Carel Mountain, Rachel Hill
Academic Electronic Health Record in Mental Health Clinical: A Quality Review
Computers, informatics, nursing : CIN
homecirculationvol 123 24components cardioprotective diet free accessresearch articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessresearch articlepdfepubcomponents cardioprotective dietnew insights dariush mozaffarian md drph lawrence j appel md mph linda van horn phd rd dariush mozaffariandariush mozaffarian division cardiovascular medicine channing laboratory brigham womens hospital harvard medical school departments epidemiology nutrition harvard school public health boston dm welch center prevention epidemiology clinical research johns hopkins university baltimore md lja department preventive medicine feinberg school medicine northwestern university chicago il lvh search papers author lawrence j appellawrence j appel division cardiovascular medicine channing laboratory brigham womens hospital harvard medical school departments epidemiology nutrition harvard school public health boston dm welch center prevention epidemiology clinical research johns hopkins university baltimore md lja department preventive medicine feinberg school medicine northwestern university chicago il lvh search papers author linda van hornlinda van horn division cardiovascular medicine channing laboratory brigham womens hospital harvard medical school departments epidemiology nutrition harvard school public health boston dm welch center prevention epidemiology clinical research johns hopkins university baltimore md lja department preventive medicine feinberg school medicine northwestern university chicago il lvh search papers author originally published21 jun 2011httpsdoiorg101161circulationaha110968735circulation 201112328702891the global burdens cardiovascular diseases cvd type 2 diabetes mellitus dm obesity rising producing enormous losses life disabilityadjusted lifeyears developed developing nations1 burdens preventable occurring unnecessarily younger ages largely owing suboptimal lifestyle includes poor diet quality excess caloric intake physical inactivity smoking25 worldwide striking differences dietary habits rates chronic diseases exist identification targeting dietary factors greatest potential reducing cvd dm obesity major scientific public health importancethe science diet chronic disease relatively young spanning perhaps half century6 new advances offer substantial evidence complementary research paradigms cardiometabolic effects specific dietary factors several recent evidencebased reviews conducted conjunction national international policymaking efforts provide context present report need prioritize selected foods overall dietary patterns rather individual nutrients relevance carbohydrate fat quality well quantity effects policy implications sodium consumption importance energy balance role dietary supplements represent several key findings interest evidencebased insights successful individual public health strategies behavior change also addressed overall present report intended provide useful framework health practitioners policy makers understand contemporary issues related effects diet cvdmethodsevidence effects dietary factors cardiometabolic health reviewed often derived recent comprehensive reviews performed policymaking similar activities including american heart association aha 2020 impact goals committee dm lja7 aha nutrition committee dm lja lvh89 us dietary guidelines advisory committee lja lvh10 world health organization expert consultation fats fatty acids human nutrition dm11 world health organization global burden diseases risk factors injuries nutrition chronic diseases expert group dm12 institute medicine report strategies reduce sodium intake lja13 views expressed present report authors necessarily represent views conclusions committees servedthe present report intended cover possible nutritional topics related cvd rather reviews selected topics reasonably robust evidence yielding important new insights several relevant criteria currently used evaluate evidence effects dietary habits chronic diseases adopted including bradford hill14 world health organization15 similar criteria evidence human studies evaluating established cardiometabolic risk factors clinical end points prioritized including systematic reviews provided quantitative pooled effect estimates multiple studiesfoodsrandomized controlled trials rcts cardiometabolic risk factors prospective cohort studies disease end points provide strong concordant evidence cardiovascular effects several specific foods contrast individual nutrients isolation health effects foods likely represent synergy composite effects interactions multiple factors including carbohydrate quality fiber content specific fatty acids proteins