Dietary strategies for weight loss typically place an emphasis on achieving a prescribed energy intake. Depending on the approach taken, this may be achieved by restricting certain nutrients or food groups, which may lower overall diet quality. Various studies have shown that a higher quality diet is associated with better cardiovascular (CV) health outcomes1. This study aimed to evaluate the effect of an energy restricted diet on diet quality, and associated changes in cardiovascular risk factors. One hundred and forty adults (42 M:98 F, 47.5 ± 10.8 years, BMI 30.7 ± 2.3 kg/m2) underwent an energy restricted diet (30% reduction) with dietary counselling for 3 months, followed by 6 months of weight maintenance. Four-day weighed food diaries captured dietary data at baseline, 3 and 9 months and were analysed using a novel algorithm to score diet quality (based on the Dietary Guideline Index, DGI)2. Total DGI scores ranged from 0-120, with sub scores for consumption of core (0-70) and non-core foods (0-50). For all scores, a higher score or increase reflects better diet quality. The CV risk factors assessed included blood pressure (SBP and DBP) and fasting lipids (total (TC), high and low-density lipoprotein cholesterol (HDL-C, LDL-C) and triglycerides (TAG). Mixed model analyses were used to determine changes over time (reported as mean ± standard error), and Spearman rho (rs) evaluated associations between DGI score and CV risk factors. Dietary energy intake was significantly restricted at 3 months (−3222 ± 159 kJ, P<0.001, n = 114) and 9 months (−2410 ± 167 kJ, P<0.001, n = 100) resulting in significant weight loss (3 months −7.0 ± 0.4 kg, P<0.001; 9 months −8.2 ± 0.4 kg, P<0.001). Clinically meaningful weight loss (>5% body mass) was achieved by 81% of participants by 3 months. Diet quality scores were low at baseline (scoring 49.2 ± 1.5), but improved significantly by 3 months (74.7 ± 1.6, P<0.000) primarily due to reductions in the consumption of non-core i.e. discretionary foods (Core sub-score +4.0. ± 0.7, Non-core sub-score +21.3.1 ± 1.6, both P<0.001). These improvements were maintained at 9 months (Total score 71.6 ± 1.7, P<0.000; Core sub-score +4.4 ± 0.7 from baseline, P<0.000; Non-core sub-score +17.9 ± 1.6 from baseline, P<0.000). There were significant inverse relationships between changes in Total DGI score and changes in DBP (rs = −0.268, P = 0.009), TC (rs = −0.298, P = 0.004), LDL-C (rs = −0.224, P = 0.032) and HDL-C (rs = −0.299, P = 0.004) but not SBP and TG at 3 months. These data emphasise the importance of including diet quality as a key component when planning energy restricted diets. Automated approaches will enable researchers to evaluate subtle changes in diet quality and their effect on health outcomes.

The aim of this study was to ascertain the level of occupational stress before and during the COVID-19 pandemic, how it changed and its association with health outcomes of hospital workers in the Recôncavo of Bahia, Brazil. A longitudinal study was conducted with 218 hospital workers over 18 years old. A semi-structured questionnaire was used for collecting sociodemographic, occupational, lifestyle, anthropometric and health data. The main exposures were occupational stress, assessed through Job Content Questionnaire and classified according to the Demand-Control Model and reported shift work. Health outcomes considered were nutritional status assessed by BMI, waist circumference and body fat percentage, health self-perception and cardiovascular risk factors. We used McNemar χ 2 or Wilcoxon tests to compare the levels of exposure and outcome variables before and during the pandemic, and OR to evaluate associations between changes in occupational stress and shift work with health outcomes. During the pandemic, participants reported increased occupational stress and shift work and lower self-perceived health and had higher BMI and cardiovascular risk factors, compared with before the pandemic. No association was observed between change in occupational stress and health outcomes. However, increased amount of shift work was related to increased BMI in the overall sample (OR 3·79, 95 % CI (1·40, 10·30)) and in health workers (OR 11·56; 95 % CI (2·57, 52·00)). These findings support calls to strengthen labour policies to ensure adequate working conditions for hospital workers in context of the COVID-19 pandemic.

