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Meta-Analysis
. 2013 Dec 6;2013(12):CD002128.
doi: 10.1002/14651858.CD002128.pub5.

Dietary advice for reducing cardiovascular risk

Karen Rees  1 , Mariana Dyakova, Nicola Wilson, Kirsten Ward, Margaret Thorogood, Eric Brunner
Affiliations
Meta-Analysis

Dietary advice for reducing cardiovascular risk

Karen Rees et al. Cochrane Database Syst Rev. .

Abstract

Background: Changes in population diet are likely to reduce cardiovascular disease and cancer, but the effect of dietary advice is uncertain. This review is an update of a previous review published in 2007.

Objectives: To assess the effects of providing dietary advice to achieve sustained dietary changes or improved cardiovascular risk profile among healthy adults.

Search methods: We searched the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects (DARE) and the HTA database on The Cochrane Library (Issue 4, 2010). We searched MEDLINE (Ovid) (1950 to week 2 October 2010) and EMBASE (Ovid) (1980 to Week 42 2010). Additional searches were done on CAB Health (1972 to December 1999), CVRCT registry (2000), CCT (2000) and SIGLE (1980 to 2000). Dissertation abstracts and reference lists of articles were checked and researchers were contacted.

Selection criteria: Randomised studies with no more than 20% loss to follow-up, lasting at least three months and involving healthy adults comparing dietary advice with no advice or minimal advice. Trials involving children, trials to reduce weight or those involving supplementation were excluded.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

Main results: Forty-four trials with 52 intervention arms (comparisons) comparing dietary advice with no advice were included in the review; 18,175 participants or clusters were randomised. Twenty-nine of the 44 included trials were conducted in the USA. Dietary advice reduced total serum cholesterol by 0.15 mmol/L (95% CI 0.06 to 0.23) and LDL cholesterol by 0.16 mmol/L (95% CI 0.08 to 0.24) after 3 to 24 months. Mean HDL cholesterol levels and triglyceride levels were unchanged. Dietary advice reduced blood pressure by 2.61 mm Hg systolic (95% CI 1.31 to 3.91) and 1.45 mm Hg diastolic (95% CI 0.68 to 2.22) and 24-hour urinary sodium excretion by 40.9 mmol (95% CI 25.3 to 56.5) after 3 to 36 months but there was heterogeneity between trials for the latter outcome. Three trials reported plasma antioxidants, where small increases were seen in lutein and β-cryptoxanthin, but there was heterogeneity in the trial effects. Self-reported dietary intake may be subject to reporting bias, and there was significant heterogeneity in all the following analyses. Compared to no advice, dietary advice increased fruit and vegetable intake by 1.18 servings/day (95% CI 0.65 to 1.71). Dietary fibre intake increased with advice by 6.5 g/day (95% CI 2.2 to 10.82), while total dietary fat as a percentage of total energy intake fell by 4.48% (95% CI 2.47 to 6.48) with dietary advice, and saturated fat intake fell by 2.39% (95% CI 1.4 to 3.37).Two trials analysed incident cardiovascular disease (CVD) events (TOHP I/II). Follow-up was 77% complete at 10 to 15 years after the end of the intervention period and estimates of event rates lacked precision but suggested that sodium restriction advice probably led to a reduction in cardiovascular events (combined fatal plus non-fatal events) plus revascularisation (TOHP I hazards ratio (HR) 0.59, 95% CI 0.33 to 1.08; TOHP II HR 0.81, 95% CI 0.59 to 1.12).

Authors' conclusions: Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 12 months, but longer-term effects are not known.

