The acute effect of commercially available pulse powders on postprandial glycaemic response in healthy young men. Pulse consumption, satiety, and weight management. First and second meal effects of pulses on blood glucose, appetite, and food intake at a later meal. Legume consumption is inversely associated with type 2 diabetes incidence in adults: A prospective assessment from the PREDIMED study. Dietetic guidelines: diet in secondary prevention of cardiovascular disease. Canadian Cardiovascular Society position statement--recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. Effect of legumes as part of a low glycemic index diet on glycemic control and cardiovascular risk factors in type 2 diabetes mellitus: a randomized controlled trial. A pulse-based diet is effective for reducing total and LDL-cholesterol in older adults. The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review Effectiveness of brief structured interventions on risk factor modification for patients with coronary heart disease: a systematic review Dietary phytochemical intake from foods and health outcomes: a systematic review protocol and preliminary scoping Chocolate and Prevention of Cardiovascular Disease: A Systematic Review Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy. Randomised controlled pilot study to assess the feasibility of a Mediterranean Portfolio dietary intervention for cardiovascular risk reduction in HIV dyslipidaemia: a study protocol The 2015 Dutch food-based dietary guidelines Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline Elusive search for effective provider interventions: a systematic review of provider interventions to increase adherence to evidence-based treatment for depression Should both HDL-C and LDL-C be targets for lipid therapy? A review of current evidence. Alpha-Linolenic Acid: Is It Essential to Cardiovascular Health? Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol Short-term effects of nitrate-rich green leafy vegetables on blood pressure and arterial stiffness in individuals with high-normal blood pressure.
Whole pulses ( beans , peas , chickpeas and lentils ) elicit low postpr and ial blood glucose ( BG ) responses in adults ; however , their consumption in North America is low . One potential strategy to increase the dietary intake of pulses is the utilisation of commercial pulse powders in food products ; however , it is unclear whether they retain the biological benefits observed with whole pulses . Therefore , the present study examined the effects of commercially prepared pulse powders on BG response before and after a subsequent meal in healthy young men . Overall , three r and omised , within-subject experiments were conducted . In each experiment , participants received whole , puréed and powdered pulses ( navy beans in Expt 1 ; lentils in Expt 2 ; chickpeas in Expt 3 ) and whole-wheat flour as the control . All treatments were controlled for available carbohydrate content . A fixed-energy pizza meal ( 50·2 kJ/kg body weight ) was provided at 120 min . BG concentration was measured before ( 0 - 120 min ) and after ( 140 - 200 min ) the pizza meal . BG concentration peaked at 30 min in all experiments , and pulse forms did not predict their effect on BG response . Compared with the whole-wheat flour control , navy bean treatments lowered peak BG concentrations ( Expt 1 , P < 0.05 ) , but not the mean BG concentration over 120 min . The mean BG concentration was lower for all lentil ( Expt 2 , P= 0.008 ) and chickpea ( Expt 3 , P= 0.002 ) treatments over 120 min . Processing pulses to powdered form does not eliminate the benefits of whole pulses on BG response , lending support to the use of pulse powders as value-added food ingredients to moderate postpr and ial glycaemic response The prevalence of obesity has reached epidemic proportions , making finding effective solutions to reduce obesity a public health priority . One part of the solution could be for individuals to increase consumption of nonoilseed pulses ( dry beans , peas , chickpeas , and lentils ) , because they have nutritional attributes thought to benefit weight control , including slowly digestible carbohydrates , high fiber and protein contents , and moderate energy density . Observational studies consistently show an inverse relationship between pulse consumption and BMI or risk for obesity , but many do not control for potentially confounding dietary and other lifestyle factors . Short-term ( ≤1 d ) experimental studies using meals controlled for energy , but not those controlled for available carbohydrate , show that pulse consumption increases satiety over 2 - 4 h , suggesting that at least part of the effect of pulses on satiety is mediated by available carbohydrate amount or composition . R and omized controlled trials generally support a beneficial effect  of pulses on weight loss when pulse consumption is coupled with energy restriction , but not without energy restriction . However , few r and omized trials have been conducted and most were short term ( 3 - 8 wk for whole pulses and 4 - 12 wk for pulse extracts ) . Overall , there is some indication of a beneficial effect of pulses on short-term satiety and weight loss during intentional energy restriction , but more studies are needed in this area , particularly those that are longer term ( ≥1 y ) , investigate the optimal amount of pulses to consume for weight control , and include behavioral elements to help overcome barriers to pulse consumption Pulses are low-glycemic appetite-suppressing foods , but it is not known whether these properties persist after being consumed as part of a meal and after a second meal . The objective of this study was to determine the effects of a fixed-size pulse meal on appetite and blood glucose ( BG ) before and after an ad libitum test meal ( pizza ) and on food intake ( FI ) at the test meal . Males ( n = 25 ; 21.3 ± 0.5 years ; 21.6 ± 0.3 kg·m(-2 ) ) r and omly consumed 4 isocaloric meals : chickpea ; lentil ; yellow split pea ; and macaroni and cheese ( control ) . Commercially available canned pulses provided 250 kcal , and were consumed with macaroni and tomato sauce . FI was measured at a pizza meal 260 min after consumption of the isocaloric meal . BG and appetite were measured from 0 to 340 min . The lentil and yellow pea , but not chickpea , treatments led to lower appetite ratings during the 260 min prepizza meal period , and less FI at the pizza meal , compared with macaroni and cheese ( p < 0.05 ) . All pulse treatments lowered BG immediately following consumption ( at 20 min ) ( p < 0.05 ) , but there was no effect of treatment on prepizza meal BG AUC ( p = 0.07 ) . Immediately after the pizza meal , BG was lower following the chickpea and lentil treatments , but not the yellow pea treatment ( p < 0.05 ) . Postpizza meal BG AUC was lower following the chickpea and lentil treatments than in the yellow pea treatment ( p < 0.05 ) . The beneficial effects of consuming a pulse meal on appetite , FI at a later meal , and the BG response to a later meal are dependent on pulse type BACKGROUND & AIMS Legumes , a low-energy , nutrient-dense and low glycemic index food , have shown beneficial effects on glycemic control and adiposity . As such , legumes are widely recommended in diabetic diets , even though there is little evidence that their consumption protects against type 2 diabetes . Therefore the aim of the present study was to examine the associations between consumption of total legumes and specific subtypes , and type 2 diabetes risk . We also investigated the effect of theoretically substituting legumes for other protein- or carbohydrate-rich foods . METHODS Prospect i ve assessment of 3349 participants in the PREvención con DIeta MEDiterránea ( PREDIMED ) study without type 2 diabetes at baseline .  