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Background Nut consumption has been related to improvements on cardiometabolic parameters and reduction in the severity of atherosclerosis mainly in primary cardiovascular prevention. The objective of this trial is to evaluate the effects of the Brazilian Cardioprotective Diet (DIetaCArdioprotetoraBrasileira, DICA Br) based on consumption of inexpensive locally accessible foods supplemented or not with mixed nuts on cardiometabolic features in patients with previous myocardial infarction (MI). Methods DICA-NUTS study is a national, multicenter, randomized 16-week follow-up clinical trial. Patients over 40 years old with diagnosis of previous MI in the last 2 to 6 months will be recruited (n = 388). A standardized questionnaire will be applied to data collection and blood samples will be obtained. Patients will be allocated in two groups: Group 1: DICA Br supplemented with 30 g/day of mixed nuts (10 g of peanuts, 10 g of cashew, 10 g of Brazil nuts); and Group 2: only DICA Br. The primary outcome will consist of LDL cholesterol means (in mg/dL) after 16 weeks of intervention. Secondary outcomes will consist of other markers of lipid profile, glycemic profile, and anthropometric data. Discussion It is expected that DICA Br supplemented with mixed nuts have superior beneficial effects on cardiometabolic parameters in patients after a MI, when compared to DICA Br. Trial registration ClinicalTrials.gov Identifier NCT03728127. First register: November 1, 2018; Last update: June 16, 2021. World Health Organization Universal Trial Number (WHO-UTN): U1111-1259-8105.

This study aimed to evaluate the association between legume intake and blood pressure, as well as the mediating role of cardiometabolic risk factors in patients in secondary cardiovascular prevention. Socio-demographic, anthropometric, clinical and food intake data were collected from the baseline of the multicentre study Brazilian Cardioprotective Nutritional Program Trial – BALANCE (RCT: NCT01620398). The relationships between variables were explored through path analysis. In total, 2247 individuals with a median age of 63·0 (45–91) years, 58·8 % (n 1321) male and 96·5 % (n 2168) with diagnosis of hypertension were included. Negative associations were observed between histidine intake and systolic blood pressure (SBP) (standardised coefficient (SC) = −0·057; P = 0·012) and between legume intake and BMI (SC = −0·061; P = 0·006). BMI was positively associated with triglycerides–glucose (TyG) index (SC = 0·173; P < 0·001), SBP (SC = 0·144; P < 0·001) and diastolic blood pressure (DBP) (SC = 0·177; P < 0·001), and TyG index was positively associated with DBP (SC = 0·079; P = 0·001). A negative indirect effect was observed between the intake of legumes, SBP and DBP, mediated by BMI (SC = −0·009; P = 0·011; SC = −0·011; P = 0·010, respectively). In addition, an indirect negative effect was found between the intake of legumes and the DBP, mediated simultaneously by BMI and TyG index (SC = −0·001; P = 0·037). In conclusion, legume intake presented a negative indirect association with blood pressure, mediated by insulin resistance (TyG) and adiposity (BMI) in individuals of secondary care in cardiology.

Background: The management of type 2 diabetes mellitus (T2DM) requires a complex and organized care that includes patient lifestyle change. Additionally, emotional well-being is an important part of self-management, and it may impair the individual’s adherence. Therefore, equipping them with the necessary coping and self-care techniques may be an important step in managing diabetes. Objective: to evaluate the effect of interventions using established based-mindfulness protocols on glycemic control of individuals T2DM. Methods: Data sources: Two electronic databases (PubMed and EMBASE) were searched from inception to December 2019. We limited our search to published studies in the English, Spanish and Portuguese language. Study selection: Randomized clinical trials that assessed the effects of mindfulness in individuals with T2DM were selected. Data extraction: Two authors independently assessed risk of bias and extracted data from the included trials. Data were pooled using inverse-variance random-effects meta-analyses. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: Four randomized trials were included. There were no differences in blood glucose change (mean difference between groups (MD) -0.73mg/dl; 95% CI, -10.49; 9.02; I2 =0%; very low quality of evidence) or glycated hemoglobin (MD 0.05%; 95%CI -0.22 to 0.32; I2 =29%; very low quality of evidence). Conclusions: Although the quality of current evidence is very low, our findings suggest that established protocols involving mindfulness has no effect on blood glucose or glycated hemoglobin in individuals with T2DM. Indeed, largescale trials are needed to evaluate the contribution of mindfulness on glycemic control in the clinical practice.