PubMed Disclaimer

Conflict of interest statement

None known

Figures

1
1
Study flow diagram for 2010 update.
1.1
1.1. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 1 Systolic blood pressure, change from baseline (mmHg).
1.2
1.2. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 2 Diastolic blood pressure, change from baseline (mmHg).
1.3
1.3. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 3 Urinary sodium output (mmol/24 hr), change from baseline.
1.4
1.4. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 4 Urinary potassium output (mmol/24hr), change from baseline.
1.5
1.5. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 5 Total cholesterol (mmol/l), change from baseline.
1.6
1.6. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 6 LDL cholesterol (mmol/l), change from baseline.
1.7
1.7. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 7 HDL cholesterol (mmol/l), change from baseline.
1.8
1.8. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 8 Triglycerides (mmol/l), change from baseline.
1.9
1.9. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 9 Plasma alpha‐carotene (nanomol/L), change from baseline.
1.10
1.10. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 10 Plasma ß‐carotene (nanomol/L), change from baseline.
1.11
1.11. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 11 Plasma lycopene (micromol/L), change from baseline.
1.12
1.12. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 12 Plasma lutein (micromol/L), change from baseline.
1.13
1.13. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 13 Plasma beta‐cryptoxanthin (micromol/L), change from baseline.
1.14
1.14. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 14 Plasma alpha‐tocopherol (micromol/L), change from baseline.
1.15
1.15. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 15 Plasma gamma‐tocopherol (micromol/L), change from baseline.
1.16
1.16. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 16 Plasma ascorbic acid (micromol/L), change from baseline.
1.17
1.17. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 17 Plasma total carotenoids (micromol/L), change from baseline.
1.18
1.18. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 18 Total dietary fat (% Kcal).
1.19
1.19. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 19 Dietary saturated fatty acids (% Kcal).
1.20
1.20. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 20 Fruit and vegetable (servings per day), change from baseline.
1.21
1.21. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 21 Fruit (servings per day), change from baseline.
1.22
1.22. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 22 Vegetable (servings per day), change from baseline.
1.23
1.23. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 23 Dietary fibre (grams per day), change from baseline.
1.24
1.24. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 24 Dietary intake of ascorbic acid (mg/day), change from baseline.
1.25
1.25. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 25 Dietary intake of beta‐carotene (mg/day), change from baseline.
1.26
1.26. Analysis
Comparison 1 Any dietary intervention versus no intervention, Outcome 26 Dietary intake of folate (μg/day), change from baseline.
2.1
2.1. Analysis
Comparison 2 Subgroup analyses, Outcome 1 Total cholesterol (gender).
2.2
2.2. Analysis
Comparison 2 Subgroup analyses, Outcome 2 Total dietary fat (gender).
2.3
2.3. Analysis
Comparison 2 Subgroup analyses, Outcome 3 Fruit & vegetable servings/day (gender).
2.4
2.4. Analysis
Comparison 2 Subgroup analyses, Outcome 4 Total cholesterol (risk group).
2.5
2.5. Analysis
Comparison 2 Subgroup analyses, Outcome 5 Total dietary fat (risk group).
2.6
2.6. Analysis
Comparison 2 Subgroup analyses, Outcome 6 Fruit & vegetable servings/day (risk group).
2.7
2.7. Analysis
Comparison 2 Subgroup analyses, Outcome 7 SBP mmHg (risk group).
2.8
2.8. Analysis
Comparison 2 Subgroup analyses, Outcome 8 DBP mmHg (risk group).
2.9
2.9. Analysis
Comparison 2 Subgroup analyses, Outcome 9 Total cholesterol (setting).
2.10
2.10. Analysis
Comparison 2 Subgroup analyses, Outcome 10 Total dietary fat (setting).
2.11
2.11. Analysis
Comparison 2 Subgroup analyses, Outcome 11 Fruit & vegetable servings/day (setting).
2.12
2.12. Analysis
Comparison 2 Subgroup analyses, Outcome 12 Total cholesterol (intensity).
2.13
2.13. Analysis
Comparison 2 Subgroup analyses, Outcome 13 Total dietary fat (intensity).
2.14
2.14. Analysis
Comparison 2 Subgroup analyses, Outcome 14 Fruit & vegetable servings/day (intensity).
2.15
2.15. Analysis
Comparison 2 Subgroup analyses, Outcome 15 SBP mmHg (intensity).
2.16
2.16. Analysis
Comparison 2 Subgroup analyses, Outcome 16 DBP mmHg (intensity).
2.17
2.17. Analysis
Comparison 2 Subgroup analyses, Outcome 17 Total cholesterol (duration).
2.18
2.18. Analysis
Comparison 2 Subgroup analyses, Outcome 18 Total dietary fat (duration).
2.19
2.19. Analysis
Comparison 2 Subgroup analyses, Outcome 19 Fruit & vegetable servings/day (duration).
2.20
2.20. Analysis
Comparison 2 Subgroup analyses, Outcome 20 SBP mmHg (duration).
2.21
2.21. Analysis
Comparison 2 Subgroup analyses, Outcome 21 DBP mmHg (duration).
See this image and copyright information in PMC

Update of

References

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Henderson WHTV 1990 {published data only}
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John 2002 {published data only}
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Keyserling 1997 {published data only}
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Koopman 1990 {published data only}
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Kristal 2000 {published data only}
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Lanza men 2001 {published data only}
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Lanza women 2001 {published data only}
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Little 2004 {published data only}
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Maskarinec 1999 {published data only}
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Moy 2001 {published data only}
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Schatzkin 2000 {published data only}
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Smith‐Warner 2000 {published data only}
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Sorensen work+family {published and unpublished data}
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Stevens 2003 {published data only}
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TOHP I {published and unpublished data}
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TOHP II {published and unpublished data}
    1. Cook NR, Cutler JA, Obarzanek E, Buring JE, Rexrode KM, Kumanyika SK, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow‐up of the trials of hypertension prevention (TOHP). BMJ 2007;334(7599):885‐8. - PMC - PubMed
    1. Whelton PK, Appel L, Charleston J, Dalcin A, Haythornthwaite J, Rosofsky W, et al. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high‐normal blood pressure. The trials of hypertension prevention, phase II. Archives of Internal Medicine 1997;157(6):657‐67. - PubMed
van der Veen 2002 {published data only}
    1. Veen J, Bakx C, Hoogen H, Verheijden M, Bosch W, Ween C, et al. Stage‐matched nutrition guidance for patients at elevated risk for cardiovascular disease: a randomized intervention study in family practice. Journal of Family Practice 2002;51(9):751‐8. - PubMed