Dietary information was assessed at baseline and yearly during follow-up . We used Cox regression models to estimate hazard ratios ( HRs ) and 95 % confidence intervals ( 95 % CIs ) for type-2 diabetes incidence according to quartiles of cumulative average consumption of total legumes , lentils , chickpeas , dry beans and fresh peas . RESULTS During a median follow-up of 4.3 years , 266 new cases of type 2 diabetes occurred . Individuals in the highest quartile of total legume and lentil consumption had a lower risk of diabetes than those in the lowest quartile ( HR : 0.65 ; 95 % CI : 0.43 , 0.96 ; P-trend = 0.04 ; and HR : 0.67 ; 95 % CI : 0.46 - 0.98 ; P-trend = 0.05 , respectively ) . A borderline significant association was also observed for chickpeas consumption ( HR 0.68 ; 95 % CI : 0.46 , 1.00 ; P-trend = 0.06 ) . Substitutions of half a serving/day of legumes for similar servings of eggs , bread , rice or baked potato was associated with lower risk of diabetes incidence . CONCLUSIONS A frequent consumption of legumes , particularly lentils , in the context of a Mediterranean diet , may provide benefits on type 2 diabetes prevention in older adults at high cardiovascular risk . TRIAL REGISTRATION The trial is registered at http://www.controlled-trials.com ( IS RCT N35739639 ) . Registration date : 5th October 2005 AIM To produce dietetic guidelines summarizing the systematic review evidence on dietary advice for secondary prevention of cardiovascular disease . METHODS The Cochrane Library , MEDLINE and EMBASE were comprehensively search ed for systematic review s on aspects of diet and heart health . Review s were included if they search ed systematic ally for r and omised controlled trials relating to diet and secondary prevention of cardiovascular disease . Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review . The quality and results of each review were discussed and summarized in a whole group meeting . The guidelines were trialled in seven dietetic departments and modified where necessary . RESULTS Providing evidence -based dietary information ( including increasing omega-3 fat plus fruit and vegetable intake ) to all people after myocardial infa rct ion will save more lives than concentrating dietary advice on those in need of weight loss or lipid lowering . The practice of prioritizing dietetic time to those with raised lipids is out of date since the advent of statin therapy . CONCLUSION There is good systematic review evidence that dietary advice to those with cardiovascular disease can reduce mortality and morbidity as well as modify risk factors .  Dietary advice that does this most effectively should be prioritized Since the last publication of the recommendations for the management and treatment of dyslipidemia , new clinical trial data have emerged that support a more vigorous approach to lipid lowering in specific patient groups . The decision was made to up date the lipid guidelines in collaboration with the Canadian Cardiovascular Society . A systematic electronic search of medical literature for original research consisting of blinded , r and omized controlled trials was performed . Meta-analyses of studies of the efficacy and safety of lipid-lowering therapies , and of the predictive value of established and emerging risk factors were also review ed . All recommendations are evidence -based , and have been review ed in detail by primary and secondary review panels . Major changes include a lower low-density lipoprotein cholesterol ( LDL-C ) treatment target ( lower than 2.0 mmol/L ) for high-risk patients , a slightly higher intervention point for the initiation of drug therapy in most low-risk individuals ( LDL-C of 5.0 mmol/L or a total cholesterol to high-density lipoprotein cholesterol ratio of 6.0 ) and recommendations regarding additional investigations of potential use in the further evaluation of coronary artery disease risk in subjects in the moderate-risk category BACKGROUND Legumes , including beans , chickpeas , and lentils , are among the lowest glycemic index ( GI ) foods and have been recommended in national diabetes mellitus ( DM ) guidelines . Yet , to our knowledge , they have never been used specifically to lower the GI of the diet . We have therefore undertaken a study of low-GI foods in type 2 DM with a focus on legumes in the intervention . METHODS A total of 121 participants with type 2 DM were r and omized to either a low-GI legume diet that encouraged participants to increase legume intake by at least 1 cup per day , or to increase insoluble fiber by consumption of whole wheat products , for 3 months . The primary outcome was change in hemoglobin A1c ( HbA1c ) values with calculated coronary heart disease ( CHD ) risk score as a secondary outcome . RESULTS The low-GI legume diet reduced HbA1c values by -0.5 % ( 95 % CI , -0.6 % to -0.4 % ) and the high wheat fiber diet reduced HbA1c values by -0.3 % ( 95 % CI , -0.4 % to -0.2 % ) . The relative reduction in HbA1c values after the low-GI legume diet was greater than after the high wheat fiber diet by -0.2 % ( 95 % CI , -0.3 % to -0.1 % ; P < .001 ) . The respective CHD risk reduction on the low-GI legume diet was -0.8 % ( 95 % CI , -1.4 % to -0.3 % ; P = .003 ) , largely owing to a greater relative reduction in systolic blood pressure on the low-GI legume diet compared with the high wheat fiber diet ( -4.5 mm Hg ; 95 % CI , -7.0 to -2.1 mm Hg ; P < .001 ) . CONCLUSION Incorporation of legumes as part of a low-GI diet improved both glycemic control and reduced calculated CHD risk score in type 2 DM Our purpose was to determine the effects of a pulse-based diet in individuals 50 years or older for reducing CVD risk factors . A total of 108 participants were  r and omised to receive pulse-based foods ( two servings daily of beans , chickpeas , peas or lentils ; about 150 g/d dry weight ) or their regular diet for 2 months , followed by a washout of 1 month and a cross-over to the other diet for 2 months . Anthropometric measures , body composition and biochemical markers ( i.e. serum LDL-cholesterol ( LDL-C ) , as the primary outcome , and other lipids , glucose , insulin and C-reactive protein ) were assessed before and after each diet phase . A total of eighty-seven participants ( thirty males and fifty-seven females ; 59·7 ( sd 6·3 ) years , body mass 76 ( sd 16 ) kg ) completed the study . Compared with the regular diet , the pulse-based diet  decreased total cholesterol by 8·3 % ( pulse , 4·57 ( sd 0·93 ) to 4·11 ( sd 0·91 ) mmol/l ; regular , 4·47 ( sd 0·94 ) to 4·39 ( sd 0·97 ) mmol/l ; P < 0·001 ) and LDL-C by 7·9 % ( pulse , 2·93 ( sd 0·84 ) to 2·55 ( sd 0·75 ) mmol/l ; regular , 2·96 ( sd 0·86 ) to 2·81 ( sd 0·83 ) mmol/l ; P = 0·01 ) . In a sub- analysis of individuals with high lipid levels at baseline ( twenty individuals with high cholesterol ) , the pulse-based diet  reduced cholesterol by 6 % compared with the regular diet ( pulse , 5·62 ( sd 0·78 ) to 5·26 ( sd 0·68 ) mmol/l ; regular , 5·60 ( sd 0·91 ) to 5·57 ( sd 0·85 ) mmol/l ; P = 0·05 ) . A pulse-based diet is effective for reducing total cholesterol and LDL-C in older adults and therefore reduces the risk of CVD Executive summary Background Older adults with dementia may have feeding difficulties for several reasons : they may experience deterioration in motor and cognitive skills making eating difficult , they may forget to eat , fail to recognise food or they may suffer from dysphagia . Food intake is often poor and malnutrition is common , leading to adverse health outcomes . This review specifically focussed on how best to promote and achieve ‘ normal ’ eating and feeding in older adults with dementia , in order that undernutrition and its consequences could be avoided . Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia . Types of Participants Adults over the age of sixty with dementia in any care setting ( who were not living independently ) . People receiving enteral tube feeding were excluded . Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers , family or volunteers , educational interventions , changes in food service . Types of Outcomes The primary outcomes were improvement in dietary intake and /or nutritional status . Measurements included : dietary intake , anthropometry , clinical outcomes , functional indicators . Types of Studies R and omised controlled trials , controlled trials and quasi‐experimental studies with a ‘ before and after ’ design . Search Strategy The search strategy aim ed to find both published and unpublished studies using a three‐step approach . Papers were limited to the English language and a date restriction of 1999 to 2009 was set . Critical appraisal Papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review . Disagreements that arose between the review ers were resolved through discussion . Data Extraction For quantitative studies , data was extracted using a data extraction form developed to include specific details about the interventions , population s , study methods and outcomes of significance to the review question and specific objectives . This was based on the JBI data extraction tool from MAStARI and 2 review ers extracted data independently . Data synthesis Heterogeneity in study design s , interventions and outcomes meant meta‐ analysis was not possible . Findings were discussed in a narrative summary . Results The review included 11 studies . This included one RCT , 1 r and omised crossover study , 3 controlled non‐r and omised trials , 6 quasi‐experimental studies . None of the studies provided robust evidence , however there was moderate evidence ( Level 3 ) to support a Grade B recommendation for improvements in dietary intake and /or nutritional status with the following interventions : education of healthcare staff , simple environmental manipulations such as the use of high contrast tableware or small dining rooms , the introduction of something of interest such as an aquarium or background music , or the provision of feeding assistance , provision of enhanced menus , use of a de central ised food service , enhanced nutritional screening combined with increased dietetic time .  Conclusion There is moderate ( Level 3 ) evidence to support each of the interventions appraised in this review . Implication s for Practice There is moderate support that warrants consideration of the interventions listed above . Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care . Implication s for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following : inclusion of reliable outcome measures , full details of interventions , r and omisation of participants , inclusion of control groups , adequate sample sizes , longitudinal follow up , consideration of baseline demographics of intervention groups , and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care Background The physical and psychosocial benefits of participation in cardiac rehabilitation following a coronary event have well been established . Despite these benefits there is strong evidence that participation in traditional cardiac rehabilitation programs remains low . Various models of cardiac rehabilitation have been implemented including the use of brief structured interventions to enable modification of coronary risk factors . Objectives The objective of this review was to determine the effect of brief structured interventions on risk factor modification in patients with coronary heart disease . Search strategy A literature search was performed using the following data bases MEDLINE ( 1966‐2006 ) , CINAHL ( 1982‐2006 ) , EMBASE ( 1980‐current ) and up to the Cochrane Controlled Trials Register ( Issue 2 , 2006 of Cochrane Library ) . In addition , the reference lists of relevant trials and conference proceedings were also scrutinised . Company representatives , experts and investigators were contacted to elicit further information . Selection criteria All r and omised and quasi‐r and omised controlled trials that compared the effects of brief structured interventions on risk factor modification in patients with coronary heart disease were considered for inclusion in the review . Data collection and analysis Eligibility of the trials for inclusion in the review , details of eligible trials and the method ological quality of the trials were assessed independently by two review ers . Relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95 % confidence intervals . Where synthesis was inappropriate , trials were considered separately . Main results Seventeen trials involving a total of 4725 participants were included in the final review : three trials compared the effects of brief structured interventions  on diet modification ; seven on smoking cessation ; and seven on multiple risk factors . Two trials involving 76 patients compared brief structured intervention versus usual care for dietary modification . Although there was a tendency for more participants in the intervention arm to lose weight at the 12‐week follow up and achieve target cholesterol levels at the 6‐month follow up , these results were not statistically significant . Only one small trial involving 36 patients compared brief structured intervention and extensive intervention for dietary  modification and demonstrated a significant reduction in the percentage of energy obtained from fat and saturated fat intake among participants receiving extensive