Context Recent evidence suggests that modulation of the gut microbiota may contribute to body weight control. Objective This systematic review aimed to assess the effects of oral supplementation with probiotics or synbiotics on body weight, body mass index (BMI), and waist circumference in overweight and obese adults (BMI ≥ 25 kg/m2). Data sources Five electronic databases-PubMed, Embase, Cochrane Library/CENTRAL, LILACS, and Web of Science-were searched from inception to August 2017. No language restrictions were applied. Study selection Randomized and quasi-randomized parallel trials that assessed the effects of oral supplementation with probiotics or synbiotics vs any other intervention but bariatric surgery or fecal transplantation in overweight or obese adults were selected. Data extraction Three teams of 2 authors independently assessed risk of bias and extracted data from the included trials. Data were pooled using inverse-variance random-effects meta-analyses. The quality of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Results Nineteen randomized trials (28 publications, 1412 participants) were included. There were no differences in mean body weight change [mean difference (MD), -0.54 kg; 95%CI, -1.09 to 0.01; I2 = 0%; moderate quality of evidence) or mean BMI change (MD, -0.19 kg/m2; 95%CI, -0.43 to 0.04; I2 = 51%; low quality of evidence) between groups who received probiotics or synbiotics and control groups. Oral supplementation with probiotics or synbiotics reduced mean waist circumference compared with control (MD, -0.82 cm; 95%CI, -1.43 to -0.21; I2 = 46%; low quality of evidence). Conclusions The findings suggest that oral supplementation with probiotics or synbiotics has a small effect to reduce waist circumference but no effect on body weight or BMI, although the quality of evidence is low to moderate. Therefore, the current evidence is not definitive. Large-scale trials are needed and may help to better inform clinical practice. Systematic review registration PROSPERO registration number CRD42018075126.

Bariatric surgery is an effective strategy for blood pressure (BP) reduction, but most of the evidence relies on office BP measurements. In this study, we evaluated the impact of bariatric surgery on 24-hour BP profile, BP variability, and resistant hypertension prevalence. This is a randomized trial including obese patients with grade 1 and 2 using at least 2 antihypertensive drugs at maximal doses or >2 at moderate doses. Patients were allocated to either Roux-en-Y Gastric Bypass (RYGB) combined with medical therapy or medical therapy alone for 12 months. The primary outcome was the 24-hour BP profile and variability (average real variability of daytime and night time BP). We evaluated the nondipping status and prevalence of resistant hypertension as secondary end points. We included 100 patients (76% female, body mass index, 36.9±2.7 kg/m 2 ). The 24-hour BP profile (including nondipping status) was similar after 12 months, but the RYGB group required less antihypertensive classes as compared to the medical therapy alone (0 [0–1] versus 3 [2.5–4] classes; P P =0.01). Prevalence of resistant hypertension was similar at baseline (RYGB, 10% versus MT, 16%; P =0.38), but it was significantly lower in the RYGB at 12 months (0% versus 14.9%; P Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01784848.

The consumption of ultra-processed foods (UPF) has been associated with cardiometabolic risk factors. However, there is scarce literature on the association between UPF consumption, cardiovascular events, and cardiometabolic risk factors in subjects undergoing secondary care for cardiovascular diseases (CVD). Thus, we aimed to evaluate the association between UPF consumption, CVD, and cardiometabolic risk factors in subjects with established CVD. Baseline data from 2,357 subjects participating in a Brazilian multicenter study were analysed finding a mean UPF consumption of 18.7% of their energy intake. Higher figures of UPF consumption were founded associated with an increased presence of high waist circumference, overweight, peripheral arterial disease, and with a decreased odds of the simultaneous presence of coronary arterial disease, peripheral arterial diseases, and stroke when comparing among tertiles of UPF contribution to energy intake. These associations were observed when analyzing the whole sample and women but not men. Thus, these findings should help improve strategies for CVD patients in secondary care.