References to studies excluded from this review

Anderson 2001 {published data only}
    1. Anderson JV, Bybee DI, Brown RM, McLean DF, Garcia EM, Breer ML, et al. 5 a day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association 2001;101(2):195‐202. - PubMed
Appel 2001 {published data only}
    1. Appel LJ, Espeland MA, Easter L, Wilson AC, Folmar S, Lacy CR. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Archives of Internal Medicine 2001;161(5):685‐93. - PubMed
Bhargava 2004 {published data only}
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Boyd 1990 {published data only}
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Braeckman 1999 {published and unpublished data}
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Burke 2005 {published data only}
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Cappuccio 2006 {published data only}
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Chalmers 1986 {published data only}
    1. Chalmers J, Morgan T, Doyle A, Dickson B, Hopper J, Mathews J, et al. Australian National Health and Medical Research Council dietary salt study in mild hypertension. Journal of Hypertension. Supplement 1986;4(6):S629‐37. - PubMed
Colombo 2005 {published data only}
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Djuric 2009 {published data only}
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Due 2008 {published data only}
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Eid 2006 {published data only}
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Estruch 2006 {published data only}
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Fehily 1983 {published data only}
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Fitzgibbon 2004 {published data only}
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Fries 2005 {published data only}
    1. Fries E, Edinboro P, McClish D, Manion L, Bowen D, Beresford SA, et al. Randomized trial of a low‐intensity dietary intervention in rural residents: the Rural Physician Cancer Prevention Project. American Journal of Preventive Medicine 2005;28(2):162‐8. - PubMed
Havas 2003 {published data only}
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Hellenius 1997 {published data only}
    1. Hellenius ML, Krakau I, DeYear FU. Favourable long‐term effects from advice on diet and exercise given to healthy men with raised cardiovascular risks. Nutrition, Metabolism, and Cardiovascular Diseases 1997;7:293‐300.
Henkin 2000 {published data only}
    1. Henkin Y, Shai I, Zuk R, Brickner D, Zuilli I, Neumann L, et al. Dietary treatment of hypercholesterolemia: do dietitians do it better? A randomized, controlled trial. American Journal of Medicine 2000;109(7):549‐55. - PubMed
HPTR 1990 {published data only}
    1. Hypertension Prevention Trial Research Group. The Hypertension Prevention Trial: three‐year effects of dietary changes on blood pressure. Archives of Internal Medicine 1990;150(1):153‐62. - PubMed
Hunt 2001 {published data only}
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Hyman 1998 {published data only}
    1. Hyman DJ, Ho KSI, Dunn JK, Simons‐Morton D. Dietary intervention for cholesterol reduction in public clinic patients. American Journal of Preventive Medicine 1998;15(2):139‐45. - PubMed
Iso 2002 {published data only}
    1. Iso H, Imano H, Nakagawa Y, Kiyama M, Kitamura A, Sato S, et al. One‐year community‐based education program for hypercholesterolemia in middle‐aged Japanese: a long‐term outcome at 8‐year follow‐up. Atherosclerosis 2002;164(1):195‐202. - PubMed
Korhonen 2003 {published data only}
    1. Korhonen M, Kastarinen M, Uusitupa M, Puska P, Nissinen A. The effect of intensified diet counseling on the diet of hypertensive subjects in primary health care: a 2‐year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland. Preventive Medicine 2003;36(1):8‐16. - PubMed
Larsen 2010 {published data only}
    1. Larsen TM, Dalskov S, Baak M, Jebb S, Kafatos A, Pfeiffer A, et al. The Diet, Obesity and Genes (Diogenes) Dietary Study in eight European countries ‐ a comprehensive design for long‐term intervention. Obesity Reviews 2010;11(1):76‐91. - PubMed
    1. Larsen TM, Dalskov S‐M, Baak M, Jebb SA, Papadaki A, Pfeiffer AFH, et al. for the Diet, Obesity, and Genes (Diogenes) Project. Diets with high or low protein content and glycemic index for weight‐loss maintenance. New England Journal of Medicine 2010;363:2102‐13. - PMC - PubMed