To evaluate the impact of adding food education sessions to an exercise programme on cardiovascular risk factors in middle-aged and older patients with type 2 diabetes (T2D), a randomised parallel-group study was performed. Glycated haemoglobin, body mass index (BMI), waist circumference, fat mass (FM) and blood pressure were assessed at baseline and after 9 months. The recruitment was made in three primary healthcare centres from Vila Real, Portugal. Thirty-three patients (65⋅4 ± 5⋅9 years old) were engaged in a 9-month community-based lifestyle intervention programme: a supervised exercise programme (EX; n = 15; combined aerobic, resistance, agility/balance and flexibility exercise; three sessions per week; 75 min per session); or the same exercise programme plus concomitant food education sessions (EXFE; n = 18; 15-min lectures and dual-task strategies during exercise (answer nutrition questions while walking); 16 weeks). Significant differences between groups were identified in the evolution of BMI (P < 0.001, $\eta _{\rm p}^2 = 0{\cdot} 150$) and FM (P < 0.001, $\eta _{\rm p}^2 = 0{\cdot}130$), with best improvements observed in the EXFE group. The addition of a simple food education dietary intervention to an exercise programme improved body weight and composition, but not glycaemic control and blood pressure in middle-aged and older patients with T2D.

Prevalence and trends of different vegetarian diets remain unknown, with estimates varying depending on the source. Evidence suggests that vegetarian diets are associated with a more favourable cardiovascular risk profile. The present study aimed to assess the prevalence and trends of different types of vegetarian diets in a population-based representative sample, sociodemographic characteristics of participants following such diets and the association of these diets with cardiovascular risk factors. Using repeated cross-sectional population-based surveys conducted in Geneva, Switzerland, 10 797 individuals participated in the study between 2005 and 2017. Participants were classified as vegetarians, pescatarians, flexitarians or omnivores using an FFQ. Sociodemographic and cardiovascular risk factors were evaluated through questionnaires, anthropometric measurements and blood tests. Findings show prevalence of vegetarians increased from 0·5 to 1·2 %, pescatarians from 0·3 to 1·1 % and flexitarians remained stable at 15·6 % of the population over the study period. Compared with omnivores, vegetarians were more likely to be young (OR 2·38; 95 % CI 1·01, 5·6), have higher education (OR 1·59; 95 % CI 1·01, 2·49) and lower income (OR 1·83; 95 % CI 1·04, 3·21); pescatarians and flexitarians were more likely to be women (pescatarian: OR 1·81; 95 % CI 1·10, 3·00; vegetarian: OR 1·57; 95 % CI 1·41, 1·75) and flexitarians were also more likely to have a lower income (OR 1·31; 95 % CI 1·13, 1·53). Participants who adhered to any diet excluding/reducing meat intake had lower BMI, total cholesterol and hypertension compared with omnivores. The present study shows an increase in the prevalence of vegetarians over a 13-year period and suggests that the different vegetarian diets assessed are associated with a better cardiovascular risk profile.

We conducted a meta-analysis of randomised controlled trials (RCT) to examine the effects of strawberry interventions on cardiovascular risk factors. We searched multiple databases including PubMed, Web of Science and Scopus to identify eligible studies published before 19 May 2019. The endpoints were blood pressure, total cholesterol (TC), HDL-cholesterol, LDL-cholesterol, TAG, fasting blood glucose, endothelial function and inflammatory factors. Pooled analyses were performed using random- or fixed-effects models according to a heterogeneity test. We also conducted sub-group analyses by baseline endpoint levels. We included eleven RCT in this meta-analysis (six for blood pressure, seven for lipid profile, seven for fasting blood glucose and six for C-reactive protein (CRP)). Overall, the strawberry interventions significantly reduced CRP levels by 0·63 (95 % CI −1·04, −0·22) mg/l but did not affect blood pressure, lipid profile or fasting blood glucose in the main analyses. Our analysis stratified by baseline endpoint levels showed the strawberry interventions significantly reduced TC among people with baseline levels >5 mmol/l (−0·52 (95 % CI −0·88, −0·15) mmol/l) and reduced LDL-cholesterol among people with baseline levels >3 mmol/l (−0·31 (95 % CI −0·60, −0·02) mmol/l). There was little evidence of heterogeneity in the analysis and no evidence of publication bias. In summary, strawberry interventions significantly reduced CRP levels and may improve TC and LDL-cholesterol in individuals with high baseline levels.