O padrão alimentar associado à redução da mortalidade e de fatores de risco para doença cardiovascular inclui ingestão adequada de cereais integrais, frutas, leguminosas, legumes, nozes, sementes, peixe e consumo reduzido de carne vermelha e carne processada. Embora essa recomendação seja a melhor evidência do efeito benéfico entre dieta e doença coronariana, profissionais da saúde devem considerar que a disponibilidade e acessibilidade dos alimentos. O programa alimentar brasileiro cardioprotetor (BALANCE) é um estudo clínico randomizado que propõe a adoção de uma dieta com potencial cardioprotetor e acessível à população brasileira. Outras propostas de dietas cardioprotetoras foram feitas ao redor do mundo e mostraram ser eficazes na prevenção das doenças cardiovasculares e redução da mortalidade. No entanto, quando implementadas fora dos países de origem tornam-se impraticáveis pela baixa acessibilidade e adaptação cultural. Esta tese será apresentada sob a forma de três artigos científico. No primeiro foi realizada uma análise transversal do início do estudo BALANCE sobre o custo direto com despesas diárias alimentares e a qualidade da dieta. Não foi observada associação entre o custo direto e o índice de qualidade da dieta revisado (IQD-R), assim como não foi observada diferença entre a adesão aos escores do IQD-R. O segundo artigo realizou uma análise de custo-efetividade da alimentação adotada pelos participantes com maior adesão ao protocolo ao longo de 36 meses. Foram considerados apenas despesas diárias para a compra dos alimentos e a efetividade foi medida pelo IQD-R. Na linha de base, os custos médios foram iguais (U$ 3,9/dia) e o IQD-R foi de 53,5 e 51,8 pontos no nos grupos BALANCE e controle, respectivamente. Após um período de três anos, a intervenção foi associada a uma economia de custo média de US $ 0,31/dia (IC 95%: -0,59; -0,44) e um aumento médio do IQD-R de 4,38 (IC 95%: 2,81; 5,95). O terceiro artigo analisou o custo-efetividade do estudo BALANCE em todos os participantes, utilizando a perspectiva da sociedade e um horizonte temporal de 36 meses. Foram considerados custos diretos médicos (hospitalizações, procedimentos e exames) e custos diretos não médicos (gastos do paciente). Após 36 meses, a diferença no custo total entre as intervenções foi de -R$ 151,9 (IC 95%: -R$ 493,3; R$ 190,50). A dieta adotada pelo grupo BALANCE foi associada a uma economia média de R$ 415,53 (IC95% -687,79; -139,78). A diferença em LYs foi de 0,011 anos (IC 95%: -0,025; 0,046) de LYGs. A relação custo-efetividade incremental foi - R$ 14.098,63 por LYG (IC 95%: -156.178; 154.864). A análise de custo-efetividade do estudo BALANCE mostrou neutralidade em relação ao grupo controle. No entanto, o custo com a dieta adotada no grupo BALANCE foi menor ao longo do tempo e a melhor qualidade da dieta não se associou a maior despesa com alimentos. Esses achados podem estimular a adesão e recomendações da estratégia de educação nutricional BALANCE em um cenário de saúde pública. The dietary pattern associated with reduced mortality and risk factors for cardiovascular disease includes adequate intake of whole grains, fruits, legumes, vegetables, nuts, seeds, fish and reduced consumption of red meat and processed meat. Although this recommendation is the best evidence of the beneficial effect between diet and coronary heart disease, healthcare professionals should consider food availability and accessibility. The Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program) is a randomized clinical study that proposed a cardiovascular-protector diet suited for the Brazilian population. Other cardiovascular protector diets were implemented outside of Brazil and were shown to be effective for the prevention of cardiovascular diseases and the reduction of mortality rates, but became unfeasible when implemented outside their countries. This thesis is presented in the form of three papers. In the first, a cross-sectional analysis of the BALANCE trial baseline was performed, considering the direct cost of daily food expenses and the quality of the diet. There was no association between direct cost and Brazilian Health Eating Index Revised (BHEI-R), as well as with adherence to BHEI-R scores. The second article carried out a cost-effectiveness analysis of the food adopted by the participants with greater adherence to the protocol over 36 months. Only daily expenses for the purchase of food were considered, and effectiveness was measured by the BHEI-R. At baseline, the average costs were equal (U$3.9/day), and BHEI-R were 53·5 and 51·8 points, in the BALANCE Program and control groups, respectively. After a three-year period, the intervention was associated with an average cost saving of U$0·31/day (95%CI: -0·59; -0·04) and an average increase of BHEI-R of 4·38 (95%CI: 2·81; 5·95). The third article analyzed the cost-effectiveness of the BALANCE study with all participants, using the perspective of the society and a 36-month time horizon. Direct medical costs (hospitalizations, procedures and examinations), direct non-medical costs (patient expenses) and indirect costs (deaths) were considered. After 36 months, difference in total interventions cost was -R$151.9 (CI 95%: -R$ 493.3; R$190.50). The diet adopted by BALANCE group was associated with a mean cost saving of R$415.53 (CI95% -687.79; -139.78). Difference in LYs was 0.011 years (CI 95%: -0.025; 0.046) of LYGs. The incremental cost-effectiveness ratio was - R$ 14.098,63 per LYG (CI95%: -156.178; 154.864). Cost-effectiveness analysis from the BALANCE study showed neutrality compared to the control group. However, diet adopted in the BALANCE group saved money over time and better diet quality was not associated with higher food expenditure. This finding may encourage the adherence and recommendations of BALANCE nutritional education strategy in a public health scenario.

