prevalence of depressive symptoms, but this association was not statistically significant (prevalence ratio (PR) 0·78; 95 % CI 0·50, 1·22, P-trend 0·27). The higher tertile of EPA+DHA intake was positively associated with dispositional optimism measured with the 4Q (PR 0·69; 95 % CI 0·46, 1·03, P-trend 0·05), but not according to the LOT-R. Fish intake was not related to either depressive symptoms or dispositional optimism. In conclusion, intake of EPA+DHA was positively associated with dispositional optimism assessed with the 4Q, but not with optimism assessed with the LOT-R or with depressive symptoms.

Alcohol may have a beneficial effect on coronary heart disease (CHD) that could be mediated by elevation of high-density lipoprotein cholesterol (HDLC). Data on alcohol consumption and blood lipids in coronary patients are scarce. We studied whether total ethanol intake and consumption of specific types of beverages are associated with blood lipids in older subjects with CHD. Blood lipids were measured in 1052 myocardial infarction patients aged 60 to 80 years (78% male). Intake of alcoholic beverages, total ethanol, and macronutrients was assessed by food frequency questionnaire. Seventy percent of the subjects used lipid-lowering medication. Total cholesterol was on average 5.14 mmol/L, and HDLC was on average 1.28 mmol/L. Among men, total ethanol intake was positively associated with HDLC (difference of 0.094 mmol/L foror =15 g/d vs 0 g/d, P = .024), whereas the association with HDLC among women was not significant (difference of 0.060 mmol/L foror =5 g/d vs 0 g/d, P = .560) after adjustment for dietary, lifestyle, and CHD risk factors. Liquor consumption was weakly positively associated with HDLC in men (P = .045). Beer consumption in men and wine consumption in women were also positively associated with HDLC, but were not significant in the fully adjusted model. In conclusion, moderate alcohol consumption may elevate HDLC in treated post-myocardial infarction patients. This may be due to ethanol and not to other beneficial substances in alcoholic beverages. Based on this finding, further research needs to be done to examine the effects of the residual substances from different types of alcoholic beverages on HDLC.