intervention . However , no difference in fish , fruit and vegetable intake between the groups was evident . Six trials involving 2020 patients compared brief structured intervention versus usual care for smoking cessation . There was no difference in the smoking cessation rates at the 3‐ and 6‐week follow up , however , there was evidence of a benefit of brief structured interventions  for smoking cessation at the 3‐ , 6‐ and 12‐month follow up . In the only trial that and compared brief structured intervention and extensive intervention for smoking cessation in 254 participants there was no clear difference of a likelihood of smoking cessation between the two groups . In the seven trials that compared brief structured intervention and usual care for multiple risk factor modification there was evidence of a benefit of the intervention on behavioural changes such as fat intake , weight loss and consequently on reduction in the body mass index , smoking cessation and physical activity among the participants . The findings concerning the effect on blood pressure , blood glucose levels and the lipid profile , however , remain inconclusive . Conclusions There is suggestive but inconclusive evidence from the trials of a benefit in the use of brief interventions for risk factor modification in patients with coronary heart disease . This review , however , supports the concept that brief interventions for patients with coronary heart disease can have beneficial effects on risk factor modification and consequently on progression of coronary heart disease . Further trials using larger sample sizes need to be undertaken to demonstrate the benefits of brief structured intervention targeted at the modification of single or multiple risk factors Introduction Dietary phytochemicals are found in plant-based foods such as fruits , vegetables and grains and may be categorised in a nested hierarchical manner with many hundred individual phytochemicals identified to date . To associate phytochemical intakes with positive health outcomes , a fundamental step is to accurately estimate the dietary phytochemical intake from foods reported . The purpose of this systematic review protocol is to describe the process to be undertaken to summarise the evidence for food-based dietary phytochemical intakes and health outcomes for adults . Methods and analysis The review will be undertaken following the PRISMA guidelines and the Cochrane H and book for Systematic Review s of Interventions using the Review Manager software . Phytochemical subclasses ( phenolic acids , flavanols , etc ) will be used to search for relevant studies using the Web of Science and Scopus scientific data bases . The retrieved studies will be screened based on inclusion of natural whole food items and health outcomes . Phytochemical studies related to cardiovascular disease , cancer , overweight , glucose tolerance , digestive , reproductive , macular and bone health and mental disorders , fatigue and immunity will be examined based on prior scoping . The evidence will be aggregated by the food types and health outcomes . Comparison of differences in the outcomes for r and omised controlled trials and observational studies will be undertaken . The strength of the review lies in its focus on whole food items and health conditions rather than one type of phytochemical related to one single health condition . Subgroup and sensitivity analyses will be conducted where an adequate number of publications are found per phytochemical subclass . Dissemination By comparing the outcomes from experimental and observational studies , the review will determine whether the overall conclusions related to the phytochemical subclasses are the same between study types for the identified health conditions . This is useful to public health policymakers and health professionals alike . Trial registration number # CRD42014015610 Background Consumption of chocolate has been often hypothesized to reduce the risk of cardiovascular disease ( CVD ) due to chocolate 's high levels of stearic acid and antioxidant flavonoids . However , debate still lingers regarding the true long term beneficial cardiovascular effects of chocolate overall . Methods We review ed English- language MEDLINE publications from 1966 through January 2005 for experimental , observational , and clinical studies of relations between cocoa , cacao , chocolate , stearic acid , flavonoids ( including flavonols , flavanols , catechins , epicatechins , and procynadins ) and the risk of cardiovascular disease ( coronary heart disease ( CHD ) , stroke ) . A total of 136 publications were selected based on relevance , and quality of design and methods . An up date d meta- analysis of flavonoid intake and CHD mortality was also conducted . Results The body of short-term r and omized feeding trials suggests cocoa and chocolate may exert beneficial effects on cardiovascular risk via effects on lowering blood pressure , anti-inflammation , anti-platelet function , higher HDL , decreased LDL oxidation . Additionally , a large body of trials of stearic acid suggests it is indeed cholesterol-neutral . However , epidemiologic studies of serum and dietary stearic acid are inconclusive due to many method ologic limitations . Meanwhile , the large body of prospect i ve studies of flavonoids suggests the flavonoid content of chocolate may reduce risk of cardiovascular mortality . Our up date d meta- analysis indicates that intake of flavonoids may lower risk of CHD mortality , RR = 0.81 ( 95 % CI : 0.71–0.92 ) comparing highest and lowest tertiles . Conclusion Multiple lines of evidence from laboratory experiments and r and omized trials suggest stearic acid may be neutral , while flavonoids are likely protective against CHD mortality . The highest priority now is to conduct larger r and omized trials to definitively investigate the impact of chocolate consumption on long-term cardiovascular outcomes Background Cardiovascular disease is the leading cause of death for adults in Australia . In recent years there has been a shift in health service delivery from institutional to community‐based care for chronic conditions , including cardiovascular disease . The general practice setting is seen to offer greater flexibility , higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector . It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management . To date , significant descriptive research has been conducted exploring the demographics , roles , educational needs and issues facing practice nurses . However , there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes , clinician satisfaction and cost‐effectiveness . Objectives This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults , as well as those with established cardiovascular disease or known cardiac risk factors . Search Strategy A systematic literature search was performed using Medline ( 1966 ‐ 2005 ) , CINAHL ( 1982 −2005 ) , Cochrane Controlled Trials Register ( Issue 4 , 2005 ) and the Joanna Briggs Institute Evidence Library . In addition , the reference