Factors associated with diet quality among Brazilian individuals with cardiovascular diseases.

BACKGROUND: An individual's dietary pattern contributes in different ways to the prevention and control of recurrent cardiovascular events. However, the quality of the diet is influenced by several factors. The present study aimed to evaluate the quality of the diet of individuals with cardiovascular diseases and determine whether there is an association between sociodemographic and lifestyle factors. METHODS: This is a cross-sectional study carried out with individuals with atherosclerosis (coronary artery disease, cerebrovascular disease or peripheral arterial disease) recruited from 35 reference centres for the treatment of cardiovascular disease in Brazil. Diet quality was assessed according to the Modified Alternative Healthy Eating Index (mAHEI) and stratified into tertiles. For comparing two groups, the Mann-Whitney or Pearson's chi-squared tests were used. However, for comparing three or more groups, analysis of variance or Kruskal-Wallis was used. For the confounding analysis, a multinomial regression model was used. p < 0.05 was considered statistically significant. RESULTS: In total, 2360 individuals were evaluated: 58.5% male and 64.2% elderly. The median (interquartile range [IQR]) of the mAHEI was 24.0 (20.0-30.0), ranging from 0.4 to 56.0 points. When comparing the odds ratios (ORs) for the low (first tertile) and medium (second tertile) diet quality groups with the high-quality group (third tertile), it was observed that there was an association between diet quality with a family income of 1.885 (95% confidence intervals [CI] = 1.302-2.729) and 1.566 (95% CI = 1.097-2.235), as well as physical activity of 1.391 (95% CI = 1.107-1.749) and 1.346 (95% CI = 1.086-1.667), respectively. In addition, associations were observed between diet quality and region of residence. CONCLUSIONS: A low-quality diet was associated with family income, sedentarism and geographical area. These data are extremely relevant to assist in coping with cardiovascular disease because they enable an assessment of the distribution of these factors in different regions of the country.

Consumption of unprocessed or minimally processed foods and their association with cardiovascular events and cardiometabolic risk factors in Brazilians with established cardiovascular events.

Consumption of food in its natural form has an inverse relationship with cardiometabolic risk factors; however, the relationship between consumption of unprocessed or minimally processed foods and the presence of cardiovascular diseases (CVD) remains unclear in individuals receiving secondary care for CVD. Thus, we aimed to evaluate the association between the consumption of unprocessed or minimally processed foods and the presence of CVD and cardiometabolic risk factors in individuals with established CVD. Baseline data from 2357 participants in a Brazilian multicentre study showed that the consumption of unprocessed or minimally processed foods corresponded to most of the daily caloric intake (69.3%). Furthermore, regression analyses showed that higher consumption of unprocessed or minimally processed foods (>78.0% of caloric intake) was associated with a lower prevalence of elevated waist circumference (WC1; PR: 0.889; CI: 0.822-0.961; WC2; PR: 0.914; CI: 0.873-0.957) and overweight (PR: 0.930; CI: 0.870-0.994), but also was associated with simultaneous occurrence of coronary and peripheral artery disease and stroke (OR: 2.802; CI: 1.241-6.325) when compared with a lower intake (<62.8% of caloric intake). These findings reinforce the importance of nutritional guidance that considers the profile of the target population and the composition and quality of the meals consumed.

Effects of supplementing a healthy diet with pecan nuts or extra-virgin olive oil on inflammatory profile of patients with stable coronary artery disease: a randomised clinical trial.