Objective:To evaluate the association of dietary inflammatory index (DII®) with the occurrence of cardiovascular events, cardiometabolic risk factors and with the consumption of processed, ultra-processed, unprocessed or minimally processed foods and culinary ingredients.Design:This was a cross-sectional study that analysed the baseline data from 2359 cardiac patients. Data on socio-demographic, anthropometric, clinical and food consumption were collected. Energy-adjusted food intake data were used to calculate DII, and the foods were classified according to the NOVA classification. Furthermore, the patients were grouped according to the number (1, 2 or ≥ 3) of manifested cardiovascular events. The data were analysed using linear and multinomial logistic regression.Settings:Multicentre study from Brazil.Participants:Patients with established cardiovascular events from the Brazilian Cardioprotective Nutritional Program Trial evaluated at baseline.Results:Most of the patients were male (58·8 %), older adults (64·2 %) and were overweight (68·8 %). Patients in the third tertile of DII (DII > 0·91) had were more likely to have 2 (OR 1·27, 95 % CI: 1·01–1·61) and ≥ 3 (OR 1·39, 95 % CI: 1·07–1·79) cardiovascular events, with poor cardiometabolic profile. They also were more likely to consume a higher percentage of processed, ultra-processed and culinary ingredients foods consumption compared with the patients in the first DII tertile (DII ≤ 0·91).Conclusion:A more pro-inflammatory diet is associated with a greater chance of having 2 and ≥ 3 cardiovascular events and cardiometabolic risk factors and were more likely to consume processed, ultra-processed and culinary ingredients compared to those with a more anti-inflammatory diet.

Summary Background & aims To evaluate the effect of the Brazilian Cardioprotective Diet Program (BALANCE Program) on inflammatory biomarkers, involved in the pathophysiology of the atherosclerosis, on inflammatory biomarkers, cardiovascular risk factors, and on plasma fatty acids in cardiovascular disease secondary prevention patients. Methods In this substudy of the BALANCE Program randomized clinical trial, a total of 369 patients aged 45 years or older, who have experienced cardiovascular disease in the previous 10 years, were included. These patients were randomized into two groups and followed up for six months: BALANCE Program group and control group (conventional nutrition advice). In the initial and six-month final visits, anthropometry (body weight, height and waist circumference), food intake evaluation by 24-h dietary recall, plasma inflammatory biomarkers (IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-α, adiponectin, and C-reactive protein levels), blood pressure, glycemia, insulinemia, lipid profile, and plasma fatty acids levels were evaluated. Results The BALANCE Program group showed increased plasma alpha-linolenic acid levels (P = 0.008), reduction in waist circumference (P = 0.049) and BMI (P = 0.032). No difference was observed among plasma inflammatory biomarkers and clinical data. Conclusion After six months of follow-up, BALANCE Program led to a significant reduction on BMI and waist circumference in individuals in secondary prevention for cardiovascular disease. Although plasmatic alpha-linolenic acid has increased, there was no impact on plasma inflammatory biomarkers. Clinical trial registration NCT01620398.

Background: A healthy diet is essential to reduce cardiovascular disease (CVD) risk and mortality. However, recent studies lack conclusive evidence on the affordability of cardioprotective diets worldwide. The Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program) is a randomized multicenter clinical trial that proposes regionally adapted cardioprotective diet that achieves nutritional recommendations and incorporates accessible and affordable foods. The study aim is to analyze cost-effectiveness of the BALANCE Program in comparison to generic dietary advice for individuals, based on diet costs and nutritional quality among patients with high adherence to the study protocol in both control and intervention groups.Methods: We conducted a cost-effectiveness analysis of subsample from the BALANCE Program (1,161 individuals with previous event of CVD and high adherence to study protocol enrolled in 35 research sites throughout Brazil) after a 3-year follow-up. Direct costs and nutritional quality of diets reported by participants were estimated at the individual level. Diet costs were based on market prices collected from five major supermarket chains. Effectiveness was measured in terms of diet quality, according to adherence to the Brazilian Health Eating Index Revised (BHEI-R). Mean differences were compared between groups using generalized estimating equation. Monte Carlo simulations were performed to comprise probabilistic sensitivity analysis regarding trends in the comparison between groups.Results: At baseline, mean direct diet costs were equal (U$3.9/day), and there were small differences in BHEI-R between groups (53.5 points in BALANCE Program, and 51.8 points in control group). After the 3-year follow-up, the intervention was associated with a mean cost saving of U$0.31/day (95%CI: -0.59; -0.04) and mean BHEI-R increase of 4.38 (95%CI: 2.81; 5.95). Conclusion: The intervention was dominant strategy in terms of cost-effectiveness due to higher effectiveness at lower costs in comparison with the control group.Conclusions: There was a statistically significant effect of the intervention regarding increase in diet quality and reduction in cost after 3 years compared to the control group. The BALANCE intervention may be an option to improve diet quality with lower costs among Brazilians with CVD.Trial registration: NCT, NCT01620398. Registered June 15, 2012. https://clinicaltrials.gov/ct2/show/NCT01620398