preparation methods food structure bioavailability inherent micronutrients phytochemicals61617 dietary patterns based particular foodscomponents table 1 established cardiometabolic benefits higher dietary fiber healthy fatty acids vitamins antioxidants potassium minerals phytochemicals lower refined carbohydrates sugars salt saturated fatty acid sfa dietary cholesterol trans fattable 1 foodbased components dietary patterns improve cardiometabolic healthgoalserving sizesnutrient benefitsconsume fruits4 5 servings per day1 mediumsized fruit cup fresh frozen unsweetened canned fruit cup dried fruit cup 100 juice many guidelines recommended 4 oz juice per day childrenwhole fruits maximize access vitamins minerals fiber phytochemicals enhance satiety five servings fruit contribute 400600 kcal vegetables4 5 servings per day1 cup raw leafy vegetable cup cutup raw vegetables cooked vegetables 100 juice limit starchy vegetables potatoes cup less per dayraw cooked minimally processed nonstarchy vegetables contribute potassium magnesium fiber antioxidant vitamins micronutrients five servings vegetables including 1 starchy contribute 300500 kcal whole grains3 servings per day place refined grains1 slice whole grain bread 1 cup highfiber whole grain cereal cup cooked whole grain rice pasta cerealwhole grains contribute b vitamins vitamin e fiber folate nutrients enhance satiety displace consumption refined carbohydrates three servings whole grains contribute 210450 kcal fish shellfish2 servings per week preferably oily see text100 g 35 oz goals met commercially prepared deep fried breaded fishprovide omega3 fatty acids proteins selenium magnesium vitamin nutrients one serving contributes 75150 kcal nuts4 5 servings per week50 g 175 oz unsalted nuts preferable minimize sodium intakeprovide fatty acids vegetable protein phosphorus magnesium phytochemicals one serving contributes 160 kcal dairy products2 3 servings per day1 cup milk yogurt 1 oz cheese dietary guidelines recommend lowfat nonfat dairy productsprovide calcium vitamin fatty acids magnesium protein two servings contribute 180300 kcal vegetable oils2 6 servings per day1 teaspoon oil eg cooking salad dressing 1 tablespoon vegetable spread goals met coconut palm kernel tropical oils low unsaturated fatscontribute polyunsaturated monounsaturated fatty acids active compounds flaxseed canola soybean oil provide alphalinolenic acid plantderived omega3 one teaspoon oil provides 40 kcal 1 tablespoon spread provides 70 kcalconsume less fats oils foods containing made partially hydrogenated vegetable oilsavoid intakereduced consumption industrially produced trans fatty acids processed meats eg bacon sausage hot dogs processed deli meatsmodest intake eg 2 servings per week50 g 175 ozreduced consumption salt preservatives heme iron saturated fat dietary cholesterol sugarsweetened beverages sweets grainbased desserts bakery foodsmodest intake eg 5 servings per week8 oz soda 1 small candy cookie doughnut muffin 1 slice cake piereduced consumption liquid sugars refined carbohydrates improved satiety consumption foods alcoholfor consume alcohol 2 daily men 1 daily women5 oz wine 12 oz beer 15 oz spiritsmoderate alcohol use raises hdl cholesterol improves insulin sensitivity reduces systemic inflammation energy balancereduce portion sizes increase physical activity minimum 150 minwk moderate 75 minwk vigorous activity limit tv watching ensure adequate sleepfor average 73kg adult 1 hour brisk walking burns 277 kcal hiking 438 kcal swimming 511 kcal jogging tennis basketball 584 kcal18on basis evidence described review generally consistent us department agriculture american heart association guidelines american heart association 2020 impact goals foodbased recommendations facilitate communication translation individual patients populations specific individual nutrients sodium industrially produced trans fats also highly relevant successfully targeted policy measures reduce consumptionbased 2000kcald diet servings adjusted accordingly higher lower energy consumptionor potentially whole legumes beans although evidence equivalent effects limited characterization whole grain content packaged foods challenging pragmatically sufficient whole grain content defined american heart association 2020 impact goals7 fiber content whole wheat ie least 11 g naturally occurring dietary fiber per 10 g carbohydrate grain productbecause alcoholrelated accidents homicides suicides especially among younger adults alcohol use overall net adverse effect population mortality2 thus alcohol use advisable populationbased strategy reduce cardiovascular risk adults already drink alcohol moderate use encouragedhigher levels physical activity may needed promote prolonged negative energy balance ie sustained weight lossfruits vegetablesin