Leduc 1994 {published data only}
    1. Leduc CP, Cherniak D, Faucher J. Effectiveness of a group dietary intervention on hypercholesterolemia: a randomised controlled clinical trial. Atherosclerosis 1994;109(1‐2):149.
Marcus 2001 {published data only}
    1. Marcus AC, Heimendinger J, Wolfe P, Fairclough D, Rimer BK, Morra M, et al. A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS. Preventive Medicine 2001;33(3):204‐16. - PubMed
Martin 2006 {published data only}
    1. Martin LJ, Greenberg CV, Kriukov V, Minkin S, Jenkins DJ, Boyd NF. Intervention with a low‐fat, high‐carbohydrate diet does not influence the timing of menopause. American Journal of Clinical Nutrition 2006 Oct;84(4):920‐8. - PubMed
Ni Mhurchu 1998 {published data only}
    1. Ni Mhurchu C, Margetts BM, Speller V. Randomised clinical trial comparing the effectiveness of two dietary interventions for patients with hyperlipidaemia. Clinical Science 1998;95:479‐87. - PubMed
Ockene 1999 {published data only}
    1. Ockene IS, Hebert JR, Ockene JK, Saperia GM, Stanek E, Nicolosi R, et al. Effect of physician‐delivered nutrition counseling training and an office‐support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Archives of Internal Medicine 1999;159(7):725‐31. - PubMed
Resnicow 2001 {published data only}
    1. Resnicow K, Jackson A, Wang T, De AK, McCarty F, Dudley WN, et al. A motivational interviewing intervention to increase fruit and vegetable intake through Black churches: results of the Eat for Life trial. American Journal of Public Health 2001;91(10):1686‐93. - PMC - PubMed
Richards 2006 {published data only}
    1. Richards A, Kattelmann KK, Ren C. Motivating 18‐ to 24‐year‐olds to increase their fruit and vegetable consumption. Journal of the American Dietetic Association 2006;106(9):1405‐11. - PubMed
Sartorelli 2005 {published data only}
    1. Sartorelli DS, Sciarra EC, Franco LJ, Cardoso MA. Beneficial effects of short‐term nutritional counselling at the primary health‐care level among Brazilian adults. Public Health Nutrition 2005;8(7):820‐5. - PubMed
Simon 1997 {published data only}
    1. Simon MS, Heilbrun LK, Boomer‐Allison, Kresge C, Depper J, Kim PN, et al. A randomized trial of a low‐fat dietary intervention in women at high risk for breast cancer. Nutrition and Cancer 1997;27(2):136‐42. - PubMed
Smith 1997 {published data only}
    1. Smith AM, Owen N, Baghurst KI. Influence of socioeconomic status on the effectiveness of dietary counselling in healthy volunteers. Journal of Nutrition Education 1997;29(1):27‐35.
Sorensen 1992 {published data only}
    1. Sorensen G, Morris DM, Hunt MK, Hebert JR, Harris DR, Stoddard A, et al. Work‐site nutrition intervention and employees' dietary habits: the Treatwell program. American Journal of Public Health 1992;82(6):877‐80. - PMC - PubMed
Torjesen 1997 {published data only}
    1. Torjesen PA, Birkeland KI, Anderssen SA, Hjermann I, Holme I, Urdal P. Lifestyle changes may reverse development of the insulin resistance syndrome. The Oslo Diet and Exercise Study: a randomized trial. Diabetes Care 1997;20(1):26‐31. - PubMed
WHI 2006 {published data only}
    1. Beresford SA, Johnson KC, Ritenbaugh C, Lasser NL, Snetselaar LG, Black HR, et al. Low‐fat dietary pattern and risk of colorectal cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA 2006;295(6):643‐54. - PubMed
    1. Howard BV, Van HL, Hsia J, Manson JE, Stefanick ML, Wassertheil‐Smoller S, et al. Low‐fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA 2006;295(6):655‐66. - PubMed
    1. Prentice RL, Caan B, Chlebowski RT, Patterson R, Kuller LH, Ockene JK, et al. Low‐fat dietary pattern and risk of invasive breast cancer: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA 2006;295(6):629‐42. - PubMed
Willaing 2004 {published data only}
    1. Willaing I, Ladelund S, Jorgensen T, Simonsen T, Nielsen LM. Nutritional counselling in primary health care: a randomized comparison of an intervention by general practitioner or dietician. European Journal of Cardiovascular Prevention & Rehabilitation 2004;11(6):513‐20. - PubMed
Williams‐Piehota {published data only}
    1. Williams‐Piehota P, Pizarro J, Navarro Silvera SA, Mowad L, Salovey P. Need for cognition and message complexity in motivating fruit and vegetable intake among callers to the cancer information service. Health Communication 2006;19(1):75‐84. - PubMed

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