The consumption of nuts and extra-virgin olive oil has been associated with suppression of inflammatory pathways that contribute to atherosclerosis, but its role on the modulation of the inflammatory profile in patients with established coronary artery disease (CAD) is unclear. The aim of this study was to evaluate the effects of adding pecan nuts or extra-virgin olive oil to a healthy diet on inflammatory markers in patients with stable CAD. In this randomised clinical trial, 204 patients were enrolled to three study groups: sixty seven to control group (CG: healthy diet), sixty eight to pecan nuts group (PNG: 30 g/d of pecans + healthy diet) and sixty nine to extra-virgin olive oil group (OOG: 30 ml/d of extra-virgin olive oil + healthy diet). High-sensitivity C-reactive protein (hs-CRP, in mg/l), fibrinogen (mg/dl), IL 2, 4, 6, 10 (pg/ml) and interferon-γ (IFN-γ, in pg/ml), IL-6/IL-10, IL-2/IL-4 and IFN-/γIL-4 ratios were evaluated at baseline and after the follow-up (12 weeks). As main results, after adjustment for sex, statin used and relative body weight variation, there were no differences between groups regarding inflammatory markers at the end of the study. IL-6 levels (primary outcome) were reduced in 12 weeks when compared with baseline in all study groups (CG: difference: -0·593 (se = 0·159) pg/dL; PNG: difference: -0·335 (se = 0·143) pg/dl; OOG: IL-6 difference: -0·325 (se = 0·143) pg/dl). In conclusion, there was no significant effect of including pecan nuts or extra virgin olive oil to a healthy diet on inflammatory markers in individuals with CAD.

Adiposity and insulin resistance mediate the inverse association between legume intake and blood pressure: a cross-sectional analysis in secondary cardiovascular prevention.

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.

Three-year effects of bariatric surgery on obstructive sleep apnea in patients with obesity grade 1 and 2: a sub-analysis of the GATEWAY trial.

BACKGROUND: Most of the evidence on bariatric surgery on obstructive sleep apnea (OSA) is based on observational studies and/or short-term follow-up in patients with obesity grade 3. SUBJECTS/METHODS: This randomized study compared the effects of roux-en-Y gastric bypass (RYGB) or usual care (UC) on OSA severity in patients with obesity grade 1-2. Mild, moderate, and severe OSA was defined by the apnea-hypopnoea index (AHI): 5-14.9; 15-29.9, and ≥30 events/h, respectively. OSA remission was defined by converting any form of OSA into normal AHI (<5 events/h). RESULTS: After 3-year of follow-up, the body-mass index increased in the UC while decreased in the RYGB group: +1.7 (-1.9; 2.7) versus -10.6 (-12.7; -9.2) kg/m2, respectively. The AHI increased by 5 (-4.2; 12.7) in the UC group while reduced in the RYGB group to -13.2 (-22.7; -7) events/h. UC significantly increase the frequency of moderate OSA (from 15.4 to 46.2%). In contrast, RYGB had a huge impact on reaching no OSA status (from 4.2 to 70.8%) in parallel to a decrease of moderate (from 41.7 to 8.3%) and severe OSA (from 20.8 to 0%). CONCLUSIONS: RYGB is an attractive strategy for mid-term OSA remission or decrease moderate-to-severe forms of OSA in patients with obesity grade 1-2.

Pro-inflammatory diet is associated with a high number of cardiovascular events and ultra-processed foods consumption in patients in secondary care.

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.

Ultra-processed foods consumption is associated with cardiovascular disease and cardiometabolic risk factors in Brazilians with established cardiovascular events.

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.

Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension).

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/m2. 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 <140 mm Hg and 90 mm Hg, respectively, at 12 months. RESULTS: We included 100 patients (70% 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<0.001). Remission of hypertension was present in 25 of 49 (51%) and 22 of 48 (45.8%) patients randomized to gastric bypass, considering office and 24-hour ambulatory blood pressure monitoring, respectively, whereas no patient submitted to medical therapy was free of antihypertensive drugs at 12 months. A post hoc analysis for the primary end point considering the SPRINT (Systolic Blood Pressure Intervention Trial) target reached consistent results, with a rate ratio of 3.8 (95% confidence interval, 1.4-10.6; 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.

Triglyceride-glucose index is associated with symptomatic coronary artery disease in patients in secondary care.

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.

Development of a dietary index based on the Brazilian Cardioprotective Nutritional Program (BALANCE).