BMI, waist circumference (WC) and waist-to-height ratio (WHtR) can be used for discriminating children and adolescents at risk of CVD. However, consensus on how to use these anthropometric indicators is lacking for children and adolescents in Asia. Discrete criteria are promoted internationally, but continuous variables could be used. Data from a survey of 10 949 Vietnamese school-aged children (6–18 years) were used to evaluate the performance of anthropometric indicators to identify elevated blood pressure (BP), dyslipidaemia or at least three cardiovascular risk factors (CVRF). Weight, height, WC and BP were measured using standardised protocols; 1009 participants who had blood lipids were analysed. AUC was used to assess the performance, and the Youden index to identify optimal cut-offs. The prevalence of elevated BP, dyslipidaemia and CVRF was 26·5, 49·3 and 12·2 %, respectively. BMI, WC and WHtR had low capacity to identify elevated BP and dyslipidaemia (AUC range 0·61–0·66) but moderate capacity to identify CVRF (0·72–0·74). Optimal BMIZ cut-offs to identify elevated BP, dyslipidaemia and CVRF were 0·40, 1·01 and 1·1 sd; for WC z-score, they were 0·06, 0·49 and 0·62 sd; for WHtR, optimal cut-offs were close to 0·5. A BMIZ cut-off of 1·0 sd and a WHtR cut-off of 0·5 would, therefore, be useful criteria to identify Vietnamese children who are likely to have CVRF. However, further validation of these criteria in other studies of Asian children and adolescents is needed.

The association between dietary patterns and CVD risk factors among non-Hispanic whites has not been fully studied. Data from 650 non-Hispanic white adults who participated in one of two clinical sub-studies (about 2 years after the baseline) of the Adventist Health Study-2 (AHS-2) were analysed. Four dietary patters were identified using a validated 204-item semi-quantitative FFQ completed at enrolment into AHS-2: vegans (8·3 %), lacto-ovo-vegetarians (44·3 %), pesco-vegetarians (10·6 %) and non-vegetarians (NV) (37·3 %). Dietary pattern-specific prevalence ratios (PR) of CVD risk factors were assessed adjusting for confounders with or without BMI as an additional covariable. The adjusted PR for hypertension, high total cholesterol and high LDL-cholesterol were lower in all three vegetarian groups. Among the lacto-ovo-vegetarians the PR were 0·57 (95 % CI 0·45, 0·73), 0·72 (95 % CI 0·59, 0·88) and 0·72 (95 % CI 0·58, 0·89), respectively, which remained significant after additionally adjusting for BMI. The vegans and the pesco-vegetarians had similar PR for hypertension at 0·46 (95 % CI 0·25, 0·83) and 0·62 (95 % CI 0·42, 0·91), respectively, but estimates were attenuated and marginally significant after adjustment for BMI. Compared with NV, the PR of obesity and abdominal adiposity, as well as other CVD risk factors, were significantly lower among the vegetarian groups. Similar results were found when limiting analyses to participants not being treated for CVD risk factors, with the vegans having the lowest mean BMI and waist circumference. Thus, compared with the diet of NV, vegetarian diets were associated with significantly lower levels of CVD risk factors among the non-Hispanic whites.