lists of retrieved papers , conference proceedings and the Internet , were scrutinised for additional trials . Selection Criteria This review considered any English language r and omised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors . Interventions conducted by specialist cardiac nurses in general practice were excluded . Outcomes measured included blood pressure , smoking cessation , total cholesterol , exercise , body weight/body mass index and cost‐effectiveness . Results Eighteen trials , reported in 33 papers , were included in the review . Ten trials investigated multifaceted interventions , while the remaining eight trials reported targeted interventions . Of the trials that reported multifaceted interventions , three trials investigated risk reduction in those with established cardiovascular disease , four trials focused on those with known cardiovascular disease risk factors and three trials included the general community . The eight trials which examined the efficacy of targeted interventions focused upon dietary intake ( two trials ) , smoking cessation ( three trials ) , weight reduction ( one trial ) and physical activity ( two trials ) . The effect of both the multifaceted and targeted interventions on patient outcomes was variable . However , both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables . Improvements were demonstrated by most studies in blood pressure , cholesterol level , dietary intake and physical activity . The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions . Conclusions While interventions to reduce cardiovascular disease risk factors have produced variable results , they offer significant potential to assist patients in modifying their personal risk profile and should be developed . The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals . Further well‐ design ed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost‐effectiveness OBJECTIVE To provide up date d , evidence -based recommendations for the prevention and management of hypertension in adults . OPTIONS AND OUTCOMES For lifestyle and pharmacological interventions , evidence was review ed from r and omized controlled trials and systematic review s of trials . Changes in cardiovascular morbidity and mortality were the primary outcomes of interest . However , for lifestyle interventions , blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field . For treatment of patients with kidney disease , the progression of kidney dysfunction was also accepted as a clinical ly relevant primary outcome . EVIDENCE A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to up date the 2006 Canadian Hypertension Education Program recommendations . In addition , reference lists were scanned and experts were contacted to identify additional published studies . All relevant articles were review ed and appraised independently by both content and method ological experts using prespecified levels of evidence . RECOMMENDATIONS Dietary lifestyle modifications for prevention of hypertension , in addition to a well-balanced diet , include a dietary sodium intake of less than 100 mmol/day . In hypertensive patients , the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day . Other lifestyle modifications for both normotensive and hypertensive patients include : performing 30 min to 60 min of aerobic exercise four to seven days per week ; maintaining a healthy body weight ( body mass index of 18.5 kg/m2 to 24.9 kg/m2 ) and waist circumference ( less than 102 cm in men and less than 88 cm in women ) ; limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women ; following a diet reduced in saturated fat and cholesterol , and one that emphasizes fruits , vegetables and low-fat dairy products , dietary and soluble fibre , whole grains and protein from plant sources ; and considering stress management in selected individuals with hypertension . For the pharmacological management of hypertension , treatment thresholds and targets should take into account each individual 's global atherosclerotic risk , target organ damage and any comorbid conditions : blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease . Most patients require more than one agent to achieve these blood pressure targets . In adults without compelling indications for other agents , initial therapy should include thiazide diuretics ; other agents appropriate for first-line therapy for diastolic and /or systolic hypertension include angiotensin-converting enzyme ( ACE ) inhibitors ( except in black patients ) , long-acting calcium channel blockers ( CCBs ) , angiotensin receptor blockers ( ARBs ) or beta-blockers ( in those younger than 60 years of age ) . First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs . Certain comorbid conditions provide compelling indications for first-line use of other agents : in patients with angina , recent myocardial infa rct ion , or heart failure , beta-blockers and ACE inhibitors are recommended as first-line therapy ; in patients with cerebrovascular disease , an ACE inhibitor plus diuretic combination is preferred ; in patients with nondiabetic chronic kidney disease , ACE inhibitors are recommended ; and in patients with diabetes mellitus , ACE inhibitors or ARBs ( or , in patients without albuminuria , thiazides or dihydropyridine CCBs ) are appropriate first-line therapies . All hypertensive patients with dyslipidemia should be treated using the thresholds , targets and agents outlined in the Canadian Cardiovascular Society position statement ( recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease ) . Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy . Once blood pressure is controlled , acetylsalicylic acid therapy should be considered . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence -Based Recommendations Task Force . All recommendations reported here achieved at least 95 % consensus . These guidelines will continue to be up date d annually Introduction HIV drug treatment has greatly improved life expectancy , but increased risk of cardiovascular disease remains , potentially due to the additional burdens of infection , inflammation and antiretroviral treatment . The Mediterranean Diet has been shown to reduce cardiovascular risk and mortality in the general population , but no evidence exists for this effect in the HIV population . This study will explore the feasibility of a r and omised controlled trial ( RCT ) to examine whether a Mediterranean-style diet that incorporates a portfolio of cholesterol-lowering foods , reduces cardiovascular risk in people with HIV dyslipidaemia . Methods and analysis 60 adults with stable HIV infection on antiretroviral treatment and low-density lipoprotein cholesterol > 3 mmol/L will be recruited from 3 West Midl and s HIV services . Participants will be r and omised 1:1 to 1 of 2 dietary interventions , with stratification by gender and smoking status . Participants allocated to Diet1 will receive advice to reduce saturated fat intake , and those to Diet2 on how to adopt the Mediterranean Portfolio Diet with