rcts diets emphasize consumption fruits vegetables produce substantial improvements several risk factors including blood pressure bp lipid levels insulin resistance inflammatory biomarker levels endothelial function weight control1925 benefits appear reproducible equivalent amounts representative mineral fiber supplements26 dependent dietary macronutrient fat protein carbohydrate composition22 evidence suggests benefits might derived 1 complex set micronutrients phytochemicals fiber found fruits vegetables 2 potentially enhanced bioavailability nutrients natural state andor 3 replacement less healthful foods diet longterm observational studies greater fruit vegetable consumption associated lower incidence coronary heart disease chd greater fruit consumption associated lower incidence stroke figure 12728 results rcts physiological measures prospective cohorts disease outcomes together provide strong concordant evidence fruit vegetable consumption lowers cvd risk table 2 potential differences health effects contributed specific types fruits vegetables juices require investigationdownload figuredownload powerpointfigure 1 relationships consumption different foods incidence coronary heart disease chd stroke diabetes metaanalyses prospective cohort studies pcs adapted permission mozaffarian29 dashes indicate reported cvd cardiovascular disease rr 95 ci relative risk 95 confidence intervaltable 2 evidence human studies using different research paradigms effects selected foods nutrients dietary patterns cardiovascular diseasesecologic studies clinical end pointsrandomized trials risk factorsprospective cohort studies clinical end pointsrandomized trials clinical end pointsfoods beverages fruits vegetables whole grains fish nuts processed meats unprocessed red meats dairy sugarsweetened beverages alcohol nutrients sodium dietary fiber refined carbohydrates starches total fat trans fat polyunsaturated fat place saturated fat carbohydrate monounsaturated fat place saturated fat carbohydrate saturated fat place carbohydrate seafood omega3 fatty acids plant omega3 fatty acids dietary cholesterol dietary patterns dash mediterranean vegetarian japanese dashes indicate studies performed provide meaningful evidence conflicting limited supporting evidence evidence relatively limited number studies relevant shortcomings eg insufficient numbers studies limited types populations inadequate sample sizes insufficient followup relevant evidence contrary raises important questions fairly consistent evidence several wellconducted studies perceived shortcomings available evidence evidence contrary precludes definite judgment consistent evidence multiple wellconducted studies little evidence contrary evidence benefit lower risk higher intake evidence harm increased risk higher intake evidence appreciable effects null dash dietary approaches stop hypertensionbased strongest evidence effects single major clinical end point including coronary heart disease stroke diabetesbased strongest evidence effects single major risk factor including blood pressure blood lipids plasma glucose insulin resistance heart rate systemic inflammationsee text table 4 evidence minerals vitamins supplementslowering lowdensity lipoprotein cholesterol also lowering highdensity lipoprotein cholesterol change ratio total cholesterol highdensity lipoprotein cholesterolthe evidence effects consuming saturated fat place polyunsaturated fat monounsaturated fat summarized reverse exchanges ie polyunsaturated fat place saturated fat monounsaturated fat place saturated fatwhole grainsalthough single accepted definition whole grain exists whole grains generally comprise bran germ endosperm natural cereal bran contains soluble insoluble dietary fiber b vitamins minerals flavonoids tocopherols germ contains numerous fatty acids antioxidants phytochemicals endosperm provides largely starch carbohydrate polysaccharides storage proteins30 type extent processing appear modify health effects grain carbohydrate consumption figure 2 example removal bran germ reduces dietary fiber important benefits including lowering bp cholesterol levels3132 increases bioavailability rapidity digestion remaining endosperm increases glycemic responses33 eliminates minerals micronutrients phytochemicals may additional independent health benefits16 see carbohydrate amount qualitydownload figuredownload powerpointfigure 2 types processing structure grains sugars starches major research policy gap absence one accepted taxonomy define whole grains carbohydrate quality incorporates various characteristics influence cardiometabolic health including extent processing food structure dietary fiber content content bran germ glycemic response ingestion figure presents proposed taxonomy integrate various characteristics types