Background: Recent research efforts on bariatric surgery have focused on metabolic and diabetes mellitus resolution. Randomized trials designed to assess the impact of bariatric surgery in patients with obesity and hypertension are needed. Methods: In this randomized, single-center, nonblinded trial, we included patients with hypertension (using ≥2 medications at maximum doses or >2 at moderate doses) and a body mass index between 30.0 and 39.9 kg/m 2 . Patients were randomized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. The primary end point was reduction of ≥30% of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure Results: We included 100 patients (76% female, mean age 43.8±9.2 years, mean body mass index 36.9±2.7 kg/m2), and 96% completed follow-up. Reduction of ≥30% of the total number of antihypertensive medications while maintaining controlled blood pressure occurred in 41 of 49 patients from the gastric bypass group (83.7%) compared with 6 of 47 patients (12.8%) from the control group with a rate ratio of 6.6 (95% confidence interval, 3.1–14.0; P P =0.005). Eleven patients (22.4%) from the gastric bypass group and none in the control group were able to achieve SPRINT levels without antihypertensives. Waist circumference, body mass index, fasting plasma glucose, glycohemoglobin, low-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, and 10-year Framingham risk score were lower in the gastric bypass than in the control group. Conclusions: Bariatric surgery represents an effective strategy for blood pressure control in a broad population of patients with obesity and hypertension. Clinical Trial Registration: URL: https://clinicaltrials.gov . Unique identifier: NCT01784848.

Objectives Dietary total antioxidant capacity (dTAC) has been introduced as a useful tool to quantify the antioxidant content of a diet. However, few studies have evaluated the association of dTAC with cardiovascular disease (CVD) occurrence and cardiometabolic risk factors in people with established CVD events. Thus, we aimed to investigate the presence of an association between dTAC values, cardiovascular events, and cardiometabolic risk factors in individuals with previous CVD in a Brazilian multicenter study. Methods This study has a cross-sectional design. We evaluated baseline data from the Brazilian Cardioprotective Nutritional Program Trial. Sociodemographic, anthropometric, clinical, and food-consumption data were collected in face-to-face interviews. We estimated dTAC from the mean of two 24-h dietary recalls by values of ferric-reducing antioxidant power. Results We evaluated 2346 participants, most of whom were men (58.4%), older adults (64.2%), and overweight (68.6%), and had coronary artery disease (92.4%). The mean dTAC was equal to 5.6 (interquartile range, 3.9-7.8) mmol/1000 kcal. Participants in the third dTAC tertile (9.2 mmol/1000 kcal) had a 22%, 59%, and 69% lower chance, respectively, of having hypertriglyceridemic waist phenotype, abdominal aortic aneurysm, and amputation due to arterial disease in comparison to the first tertile (3.4 mmol/1000 kcal). Conclusions The dTAC was inversely associated with hypertriglyceridemic waist phenotype, abdominal aortic aneurysm, and amputation due to arterial disease in individuals undergoing secondary care for CVD. Our results can guide strategies for the prevention of new CVD and its consequences.