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 < 0,05). The components of the index showed low correlations with each other. The correlations between each individual component with the total index were > 0.40. Cronbach's alpha coefficient was 0.66. High scores in the index were inversely associated (p < 0,05) with energy, total fat, monounsaturated fat (MUFA) and cholesterol; they were positively associated (p < 0,05) with carbohydrates and fiber. Hypertensive men and diabetic women had higher scores, while male smokers had lower scores. CONCLUSIONS: The BALANCE DI showed reliability and construct validity similar to other DI. It also detected characteristics of individuals that are associated with higher or lower index scores.

Association between plasma fatty acids and inflammatory markers in patients with and without insulin resistance and in secondary prevention of cardiovascular disease, a cross-sectional study.

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)-1ß, 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 < 0.05). Among those with insulin resistance there was a positive association between monounsaturated fatty acids and arachidonic fatty acid and adiponectin (p < 0.05), and a negative association between monounsaturated and polyunsaturated fatty acids and pro-inflammatory biomarkers (p < 0.05), as well as a negative association between polyunsaturated fatty acids and adiponectin (p < 0.05). Our study has not found any association between hs-CRP and plasma fatty acids. CONCLUSIONS: Subjects in secondary prevention for cardiovascular disease with insulin resistance have a higher concentration of hs-CRP and IL-6 than individuals without insulin resistance, and these inflammatory biomarkers are positively associated with saturated fatty acids and negatively associated with unsaturated fatty acids.

The Brazilian Cardioprotective Nutritional Program to reduce events and risk factors in secondary prevention for cardiovascular disease: study protocol (The BALANCE Program Trial).

This article reports the rationale for the Brazilian Cardioprotective Nutritional Program (BALANCE Program) Trial. This pragmatic, multicenter, nationwide, randomized, concealed, controlled trial was designed to investigate the effects of the BALANCE Program in reducing cardiovascular events. The BALANCE Program consists of a prescribed diet guided by nutritional content recommendations from Brazilian national guidelines using a unique nutritional education strategy, which includes suggestions of affordable foods. In addition, the Program focuses on intensive follow-up through one-on-one visits, group sessions, and phone calls. In this trial, participants 45 years or older with any evidence of established cardiovascular disease will be randomized to the BALANCE or control groups. Those in the BALANCE group will receive the afore mentioned program interventions, while controls will be given generic advice on how to follow a low-fat, low-energy, low-sodium, and low-cholesterol diet, with a view to achieving Brazilian nutritional guideline recommendations. The primary outcome is a composite of death (any cause), cardiac arrest, acute myocardial infarction, stroke, myocardial revascularization, amputation for peripheral arterial disease, or hospitalization for unstable angina. A total of 2468 patients will be enrolled in 34 sites and followed up for up to 48 months. If the BALANCE Program is found to decrease cardiovascular events and reduce risk factors, this may represent an advance in the care of patients with cardiovascular disease.

The Brazilian Cardioprotective Nutritional (BALANCE) Program improves diet quality in patients with established cardiovascular disease: Results from a multicenter randomized controlled trial.

Dietary modifications are essential strategies for cardiovascular disease prevention. However, studies are needed to investigate the diet quality of individuals undergoing secondary prevention in cardiology and who received dietary intervention based on cardiovascular disease management. We prospectively evaluated the diet quality in the Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program Trial). We hypothesized that the BALANCE Program could improve patients' dietary pattern according to different indices of diet quality such as the Dietary Inflammatory Index (DII); the dietary total antioxidant capacity; overall, healthful, and unhealthful Plant-Based Diet Index (PDI, hPDI, and uPDI, respectively); and modified Alternative Healthy Eating Index (mAHEI). This multicenter randomized, controlled trial included patients aged ≥45 years randomly assigned to either the experimental or control group. Data from 2185 participants at baseline and after 12, 24, 36, and 48 months showed that the intervention group (n = 1077) had lower mean values of DII and higher dietary total antioxidant capacity, PDI, hPDI, and mAHEI than the control group. The results also showed differences between the follow-up times for DII, hPDI, and uPDI (48 months vs baseline) and for PDI and mAHEI (24 months vs baseline), regardless of group. The interaction analysis demonstrated that the intervention group showed better results than the control group at 12, 24, 36, and 48 months for the DII and at months 12, 36, and 48 for the mAHEI. Our results provide prospective evidence that the BALANCE Program improved the diet quality in those in secondary cardiovascular prevention according to different indices, with the intervention group showing better results than the control group.