foods evidence cardiometabolic benefits shaded green evidence adverse cardiometabolic effects shaded red intact minimally processed whole grains darker green ie greater benefits may plausibly greater benefits milled whole grains lighter green ie lesser benefits intact food structure lower glycemic response refined sugars liquid form darkest red ie greatest harms may greater adverse effects refined grains starches sugars lighter red ie lesser harms particularly unfavorable effects satiety weight gain simple complex refined carbohydrates induce similarly high glycemic responses following ingestion amounts typically consumed western diets induce de novo lipogenesis liver ie conversion carbohydrates fat compared glucose fructose produces smaller blood glycemic responses strongly stimulates de novo lipogenesis animalexperimental limited human studies suggest fructose represents half sugars refined sugars either high frucose corn syrup sucrose eg cane sugar beet sugar may additional adverse effects hepatic steatosis insulin resistance corn provides reasonable fiber modestly lower glycemic responses many types potatoes yams sweet potatoes included herein higher nutrient contents lower glycemic responses ingestionin rcts consumption whole grains improves glucoseinsulin homeostasis endothelial function possibly reduces inflammation improves weight loss3436 consumption whole grain oats reduces lowdensity lipoprotein ldl cholesterol without reducing highdensity lipoprotein cholesterol raising triglycerides37 consistent physiological benefits greater whole grain consumption associated lower incidence chd dm possibly stroke figure 1 higher dietary fiber whole grains contributes benefits rcts increased dietary fiber reduces serum triglycerides ldl cholesterol blood glucose bp3132 emerging evidence supports additional independent contributions health characteristics whole grains including slower digestion lower glycemic responses higher content minerals phytochemicals fatty acids1617 thus similar fruits vegetables health effects whole grains may result synergistic effects multiple constituents unlikely matched supplemental fiber alone added bran isolated micronutrients well dietary substitution highly refinedprocessed carbohydrates starches may induce adverse cardiometabolic effects see carbohydrate amount qualityimproved nutritional assessment techniques databases needed quantify evaluate potential contributions health component whole grains evidencebased yet pragmatic definitions constitutes whole grain food figure 2 also essential reduce public confusion allow consumers choose healthy grains wisely one example help monitor national progress toward achieving dietary goals aha 2020 impact goals developed pragmatic definition whole grains based fiber content whole wheat ie 11 g naturally occurring dietary fiber per 10 g carbohydrate grain product eg bread cracker etc7fishfish seafood contain several healthful constituents including specific proteins unsaturated fats vitamin selenium longchain omega3 polyunsaturated fatty acids pufas include eicosapentaenoic acid epa 205 omega3 docosahexaenoic acid dha 226 omega3 humans epa especially dha synthesized low amounts 5 plantderived precursor linolenic acid 183 omega338 thus tissue levels epa plus dha strongly influenced direct dietary consumption average epa plus dha contents different seafood species vary 10fold fatty oily fish anchovies herring farmed wild salmon sardines trout white tuna tend highest concentrations39in vitro animal experiments suggest fish oil direct antiarrhythmic effects40 trials establish direct antiarrhythmic effects patients preexisting arrhythmias inconsistent4142 human trials fish oil lowers triglyceride levels43 systolic diastolic bp44 resting heart rate45 observational rct evidence suggests fish fish oil consumption may also reduce inflammation improve endothelial function normalize heart rate variability improve myocardial relaxation efficiency high doses limit platelet aggregation46consistent physiological benefits habitual fish consumption associated lower incidence chd ischemic stroke especially risk cardiac death figure 1 among generally healthy populations394748 compared fish consumption consumption 250 mgd epa plus dha fish associated 36 lower chd mortality39 fish fish oil among handful dietary factors longterm observational studies rcts cvd outcomes performed table 2 four 8 large rcts fish fish oil including participants without prevalent heart disease documented significant reductions chd events46 several rcts relevant limitations46 metaanalyses rcts fish oil supplementation significantly reduced cardiac mortality including fatal chd sudden cardiac death464950 overall findings concordant longterm observational studies habitual fish intake generally healthy populations