Adherence to a healthy diet depends on factors such as food prices, while studies in developed countries have identified higher costs of more nutritional foods. The current study aimed to assess the direct food expenditures by adults with cardiovascular disease in Brazil, investigating the relationship between cost and quality of diet. The study used data from a randomized clinical trial, the BALANCE Program. The current study is a cross-sectional baseline analysis of participants with high adherence to the trial, conducted in 35 sites in all five major geographic regions of Brazil. Food consumption by 1,160 individuals was collected with a 24-hour dietary recall (24HR), quality of diet was measured with the Diet Quality Index Revised (DQI-R), and direct food costs were estimated from market prices. No significant differences were observed between tertiles of adherence in the direct costs of food or individual characteristics. When all the 24HR were analyzed, there was no correlation between cost and quality of diet (r = 0.38; p = 0.17), while analysis by tertiles showed a weak correlation in the lowest tertile of adherence (r = -0.112; p = 0.03). The study showed absence of differences between direct costs of healthy versus unhealthy foods, a finding that can serve as an incentive for adherence to food recommendations in Brazil, thereby minimizing barriers to the adoption of healthy lifestyles.A adesão a uma alimentação saudável depende de fatores como os preços dos alimentos, sendo que alguns estudos conduzidos em países desenvolvidos apontam para um maior custo de uma alimentação de melhor qualidade nutricional. O objetivo do presente trabalho foi avaliar o custo direto da alimentação de indivíduos adultos com doença cardiovascular no Brasil, investigando a relação entre o custo e a qualidade da dieta. Foram utilizados os dados de um ensaio clínico randomizado, o BALANCE Program. A investigação atual é uma análise transversal no momento inicial dos participantes com alta adesão ao estudo realizado em 35 centros das cinco regiões brasileiras. O consumo alimentar de amostra com 1.160 indivíduos foi coletado pelo recordatório alimentar de 24 horas (R24h), a avaliação da qualidade da dieta pelo Índice da Qualidade da Dieta Revisado (IQD-R) e os custos diretos da alimentação foram estimados por meio de preços de mercado. Não foram observadas diferenças significativas no custo direto da alimentação ou características dos indivíduos entre os tercis de adesão. Quando analisados todos os recordatórios não houve correlação entre custo e qualidade da dieta (r = 0,38; p = 0,17), já a análise por tercis mostrou fraca correlação entre o menor tercil de adesão (r = -0,112; p = 0,03). O presente estudo apontou ausência de diferenças entre os custos diretos da alimentação classificada como saudável e daquela com a pior qualidade nutricional, o que pode ser um incentivo à adesão às orientações alimentares no Brasil, minimizando barreiras à adoção de estilos de vida saudáveis.La adhesión a una alimentación saludable depende de factores como los precios de los alimentos, siendo que algunos estudios realizados en países desarrollados apuntan hacia un mayor coste de una alimentación de mejor calidad nutricional. El objetivo del presente estudio fue evaluar el coste directo de la alimentación en individuos adultos con enfermedad cardiovascular en Brasil, investigando la relación entre el coste y la calidad de la dieta. Se utilizaron los datos de un ensayo clínico aleatorio, el BALANCE Program. La investigación actual es un análisis transversal desde el principio con participantes de alta adhesión al estudio, realizado en 35 centros de las cinco regiones brasileñas. El consumo alimentario de la muestra con 1.160 individuos fue recogido mediante el recordatorio alimentario de 24 horas (R24h), la evaluación de la calidad de la dieta se evaluó mediante el Índice de Calidad de la Dieta Revisado (IQD-R por sus siglas en portugués) y los costes directos de la alimentación se estimaron mediante precios de mercado. No se observaron diferencias significativas en el coste directo de la alimentación o características de los individuos entre los terciles de adhesión. Cuando se analizaron todos los recordatorios no hubo correlación entre coste y calidad de la dieta (r = 0,38; p = 0,17), ya en el análisis por terciles hubo una débil correlación entre el menor tercil de adhesión (r = -0,112; p = 0,03). El presente estudio apuntó una ausencia de diferencias entre los costes directos de la alimentación clasificada como saludable y aquella con peor calidad nutricional, lo que puede ser un incentivo para la adhesión a las orientaciones alimentarias en Brasil, minimizando barreras para la adopción de estilos de vida saludables.

Background The triglyceride-glucose index (TyG index) is a tool for insulin resistance evaluation, however, little is known about its association with coronary artery disease (CAD), which is the major cardiovascular death cause, and what factors may be associated with TyG index. Objective To evaluate the association between the TyG index and the prevalence of CAD phases, as well as cardiovascular risk factors. Methods The baseline data of patients in secondary care in cardiology from Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program Trial) were analyzed. Anthropometric, clinical, socio-demographic and food consumption data were collected by trained professionals. The TyG index was calculated by the formula: Ln (fasting triglycerides (mg/dl) × fasting blood glucose (mg/dl)/2) and regression models were used to evaluate the associations. Results We evaluated 2330 patients, which the majority was male (58.1%) and elderly (62.1%). The prevalence of symptomatic CAD was 1.16 times higher in patients classified in the last tertile of the TyG index (9.9 ± 0.5) compared to those in the first tertile (8.3 ± 0.3). Cardiometabolic risk factors were associated with TyG index, with the highlight for higher carbohydrate and lower lipid consumption in relation to recommendations that reduced the chance of being in the last TyG index tertile. Conclusion The TyG index was positively associated with a higher prevalence of symptomatic CAD, with metabolic and behavioral risk factors, and could be used as a marker for atherosclerosis. Trial registration ClinicalTrials.gov identifier: NCT01620398. Registered 15 June, 2012