Could the Wheel of Cardiovascular Health Diet Be a Tool for Diet Quality in Nutritional Counseling? Comparison with Healthy Eating Index-2020.

OBJECTIVE: The Wheel of Cardiovascular Health Diet was recently elaborated based on current nutritional recommendations for healthy eating and was made for person-centered nutritional counseling, thus it may be an interesting tool to improve food awareness. However, its validity is yet to be tested. We hypothesized that the self-perception of patients diagnosed with chronic diseases, evaluated by the Wheel of Cardiovascular Health Diet, is satisfactory in assessing the quality of their diets, compared with the Healthy Eating Index-2020. METHODS: This is a cross-sectional analysis of adults with uncontrolled hypertension or type 2 diabetes. The patients answered the Wheel of Cardiovascular Health Diet, and then, based on the food frequency questionnaire, we analyzed the Healthy Eating Index-2020. RESULTS: A total of 330 patients were included in the study: 91.5% had hypertension, 58.5% had type 2 diabetes, and the median age was 58 (50-65) years. The mean difference observed between the percentage of the graphic area assessed by the patients' self-perception from the Wheel of Cardiovascular Health Diet and Healthy Eating Index-2020 was -10.0% (95%CI -35.3 to 15.3), and a moderate correlation was observed. Linear Regression models showed that a 10-point increase in patients' self-perception in the Wheel of Cardiovascular Health Diet is associated with a 2.9% increase (95%CI 2.08 to 3.70) in the diet quality by the Healthy Eating Index-2020 and is associated with lower BMI values: ß = -0.42 kg/m2 (95%CI -0.83 to -0.01). CONCLUSION: The Wheel of Cardiovascular Health Diet performed satisfactorily regarding validity and reliability by BMI and was associated with higher overall dietary quality, with the Healthy Eating Index-2020 as a relative reference.

Adequacy of Fatty Acids Consumption Among Individuals in Secondary Cardiovascular Prevention. / Adequação do Consumo de Ácidos Graxos entre Pacientes em Prevenção Cardiovascular Secundária.

BACKGROUND: Adhering to a diet adequate in macronutrients is crucial for the secondary prevention of cardiovascular diseases. OBJECTIVE: To assess the prevalence of adherence to recommendations for the consumption of dietary fatty acids for the prevention and treatment of cardiovascular diseases and to estimate whether the presence of certain cardiovascular risk factors would be associated with adherence. METHODS: Cross-sectional study using baseline data from 2,358 participants included in the "Brazilian Cardioprotective Nutritional Program Trial". Dietary intake and cardiovascular risk factors were assessed. Adequate intake of polyunsaturated fatty acids (PUFA) was considered as ≥10% of total daily energy intake; for monounsaturated fatty acids (MUFA), 20%; and for saturated fatty acids (SFA), <7% according to the Brazilian Society of Cardiology. A significance level of 5% was considered in the statistical analysis. RESULTS: No participant adhered to all recommendations simultaneously, and more than half (1,482 [62.9%]) did not adhere to any recommendation. Adherence exclusively to the SFA recommendation was the most prevalent, fulfilled by 659 (28%) participants, followed by adherence exclusively to the PUFA (178 [7.6%]) and MUFA (5 [0.2%]) recommendations. There was no association between the number of comorbidities and adherence to nutritional recommendations (p = 0.269). Participants from the Brazilian Northeast region showed a higher proportion of adherence to SFA consumption recommendations (38.42%) and lower adherence to PUFA intake (3.52%) (p <0.001) compared to other regions. CONCLUSIONS: Among the evaluated sample, there was low adherence to nutritional recommendations for dietary fatty acid consumption.

