Nordic dietary patterns and cardiometabolic outcomes: a systematic review and meta-analysis of prospective cohort studies and randomised controlled trials,Diabetologia

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Nordic dietary patterns and cardiometabolic outcomes: a systematic review and meta-analysis of prospective cohort studies and randomised controlled trials
Diabetologia ( IF 8.4 ) Pub Date : 2022-08-26 , DOI: 10.1007/s00125-022-05760-z
Paraskevi Massara ₁ , Andreea Zurbau _{1,

2,

3} , Andrea J Glenn _{1,

2,

3,

4} , Laura Chiavaroli _{1,

2,

3} , Tauseef A Khan _{1,

2,

3} , Effie Viguiliouk _{1,

5} , Sonia Blanco Mejia _{1,

2,

3} , Elena M Comelli _{1,

6} , Victoria Chen ₁ , Ursula Schwab _{7,

8} , Ulf Risérus ₉ , Matti Uusitupa ₇ , Anne-Marie Aas ₁₀ , Kjeld Hermansen _{11,

12} , Inga Thorsdottir _{13,

14} , Dario Rahelić _{15,

16,

17} , Hana Kahleová _{18,

19} , Jordi Salas-Salvadó _{20,

21} , Cyril W C Kendall _{1,

2,

3,

22} , John L Sievenpiper _{1,

2,

3,

6,

23,

24,

25}

Affiliation

Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Toronto, ON, Canada.
Clinical Nutrition and Risk Factor Modification Centre, St Michael's Hospital, Toronto, ON, Canada.
Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
Joannah and Brian Lawson Centre for Child Nutrition, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
Department of Medicine, Endocrinology and Clinical Nutrition, Kuopio University Hospital, Kuopio, Finland.
Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden.
Division of Medicine, Department of Clinical Service, Section of Nutrition and Dietetics, Oslo University Hospital, Oslo, Norway.
Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark.
Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
Unit for Nutrition Research, Health Science Institute, University of Iceland, Reykjavík, Iceland.
Landspitali - University Hospital of Iceland, Reykjavík, Iceland.
Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Zagreb, Croatia.
Croatian Catholic University School of Medicine, Zagreb, Croatia.
Josip Juraj Strossmayer University School of Medicine, Osijek, Croatia.
Institute for Clinical and Experimental Medicine, Diabetes Centre, Prague, Czech Republic.
Physicians Committee for Responsible Medicine, Washington, DC, USA.
Centro de Investigacion Biomedica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III, Madrid, Spain.
Human Nutrition Department, IISPV, Universitat Rovira i Virgili, Reus, Spain.
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada.
Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
Division of Endocrinology and Metabolism, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada.
Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

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 (HbA_1c, 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%, p_Q<0.001), and similar or greater reductions in the secondary outcomes of CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). Inverse dose–response gradients were seen for total CVD incidence, CVD mortality and incidence of CHD, stroke and type 2 diabetes (p<0.05). No studies assessed CHD or stroke mortality. In the RCTs, there were small important reductions in LDL-cholesterol (mean difference [MD] −0.26 mmol/l [95% CI −0.52, −0.00], p_MD=0.05; substantial heterogeneity: I²=89%, p_Q<0.01), and ‘small important’ or greater reductions in the secondary outcomes of non-HDL-cholesterol, apolipoprotein B, insulin, body weight, BMI and systolic blood pressure (p<0.05). For the other outcomes there were ‘trivial’ reductions or no effect. The certainty of the evidence was low for total CVD incidence and LDL-cholesterol; moderate to high for CVD mortality, established lipid targets, adiposity markers, glycaemic control, blood pressure and inflammation; and low for all other outcomes, with evidence being downgraded mainly because of imprecision and inconsistency.

Conclusions/interpretation

Adherence to Nordic dietary patterns is associated with generally small important reductions in the risk of major CVD outcomes and diabetes, which are supported by similar reductions in LDL-cholesterol and other intermediate cardiometabolic risk factors. The available evidence provides a generally good indication of the likely benefits of Nordic dietary patterns in people with or at risk for diabetes.

Registration

ClinicalTrials.gov NCT04094194.

Funding

Diabetes and Nutrition Study Group of the EASD Clinical Practice.

Graphical abstract

中文翻译：

北欧饮食模式和心脏代谢结果：前瞻性队列研究和随机对照试验的系统回顾和荟萃分析

目标/假设

富含健康传统北欧食品的北欧饮食模式可能在预防和管理糖尿病方面发挥作用。为了更新 EASD 营养治疗临床实践指南，我们对北欧饮食模式和心脏代谢结果进行了系统回顾和荟萃分析。

方法

我们检索了 MEDLINE、EMBASE 和 Cochrane 图书馆，从开始到 2021 年 3 月 9 日。我们纳入了前瞻性队列研究和随机对照试验，随访时间分别为 ≥1 年和 ≥3 周。两名独立评审员提取相关数据并评估偏倚风险（纽卡斯尔-渥太华量表和 Cochrane 偏倚风险工具）。主要结局是前瞻性队列研究中的心血管疾病总发生率和随机对照试验中的低密度脂蛋白胆固醇。前瞻性队列研究的次要结果是 CVD 死亡率、CHD 发病率和死亡率、中风发病率和死亡率以及 2 型糖尿病发病率；在随机对照试验中，次要结果是其他已确定的脂质目标（非 HDL 胆固醇、载脂蛋白 B、HDL 胆固醇、甘油三酯）、血糖控制标志物（HbA _1c 、空腹血糖、空腹胰岛素）、肥胖（体重、BMI、腰围）、炎症（C 反应蛋白）和血压（收缩压和舒张压）。使用建议、评估、制定和评价分级（GRADE）方法来评估证据的确定性。

结果

我们纳入了 15 项独特的前瞻性队列研究（ n = 1,057,176，涉及 41,708 例心血管事件和 13,121 例糖尿病病例），针对糖尿病患者评估心血管结局，或针对非糖尿病患者评估糖尿病发病率，以及 6 项随机对照试验（ n = 717）患有一种或多种糖尿病危险因素的人。在前瞻性队列研究中，对北欧饮食模式的较高依从性与主要结局、CVD 总发病率的“小幅重要”降低相关（最高与最低依从性的 RR：0.93 [95% CI 0.88, 0.99]， p = 0.01；显着异质性： I ² =88%， p _Q <0.001），CVD 死亡率以及 CHD、中风和 2 型糖尿病发病率的次要结局有相似或更大的降低（ p <0.05）。 CVD 总发病率、CVD 死亡率以及 CHD、中风和 2 型糖尿病的发病率出现反剂量反应梯度 ( p< 0.05)。没有研究评估冠心病或中风死亡率。在随机对照试验中，LDL 胆固醇有小幅重要降低（平均差 [MD] -0.26 mmol/l [95% CI -0.52, -0.00]， p _MD =0.05；显着异质性： I ² =89%， p _Q <0.01)，以及非 HDL 胆固醇、载脂蛋白 B、胰岛素、体重、BMI 和收缩压等次要结果的“小重要”或较大降低 ( p< 0.05)。对于其他结果，有“微不足道”的减少或没有影响。心血管疾病总发生率和低密度脂蛋白胆固醇的证据质量较低； CVD死亡率、既定血脂目标、肥胖标志物、血糖控制、血压和炎症的中度至高度；所有其他结果都较低，证据被降级主要是因为不精确和不一致。