Diet is recognised as one modifiable lifestyle factor for ischaemic heart disease (IHD). We aimed at investigating the associations between adherence to the Danish Food-Based Dietary Guidelines (FBDG) indicated by a Dietary Quality Index (DQI) and selected cardiometabolic risk factors in a cross-sectional study with 219 Danish adult participants (59 %women; age 31–65years) with a minimum of one self-rated risk marker of IHD. Information regarding diet was obtained using web-based dietary assessment software and adherence to the Danish FBDG was expressed by a DQI calculated from 5 food and nutrient indicators (whole grain, fish, fruit and vegetables, energy from saturated fat and from added sugar). Background information, blood samples and anthropometrics were collected and blood pressure was measured. Linear regression analyses were used to evaluate the association between DQI and cardiometabolic risk factors. DQI was inversely associated with LDL:HDL ratio and TAG (−0·089 per unit; 95 % CI −0·177, −0·002 and −5 % per unit; 95 % CI −9, 0, respectively) and positively associated with HDL-cholesterol (0·047 mmol/l per unit; 95 % CI 0·007, 0·088). For men, DQI was inversely associated with BMI (−3 %per unit; 95 % CI −5, −1), trunk fat (−1 % per unit; 95 % CI −2, −1), high-sensitivity C-reactive protein (−30 % per unit; 95 % CI −41, −16 %), HbA1c (−0·09 % per unit; 95 % CI −0·14, −0·04), insulin (−13 % per unit; 95 % CI −19, −7) and homoeostatic model assessment-insulin resistance (−14 % per unit; 95 % CI −21, −7). In women, DQI was positively associated with systolic blood pressure (2·6 mmHg per unit; 95 % CI 0·6, 4·6). In conclusion, higher adherence to the current Danish FBDG was associated with a more beneficial cardiometabolic risk profile in a Danish adult population with a minimum of one self-rated risk factor for IHD.

The purpose of this study was to investigate the joint associations of dietary pattern and television viewing with risk factors of CVD among urban adults in China. A community-based cross-sectional study was conducted among urban adults in Nanjing, China. Five dietary patterns were identified based on a FFQ. Television time was obtained from a standard questionnaire and further classified into two categories (≤7, >7 h/week). Multiple logistic regression was used to calculate the OR and 95 % CI for the separate and joint associations of dietary patterns and television viewing with CVD risk factors. Compared with other dietary patterns, participants who followed the healthy traditional pattern had a lower likelihood of abdominal obesity (AO) (OR 0·52; 95 % CI 0·41, 0·67). Participants watching television no more than 7 h/week presented a 19 and 21 % lower likelihood for hypertension (HT) and elevated total cholesterol (ETC) than those with television time >7 h/week. Individuals who had less television time and a healthy dietary pattern had a lower OR for the presence of AO (OR 0·48; 95 % CI 0·36, 0·65), HT (OR 0·71; 95 % CI 0·66, 0·77), ETC (OR 0·72; 95 % CI 0·57, 0·91) and elevated TAG (OR 0·76; 95 % CI 0·61, 0·95), compared with those who followed other dietary patterns and television time >7 h/week. In conclusion, both healthy traditional pattern and less television time are jointly associated with reduced levels of CVD risk factors. It has important public health implications regarding the precision prevention of CVD at population level.