Background: Appropriate dietary recommendations represent a key part of secondary prevention in cardiovascular disease (CVD). We evaluated the effectiveness of the implementation of a nutritional program on quality of diet, cardiovascular events, and death in patients with established CVD. Methods: In this open-label, multicenter trial conducted in 35 sites in Brazil, we randomly assigned (1:1) patients aged 45 years or older to receive either the BALANCE Program (experimental group) or conventional nutrition advice (control group). The BALANCE Program included a unique nutritional education strategy to implement recommendations from guidelines, adapted to the use of affordable and regional foods. Adherence to diet was evaluated by the modified Alternative Healthy Eating Index. The primary end point was a composite of all-cause mortality, cardiovascular death, cardiac arrest, myocardial infarction, stroke, myocardial revascularization, amputation, or hospitalization for unstable angina. Secondary end points included biochemical and anthropometric data, and blood pressure levels. Results: From March 5, 2013, to Abril 7, 2015, a total of 2534 eligible patients were randomly assigned to either the BALANCE Program group (n = 1,266) or the control group (n = 1,268) and were followed up for a median of 3.5 years. In total, 235 (9.3%) participants had been lost to follow-up. After 3 years of follow-up, mean modified Alternative Healthy Eating Index (scale 0-70) was only slightly higher in the BALANCE group versus the control group (26.2 ± 8.4 vs 24.7 ± 8.6, P

Background: Bariatric surgery represents an effective strategy for office blood pressure (BP) reduction in obese hypertensive patients. However, no previous study evaluated the impact of bariatric surgery on 24-h BP profile, non-dipping status and incidence of resistant hypertension (RH). Methods: This is a sub-analysis of a randomized clinical trial including hypertensive patients with grade 1 and 2 obesity, aged 18 to 65 years, using at least 2 drugs at optimal doses or >2 at moderate doses. Patients were randomly allocated to either Roux-en-Y Gastric Bypass (RYGB) with medical therapy (MT) or MT alone for 12 months. We analyzed the 24-h BP profile, non-dipping status (defined by Results: A total of 100 patients were included (76% female, age 43.8±9.2 years, BMI 36.9±2.7 Kg/m 2 ). The 24-h BP profile was similar at 12 months in both groups, but the RYGB group required less anti-hypertensive classes compared to the MT alone (Figure). The rate of non-dipping BP did not change significantly during the follow-up (RYGB: from 18/48 (37.5%) to 22/48 (45.8%); p=0.30; MT: from 16/33 (48.5%) to 15/33 (45.5%); p=0.80). In an exploratory analysis, the incidence of RH was similar at the baseline (RYGB 10% (5/50) and MT 16% (8/50); p=0.38). After 12 months, it changed significantly in the RYGB group: 0% (0/49) while remained stable in the MT group: 14.9% (7/47) (p Conclusions: RYGB significantly reduced anti-hypertensive medications while promoting similar 24-h BP profile and non-dipping BP status compared to the MT alone. RYGB may be an attractive strategy to reduce RH incidence in obese patients.

Background The diet of the Brazilian Cardioprotective Nutritional Program (BALANCE) classifies food into four groups and sets the daily amount to be consumed. The dietary approach of BALANCE is different from other dietary recommendations; therefore, it is not possible to use existing dietary indexes (DI) to assess patient’s adequacy to BALANCE diet. For this reason, it is important to develop a specific dietary index based on BALANCE diet. This study aims to describe the development of the BALANCE DI, evaluate its internal consistency, construct and content validity and population characteristics associated with the index. Methods We analyzed baseline data from the BALANCE randomized clinical trial (https://www.clinicaltrials.gov/; NCT01620398). The four food groups of the diet were adopted as index components. Points ranging from 0 to 10 were given to each index component. Internal consistency was evaluated by correlation coefficients between total score and component scores, as well as Cronbach’s Alpha. Content and construct validity were assessed by checking how nutrients are associated with the index and if the index could distinguish between groups with known differences in diet, respectively. Crude and adjusted linear regression analyses were performed to evaluate population characteristics associated with the index. Results The analysis included 2044 subjects (58.6% men). The average of the total index was higher among women (p 0.40. Cronbach’s alpha coefficient was 0.66. High scores in the index were inversely associated (p