additional cholesterol-lowering foods ( nuts , stanols , soya , oats , pulses ) . Measurements of fasting blood lipids , body composition and arterial stiffness will be conducted at baseline , and month 6 and 12 of the intervention . Food intake will be assessed using the Mediterranean Diet Score , 3-day food diaries and metabolomic biomarkers . Question naires will be used to assess quality of life and process evaluation . Qualitative interviews will explore barriers and facilitators to making dietary changes , and participant views on the intervention . Qualitative data will be analysed using the Framework Method . Feasibility will be assessed in terms of trial recruitment , retention , compliance to study visits and the intervention . SD of outcomes will inform the power calculation of the definitive RCT . Ethics The West Midl and s Ethics Committee has approved this study and informed consent forms . This trial is the first to test cholesterol-lowering foods in adults with HIV . Trial registration number IS RCT N32090191 ; Pre- results The objective of this study was to derive food-based dietary guidelines for the Dutch population . The dietary guidelines are based on 29 systematic review s of English language meta-analyses in PubMed summarizing r and omized controlled trials and prospect i ve cohort studies on nutrients , foods and food patterns and the risk of 10 major chronic diseases : coronary heart disease , stroke , heart failure , diabetes , breast cancer , colorectal cancer , lung cancer , chronic obstructive pulmonary disease , dementia and depression . The committee also selected three causal risk factors for cardiovascular diseases or diabetes : systolic blood pressure , low-density lipoprotein cholesterol and body weight . Findings were categorized as strong or weak evidence , inconsistent effects , too little evidence or effect unlikely for experimental and observational data separately . Next , the committee selected only findings with a strong level of evidence for deriving the guidelines . Convincing evidence was based on strong evidence from the experimental data either or not in combination with strong evidence from prospect i ve cohort studies . Plausible evidence was based on strong evidence from prospect i ve cohort studies only . A general guideline to eat a more plant food-based dietary pattern and limit consumption of animal-based food and 15 specific guidelines have been formulated . There are 10 new guidelines on legumes , nuts , meat , dairy produce , cereal products , fats and oils , tea , coffee and sugar-containing beverages . Three guidelines on vegetables , fruits , fish and alcoholic beverages have been sharpened , and the 2006 guideline on salt stayed the same . A separate guideline has been formulated on  nutrient supplements .  Completely food-based dietary guidelines can be derived in a systematic and transparent way Atherosclerotic cardiovascular disease ( ASCVD ) is the leading cause of death , decreased quality of life , and medical costs in the United States . Nearly 1 in 3 Americans die of heart disease and stroke ( 1 ) . Most ASCVD is preventable through a healthy lifestyle and effective treatment of cholesterol and blood pressure . The 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association ( ACC/AHA ) provides an evidence -based approach to reducing ASCVD risk ( 2 ) . Guideline Development Process In 2008 , the National Heart , Lung , and Blood Institute ( NHLBI ) convened the Adult Treatment Panel ( ATP ) IV to up date the 2001 ATP-III cholesterol guidelines using a rigorous systematic process to identify and review r and omized , controlled trials ( RCTs ) with cardiovascular outcomes and meta-analyses of these RCTs . The panel comprised experts and clinicians from the fields of cardiology , epidemiology , primary care , and endocrinology ( 2 ) and received support from the Lifestyle Management and Risk Assessment Work Groups ( 3 , 4 ) . Systematic evidence review s conducted according to principles recommended by the Institute of Medicine ( 5 ) were performed to answer 3 questions relevant to clinical care . Two questions focused on the evidence supporting low-density lipoprotein cholesterol ( LDL-C ) and nonhigh-density lipoprotein cholesterol ( HDL-C ) levels as targets of treatment . One question examined the reduction in ASCVD events and adverse effects for each cholesterol-lowering drug class . The panel synthesized the evidence from these 3 review s as well as from Lifestyle Management and Risk Assessment Work Groups review s ( 3 , 4 ) that addressed 5 additional critical questions . Systematic electronic search es of relevant data bases of the peer- review ed English- language literature published from 1 January 1995 through 1 December 2009 for each critical question were conducted by an NHLBI-selected independent contractor and focused on RCTs and systematic review s and meta-analyses of RCTs assessed as fair to good quality . In addition , RCTs with ASCVD outcomes that included coronary heart disease , stroke , and cardiovascular deaths published after that date were eligible for consideration through July 2013 . Evidence tables were constructed , and the strength of evidence was rated according to the NHLBI ( Table 1 of the Supplement ) . Recommendations were grade d according to criteria from the NHLBI ( Table 2 of the Supplement ) and ACC/AHA ( Table 3 of the Supplement ) . Because of the inherent differences in grading systems and the clinical questions driving the recommendations , alignment between the NHLBI and ACC/AHA formats was imperfect . A complete description of the methods used and results of the evidence review are provided in the guideline ( 2 ) and the NHLBI evidence report ( www.nhlbi.nih.gov/ guidelines /cholesterol/ser/index.htm ) . Supplement . NHLBI and ACC/AHA Criteria for Rating Strength of Evidence To help clinicians estimate ASCVD risk , the risk assessment working group developed the Pooled Cohort Equations using data from 5 NHLBI-sponsored longitudinal , population -based cohorts of African American and non-Hispanic white men and women to estimate risk for a first myocardial infa rct ion , coronary heart disease death , or fatal or nonfatal stroke on the basis of age , sex , race , smoking status , total cholesterol level , HDL-C level , systolic blood pressure , antihypertensive therapy , and diabetes ( 4 , 6 ) . These equations significantly advance ASCVD risk estimation by providing sex- and race-specific estimates and including stroke as an outcome . The earlier Framingham equations calculated only coronary heart disease risk for non-Hispanic whites . The draft recommendations were review ed by 23 experts and representatives of federal agencies identified by the NHLBI . In September 2013 , the recommendations developed by the panel were transitioned to the ACC/AHA and had additional review by 4 experts nominated by the ACC Foundation and the AHA . The governing bodies of the ACC and AHA approved the guideline , which also received endorsement from the American Association of Cardiovascular and Pulmonary Rehabilitation , American Pharmacists Association , American Society for Preventive Cardiology , Association of Black Cardiologists , Preventive Cardiovascular Nurses Association , and WomenHeart : The National Coalition for Women with Heart Disease . Recommendations The guideline focuses on treatment of blood cholesterol to reduce ASCVD risk in adults . Major recommendations are summarized here and in Table 1 . The guideline report provides a complete listing of recommendations and supporting evidence behind each recommendation ( 2 ) . Table 1 . Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults * 1 . Encourage Adherence to a Healthy Lifestyle A healthy lifestyle is the foundation for cardiovascular health . The panel endorsed the 2013 ACC/AHA Lifestyle Management Guideline ( 3 ) for a diet that is low in saturated fat , trans fat , and sodium ; emphasizes vegetables , fruits , whole grains , low-fat dairy products , poultry , fish , legumes , nontropical vegetable oils , and nuts ; and limits sweets , sugar-sweetened beverages , and red meats and engage in regular aerobic physical activity . Adults also should maintain a healthy body weight , avoid smoking , and control hypertension and diabetes when present . 2 . Statin Therapy Is Recommended for Adults in Groups Demonstrated to Benefit Strong RCT evidence shows that reduction in ASCVD events from statin therapy exceeds adverse events for 4 patient groups : those with clinical ASCVD ( acute coronary syndromes , myocardial infa rct ion , stable angina , coronary or other arterial revascularization , stroke , transient ischemic attack , or peripheral arterial disease of atherosclerotic origin ) when  statins are used for secondary prevention , and those with LDL-C levels 190 mg/dL ; those aged 40 to 75 years with diabetes and LDL-C levels 70 to 189 mg/dL ; and those aged 40 to 75 years without diabetes and with a 10-year ASCVD risk 7.5 % when statins are used for primary prevention . Moderate evidence supports consideration of statin therapy for primary prevention in individuals with a 10-year ASCVD risk of 5 % to < 7.5 % . Routine initiation of statin therapy is not recommended in adults with New York Heart Association heart failure class II to IV or those receiving maintenance hemodialysis . R and omized , controlled trials in these groups showed no reduction in ASCVD . 3 . Statins have an Acceptable Margin of Safety When Used in Properly Selected Individuals and Appropriately Monitored Strong RCT evidence supports safety of statins when they are used as directed in conjunction with regular follow-up assessment s in properly selected patients . Adjustment of statin intensity is recommended in individuals older than 75 years with a history of statin intolerance or other characteristics ( 2 ) or those receiving drug therapy that may increase statin adverse events . Routine monitoring of hepatic aminotransferase level or creatine kinase level is not recommended unless clinical ly indicated by symptoms suggesting hepatotoxicity or myopathy . Given the potential for decreasing ASCVD events and death , the relationship of muscle and other symptoms to statin treatment must be confirmed . Therefore , eliciting a history of muscle symptoms before statin initiation and carefully monitoring symptoms during statin discontinuation and rechallenge is recommended . Severe myopathy , rhabdomyolysis , and possibly hemorrhagic stroke are rare complications of statin therapy . Although statin therapy modestly increases the risk for type 2 diabetes , ASCVD risk reduction outweighs the excess risk for diabetes for high-intensity statins in secondary prevention or for 10-year ASCVD risk 7.5 % . Similarly , ASCVD risk reduction outweighs the excess risk for diabetes for moderate-intensity statin therapy in adults with a 10-year ASCVD risk 5 % . 4 . Engage in a ClinicianPatient Discussion Before Initiating Statin Therapy , Especially for Primary Prevention in Patients With Lower ASCVD Risk Decisions to initiate statin therapy in primary prevention should be based on clinical judgment and preferences of informed patients . In adults without clinical ASCVD or diabetes whose LDL-C level is < 190 mg/dL , calculating the estimated 10-year ASCVD risk should be the start of the clinicianpatient discussion and should not automatically lead to statin initiation . As the absolute risk for ASCVD events decreases , so does the net benefit of the intervention . Therefore , discussion of the potential for ASCVD event reduction , adverse effects , drugdrug interactions , and patient preferences is especially important for lower-risk primary prevention . The discussion provides the opportunity to encourage healthy lifestyle habits and control other risk factors . Additional factors may be considered when a risk-based decision is uncertain , including LDL-C levels 160 mg/dL , family history of premature ASCVD , elevated  lifetime ASCVD risk  , high-sensitivity C-reactive protein level 2.0 mg/L ,  coronary artery calcification score  > 300 Agatston units , and anklebrachial index < 0.9 . After age 75 years , comorbid conditions , anticipated longevity , safety considerations , and patient preferences should play a large role in decision making . 5 . Use the Newly Developed Pooled Cohort Equations for Estimating 10-Year ASCVD Risk The Pooled Cohort Equations are currently the best available method for estimating 10-year ASCVD risk to guide statin initiation ( 4 , 6 ) . Application of the inclusion and exclusion criteria from RCTs is cumbersome and results in underidentifying high-risk and overidentifying low-risk individuals for statin treatment . The Pooled Cohort Equations were developed using recent data from 5 NHLBI-sponsored , longitudinal , population -based cohorts of African American and white men and women ( ARIC [ Background Depression is a common mental health disorder for which clinical practice guidelines have been developed . Prior systematic review s have identified complex organizational interventions , such as collaborative care , as effective for guideline implementation ; yet , many healthcare delivery organizations are interested in less re source -intensive methods to increase provider adherence to guidelines and guideline -concordant practice s. The objective of this systematic review was to assess the effectiveness of  healthcare provider  interventions that aim to increase adherence to evidence -based treatment of depression in routine clinical practice . Methods We search ed five data bases through August 2017 using a comprehensive search strategy to identify English- language r and omized controlled trials ( RCTs ) in the quality improvement , implementation science , and behavior change literature that evaluated outpatient provider interventions , in the absence of practice re design efforts , to increase adherence to treatment guidelines or guideline -concordant practice s for depression . We used meta- analysis to summarize odds ratios , st and ardized mean differences , and incidence rate ratios , and assessed quality of