Recent evidence suggests that vitamin D deficiency is associated with CVD, impaired kidney function and proteinuria. To date, no study has evaluated these associations in renal transplant recipients (RTR) adjusting for body adiposity assessed by a ‘gold standard’ method. This study aimed to evaluate the vitamin D status and its association with body adiposity, CVD risk factors, estimated glomerular filtration rate (eGFR) and proteinuria in RTR, living in Rio de Janeiro, Brazil (a low-latitude city (22°54'10"S)), taking into account body adiposity evaluated by dual-energy X-ray absorptiometry (DXA). This cross-sectional study included 195 RTR (114 men) aged 47·6 (sd 11·2) years. Nutritional evaluation included anthropometry and DXA. Risk factors for CVD were hypertension, diabetes mellitus, dyslipidaemia and the metabolic syndrome. eGFR was evaluated using the Chronic Kidney Disease Epidemiology Collaboration equation. Serum 25-hydroxyvitamin D (25(OH)D) concentration was used to define vitamin D status as follows: 10 % (n 19) had vitamin D deficiency (<16 ng/ml), 43 % (n 85) had insufficiency (16–30 ng/ml) and 47 % (n 91) had sufficiency (>30 ng/ml). Percentage of body fat (DXA) was significantly associated with vitamin D deficiency independently of age, sex and eGFR. Lower 25(OH)D was associated with higher odds of the metabolic syndrome and dyslipidaemia after adjustment for age, sex and eGFR, but not after additional adjustment for body fat. Hypertension and diabetes were not related to 25(OH)D. Lower serum 25(OH)D was associated with increasing proteinuria and decreasing eGFR even after adjustments for age, sex and percentage of body fat. This study suggests that in RTR of a low-latitude city hypovitaminosis D is common, and is associated with excessive body fat, decreased eGFR and increased proteinuria.

The healthy Nordic diet has been previously shown to have health beneficial effects among subjects at risk of CVD. However, the extent of food changes needed to achieve these effects is less explored. The aim of the present study was to investigate the effects of exchanging a few commercially available, regularly consumed key food items (e.g. spread on bread, fat for cooking, cheese, bread and cereals) with improved fat quality on total cholesterol, LDL-cholesterol and inflammatory markers in a double-blind randomised, controlled trial. In total, 115 moderately hypercholesterolaemic, non-statin-treated adults (25–70 years) were randomly assigned to an experimental diet group (Ex-diet group) or control diet group (C-diet group) for 8 weeks with commercially available food items with different fatty acid composition (replacing SFA with mostly n-6 PUFA). In the Ex-diet group, serum total cholesterol (P<0·001) and LDL-cholesterol (P<0·001) were reduced after 8 weeks, compared with the C-diet group. The difference in change between the two groups at the end of the study was −9 and −11 % in total cholesterol and LDL-cholesterol, respectively. No difference in change in plasma levels of inflammatory markers (high-sensitive C-reactive protein, IL-6, soluble TNF receptor 1 and interferon-γ) was observed between the groups. In conclusion, exchanging a few regularly consumed food items with improved fat quality reduces total cholesterol, with no negative effect on levels of inflammatory markers. This shows that an exchange of a few commercially available food items was easy and manageable and led to clinically relevant cholesterol reduction, potentially affecting future CVD risk.

The effects of low-carbohydrate (LC) diets on body weight and cardiovascular risk are unclear, and previous studies have found varying results. Our aim was to conduct a meta-analysis of randomised controlled trials (RCT), assessing the effects of LC diets v. low-fat (LF) diets on weight loss and risk factors of CVD. Studies were identified by searching MEDLINE, Embase and Cochrane Trials. Studies had to fulfil the following criteria: a RCT; the LC diet was defined in accordance with the Atkins diet, or carbohydrate intake of <20 % of total energy intake; twenty subjects or more per group; the subjects were previously healthy; and the dietary intervention had a duration of 6 months or longer. Results from individual studies were pooled as weighted mean difference (WMD) using a random effect model. In all, eleven RCT with 1369 participants met all the set eligibility criteria. Compared with participants on LF diets, participants on LC diets experienced a greater reduction in body weight (WMD –2·17 kg; 95 % CI –3·36, –0·99) and TAG (WMD –0·26 mmol/l; 95 % CI –0·37, –0·15), but a greater increase in HDL-cholesterol (WMD 0·14 mmol/l; 95 % CI 0·09, 0·19) and LDL-cholesterol (WMD 0·16 mmol/l; 95 % CI 0·003, 0·33). This meta-analysis demonstrates opposite change in two important cardiovascular risk factors on LC diets – greater weight loss and increased LDL-cholesterol. Our findings suggest that the beneficial changes of LC diets must be weighed against the possible detrimental effects of increased LDL-cholesterol.