Background Proinflammatory biomarkers levels are increased among patients with cardiovascular disease, and it is known that both the presence of insulin resistance and diet may influence those levels. However, these associations are not well studied among patients with established cardiovascular disease. Our objective is to compare inflammatory biomarker levels among cardiovascular disease secondary prevention patients with and without insulin resistance, and to evaluate if there is any association between plasma fatty acid levels and inflammatory biomarker levels among them. Methods In this cross-sectional sub-study from the BALANCE Program Trial, we collected data from 359 patients with established cardiovascular disease. Plasma fatty acids and inflammatory biomarkers (interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12, high sensitive C-reactive protein (hs-CRP), adiponectin, and tumor necrosis factor (TNF)-alpha) were measured. Biomarkers and plasma fatty acid levels of subjects across insulin resistant and not insulin resistant groups were compared, and general linear models were used to examine the association between plasma fatty acids and inflammatory biomarkers. Results Subjects with insulin resistance had a higher concentration of hs-CRP (p = 0.002) and IL-6 (p = 0.002) than subjects without insulin resistance. Among subjects without insulin resistance there was a positive association between stearic fatty acid and IL-6 (p = 0.032), and a negative association between alpha-linolenic fatty acid and pro-inflammatory biomarkers (p

As doenças cardiovasculares (DCV) representam a principal causa de mortalidade e de incapacidade, em ambos os gêneros, no Brasil e no mundo. O padrão de consumo alimentar está tanto positiva como negativamente associado aos principais fatores de risco para DCV, entre eles diabetes, hipertensão, obesidade e hipertrigliceridemia, todos componentes da síndrome metabólica. Este estudo tem como objetivos identificar os padrões alimentares em indivíduos com DCV, considerando a densidade de energia, a gordura saturada, a fibra, o sódio e o potássio consumidos, e investigar sua associação com fatores de risco de DCV e síndrome metabólica. Trata-se de um estudo transversal. Foram utilizados dados do estudo DICA Br. A amostra foi composta de indivíduos com DCV, com idade superior a 45 anos, de todas as regiões brasileiras. O consumo alimentar foi obtido por recordatório alimentar de 24h e os padrões alimentares obtidos pela regressão por posto reduzido (RPR). Para a RPR, utilizaram-se 28 grupos alimentares como preditores e como variáveis respostas componentes dietéticos. O teste de Mann Whitney foi utilizado para testar as diferenças entre as médias dos escores. Foram obtidos dados de 1.047 participantes; 95% apresentavam doença arterial coronariana; em sua maioria, eram idosos, da classe econômica C1 e C2 e estudaram até o ensino médio. A prevalência de síndrome metabólica foi de 58%. Foram extraídos dois padrões alimentares. O primeiro foi marcado pelo maior consumo de fibra alimentar e potássio, composto por arroz e feijão, frutas e sucos naturais com ou sem açúcar, legumes, carne bovina ou processada, verduras, raízes e tubérculos. O segundo padrão caracterizou-se pelo consumo de gordura saturada e maior densidade energética, representado por panificados salgados, gorduras, carne bovina e processada, doces caseiros, pizza, salgadinhos de pacote ou festa, sanduíche e alimento salgado pronto para consumo. Houve associação significativa entre o padrão alimentar 1 com medida da circunferência da cintura e nível de HDL adequados e com o padrão 2 e HDL adequado. A adoção do padrão alimentar 1 pode estar associada à proteção contra alguns dos componentes da síndrome metabólica. Cardiovascular diseases (CVD) are the leading cause of mortality and disability in both genders in Brazil and worldwide. The dietary pattern is at the same time positive and negatively associated with the main risk factors for CVD, including diabetes, hypertension, obesity and hypertriglyceridemia, all components of the metabolic syndrome. This study aims to identify dietary patterns in individuals with CVD, considering the energy density, and the amount of saturated fatty acid, fiber, sodium and potassium of the diet, and to investigate its association with CVD risk factors and metabolic syndrome. This is a cross-sectional study, data were used from \"DICA Br\" study. The sample consisted of individuals with CVD, over 45 years old, residents from all Brazilian regions. Food consumption was obtained by one 24-hours diet recall and dietary patterns by reduced rank regression (RRR). In the RRR, 28 food groups were included as predictors and dietary components was chosen as the response variable. The Mann-Whitney test was used to test the differences between the factors scores\' means. Data of 1047 participants were analyzed. 95% have coronary artery disease, most are elderly, economical class most observed are C1 and C2. Also, most of them and studied up to high school. The prevalence of metabolic syndrome was 58%. Two dietary patterns were extracted: the first one is higher in dietary fiber and potassium, which is composed by rice, beans, fruits and natural juices with or without sugar, vegetables, beef or processed meat, roots and tubers. The second pattern is higher in saturated fatty acid and energy density, represented by breads, fats, and processed meat, homemade pastries, pizza, snacks or party package, sandwich and salty food ready for consumption. There was a significant association between dietary pattern 1 and low waist circumference and adequate high density cholesterol blood concentration. There was a significant association between dietary pattern 2 and adequate high density cholesterol blood concentration. We suggest that the adoption of the dietary pattern 1 may be associated with protection against some of the components of metabolic syndrome.