evidence ( QoE ) using the GRADE approach . Results Twenty-two RCTs promoting adherence to clinical practice guidelines or guideline -concordant practice s met inclusion criteria . Studies evaluated diverse provider interventions , including distributing guidelines to providers , education/training such as academic detailing , and combinations of education with other components such as targeting implementation barriers . Results were heterogeneous and analyses comparing provider interventions with usual clinical practice did not indicate a statistically significant difference in guideline adherence across studies . There was some evidence that provider interventions improved individual outcomes such as medication prescribing and indirect comparisons indicated more complex provider interventions may be associated with more favorable outcomes . We did not identify types of provider interventions that were consistently associated with improvements across indicators of adherence and across studies . Effects on patients ’ health in these RCTs were inconsistent across studies and outcomes . Conclusions Existing RCTs describe a range of provider interventions to increase adherence to depression guidelines . Low QoE and lack of replication of specific intervention strategies across studies limited conclusions that can be drawn from the existing research . Continued efforts are needed to identify successful strategies to maximize the impact of provider interventions on increasing adherence to evidence -based treatment for depression . Trial registration PROSPERO record CRD42017060460 on The current guidelines for treatment of high-risk of lipid disorders do not specify a therapeutic target level of high-density lipoprotein cholesterol ( HDL-C ) for prevention of vascular disease in high-risk population s. However , there is a substantial body of evidence from basic science and epidemiologic studies and from clinical trials , providing the strong , consistent message that raising HDL-C by therapeutic means will effectively and independently reduce cardiovascular risk . This review summarizes epidemiologic evidence and the results of a meta- analysis of 23 published , prospect i ve , r and omized , placebo-controlled clinical trials . It focuses on the effects of lipid therapies on coronary stenosis progression , as measured by quantitative arteriography and /or , on clinical cardiovascular endpoints . Among the seven drug/treatment classes into which individual study results were categorized and averaged , reduction in stenosis progression and reduction in clinical events are both very highly correlated with the composite lipid variable ( % ΔHDL-C - % Δ low-density lipoprotein cholesterol [ LDL-C ] ; where % Δ is percent change relative to the placebo group response ) . This holds true for all lipid drug classes or combinations of lipid drug therapy , with the exception of the unexpectedly anomalous effects of the torcetrapib-atorvastatin combination . There is a strong and consistent body of evidence that therapeutic HDL-C-raising is at least as effective as comparable percentages of LDL-C-lowering for reduction of atherosclerosis progression or clinical cardiovascular events over a broad range of risk levels . Adoption of this strategy into guidelines probably awaits results of at least one large controlled HDL-C-raising clinical trial , of which two are ongoing and one other is planned There is a large body of scientific evidence that has been confirmed in r and omized controlled trials indicating a cardioprotective effect for omega-3 fatty acids from fish . For alpha-linolenic acid ( ALA ) , which is the omega-3 fatty acid from plants , the relation to cardiovascular health is less clear . We review ed the recent literature on dietary ALA intake , ALA tissue concentrations , and cardiovascular health in humans . Short-term trials ( 6–12 weeks ) in generally healthy participants mostly showed no or inconsistent effects of ALA intake ( 1.2–3.6 g/d ) on blood lipids , low-density lipoprotein oxidation , lipoprotein(a ) , and apolipoproteins A-I and B. Studies of ALA in relation to inflammatory markers and glucose metabolism yielded conflicting results . With regard to clinical cardiovascular outcomes , there is observational evidence for a protective effect against nonfatal myocardial infa rct ion . However , no protective associations were observed between  ALA status and risk of heart failure , atrial fibrillation , and sudden death . Findings from long-term trials of ALA supplementation are awaited to answer the question whether food-based or higher doses of ALA could be important for cardiovascular health in cardiac patients and the general population The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641 Evidence for a beneficial effect of dietary nitrate , through the nitrate-nitrite-NO pathway , on measures of cardiovascular function in healthy individuals is accumulating . It is less clear whether increased dietary nitrate intake from green leafy vegetables would have similar beneficial vascular effects in those at increased risk of developing hypertension . Our aim was to assess the effects of short-term regular consumption of increased nitrate from green leafy vegetables on blood pressure and arterial stiffness in individuals with high-normal blood pressure . Thirty-eight men and women ages 30 - 70 years with systolic blood pressure 120 to 139 mm Hg were recruited to a r and omized controlled crossover trial . The effects of a 7-day high-nitrate diet intervention ( increased nitrate intake by at least 300 mg/day from green leafy vegetables ) were compared to a 7-day low-nitrate diet intervention . Outcome measures included pre- and postintervention salivary and plasma nitrate and nitrite concentrations ; ambulatory , home , and office blood pressure ; augmentation index ; and carotid-femoral pulse wave velocity . The high-nitrate diet intervention result ed in at least a fourfold increase in salivary and plasma nitrate and nitrite ( P<0.001 ) . Ambulatory , home , and office blood pressure and arterial stiffness were not different between the high-nitrate diet and the low-nitrate diet . Increasing dietary nitrate intake in those with high-normal blood pressure and at increased risk of hypertension may not be an effective short-term strategy to lower blood pressure
Treatment effects on apolipoprotein B and non-HDL cholesterol were not observed .
INTERPRETATION Our findings suggest that dietary pulse intake significantly reduces LDL cholesterol levels .
BACKGROUND Evidence from controlled trials encourages the intake of dietary pulses ( beans , chickpeas , lentils and peas ) as a method of improving dyslipidemia , but heart health guidelines have stopped short of ascribing specific benefits to this type of intervention or have grade d the beneficial evidence as low .
We conducted a systematic review and meta- analysis of r and omized controlled trials ( RCTs ) to assess the effect of dietary pulse intake on established therapeutic lipid targets for cardiovascular risk reduction .