physiological benefits fish fish oil intervention studies table 2 whether benefits eating fish fully reproduced fish oil supplements yet establishedconsumption commercially fried fish fish sandwiches linked benefits possibly lower epa plus dha content added ingredients395154 evidence possible adverse cardiovascular effects methylmercury found fish species limited conflicting present effects appear outweigh net cardiovascular benefits fish consumption1054anutsnuts contain several bioactive constituents could improve cardiometabolic health including unsaturated fatty acids vegetable proteins eg larginine nitric oxide precursor fiber folate minerals antioxidants phytochemicals5557 rcts nut consumption reduces total cholesterol ldl cholesterol postprandial hyperglycemia highcarbohydrate meals variably oxidative inflammatory endothelial biomarkers555759 nut consumption also associated less adiposity observational studies rcts addition nuts weight loss diets results either similar greater overall weight loss60 prospective cohorts modest nut consumption associated lower chd incidence figure 16162 epidemiological clinical studies predominantly evaluated tree nuts peanuts effects specific types nuts require study overall cardiovascular benefits modest nut consumption supported effects risk factors shortterm trials magnitude consistency reduced cvd risk observed prospective cohort studies table 2legumes eg peas beans lentils chickpeas may also provide cardiovascular benefits metaanalysis rcts consumption soycontaining foods produced trends toward lowering systolic 58 mm hg diastolic 40 mm hg bp effects achieve statistical significance63 isolated soy protein isoflavones phytoestrogens appear smaller effects producing modest reductions diastolic bp 2 mm hg ldl cholesterol 36364 legumes provide overall package micronutrients phytochemicals fiber could plausibly reduce cardiometabolic risk investigation effects wellconducted prospective cohorts rcts requiredmeatsseveral constituents red meats could increase cardiometabolic risk including sfa cholesterol heme iron processed meats high levels salt preservatives lower consumption red meats consistently part overall dietary patterns associated lower cvd risk see dietary patterns table 2 metaanalyses prospective cohort studies total red meat consumption associated overall nonsignificant trends toward higher risk chd dm figure 16165 different types meat evaluated systematically consumption processed meats unprocessed red meats associated higher incidence chd dm65 findings suggest adverse effects preservatives eg sodium nitrites phosphates andor preparation methods eg hightemperature commercial cookingfrying could influence health effects meat consumption65 one observational analysis unprocessed processed meat consumption associated higher chd risk consumption replaced foods cardiometabolic benefits lowfat dairy nuts fish66dairy foodssome shortterm rcts evaluated potential benefits dairy consumption satiety weight loss inconsistent inconclusive findings6768 multicomponent dietary interventions included daily intake lowfat dairy foods significantly lowered bp lipid levels insulin resistance improved endothelial function independent changes weight202226 multicomponent interventions specific benefits dairy foods cannot quantified separately nonetheless consistent physiological benefits higher dairy consumption associated lower risk stroke dm longterm observational cohorts figure 16971the active constituents cardiometabolic benefits established basis lower content calories sfa cholesterol together established nutritional advantage wholefat dairy dietary guidelines scientific organizations recommend lowfat nonfat dairy consumption10 guidelines generally recommend dairy foods source selected nutrients eg calcium vitamin protein potassium magnesium vitamins rather based equally relevant evidence effects whole food may reduce cardiometabolic risk longterm observational studies lower risk dm metabolic abnormalities variably linked consumption lowfat dairy wholefat dairy both7277 conjugated linoleic acid calcium proposed potential mediators rcts demonstrated small benefits even adverse cardiometabolic effects factors7884 dairy foods contain complex assortment ingredients could play role lowering cardiometabolic risk including specific fatty acids77 proteins peptides vitamins nutrients potentially varying health effects specific dairy foods eg milk yogurt cheese butter also require study8587asugarsweetened beveragesevidence ecological comparisons prospective cohorts supports positive associations sugarsweetened beverage intake adiposity children adults87a88 united states 1965 2002 overweightobesity increasing rapidly proportion total dietary calories consumed beverages increased 118 210 222 caloriesd per pe