FUNDAMENTO: A adesão à uma alimentação adequada em macronutrientes é fundamental para a prevenção secundária de doenças cardiovasculares. OBJETIVO: Avaliar a prevalência de adesão às recomendações de consumo de ácidos graxos para prevenção e tratamento de doenças cardiovasculares, e estimar se a presença de determinados fatores de risco cardiovascular estaria associada à adesão. MÉTODOS: Estudo transversal com os dados de linha de base de 2358 participantes do estudo "Brazilian Cardioprotective Nutritional Program Trial". Dados de consumo alimentar, e fatores de risco cardiovascular foram avaliados. Foi considerada, de acordo com a Sociedade Brasileira de Cardiologia, uma ingestão adequada de ácidos graxos poli-insaturados (AGPI) ≥10% do consumo total de energia diária, para ácidos graxos monoinsaturados (AGM), 20% e para ácidos graxos saturados (AGS), <7%. Na análise estatística foi considerando nível de significância de 5%. RESULTADOS: Nenhum participante aderiu a todas as recomendações de forma simultânea e mais da metade (1482 [62,9%]) não aderiu a nenhuma recomendação. A adesão exclusivamente à recomendação de AGS foi a mais prevalente, sendo cumprida por 659 (28%) dos participantes, seguida da adesão exclusivamente à recomendação de AGP (178 [7,6%]) e de AGM (5 [0,2%]). Não houve associação entre o número de comorbidades e a adesão às recomendações nutricionais (p =0,269). Os participantes da região Nordeste do país apresentaram maior proporção de adesão às recomendações para consumo de AGS (38,42%), e menor para ingestão de AGPI (3,52%) (p <0,001) em comparação às demais. CONCLUSÕES: Na amostra avaliada, evidenciou-se baixa adesão às recomendações nutricionais para consumo de ácidos graxos.

The remote intercessory prayer, during the clinical evolution of patients with COVID -19, randomized double-blind clinical trial.

The objective of this study was to evaluate the effect of intercessory prayer performed by a group of spiritual leaders on the health outcomes of hospitalized patients with Novel Coronavirus (COVID-19) infection, specifically focusing on mortality and hospitalization rates. DESIGN: This was a double-blinded, controlled, and randomized trial conducted at a private hospital in São Paulo, Brazil. INTERVENTIONS: Both groups continued to receive their usual medical care in accordance with HCor Hospital's institutional patient care protocol for COVID-19 patients. INTERVENTION: Both groups received their regular medical care according to HCor's institutional patient care protocol for COVID-19 patients. The intervention group, in addition to standard treatment, received intercessory prayers performed by a group of spiritual leaders. MAIN OUTCOME MEASURES: The primary endpoint was in-hospital mortality. Secondary endpoints included the need for mechanical ventilation during hospitalization, duration of mechanical ventilation, length of ICU stay, and length of hospital stay. RESULTS: A total of 199 participants were randomly assigned to the groups. The primary outcome, in-hospital mortality, occurred in 8 out of 100 (8.0 %) patients in the intercessory prayer group and 8 out of 99 (8.1 %) patients in the control group (HR 0.86 [0.32 to 2.31]; p = 0.76). Additionally, there were no significant differences between the groups in terms of secondary outcomes. CONCLUSION: The study found no evidence of an effect of intercessory prayer on the primary outcome of mortality or on the secondary outcomes of hospitalization time, ICU time, and mechanical ventilation time.

The AHA Recommendations for a Healthy Diet and Ultra-Processed Foods: Building a New Diet Quality Index.

The American Heart Association (AHA) has developed the concept of "ideal cardiovascular health" (ICH), a seven-component score, which includes health dietary metrics. Higher ultra-processed foods intake is related with several cardiometabolic and cardiovascular diseases. We propose to develop and validate the Cardiovascular Health Diet Index (CHDI), a diet quality index that combines the AHA's recommendations of a healthy diet for cardiovascular health and ultra-processed foods. We used dietary data obtained through a 114-item FFQ from 14,779 participants of the Brazilian Longitudinal Study of Adults Health (ELSA-Brasil). The CHDI had 11 components and a total score ranging from 0 to 110 points. Validation and reliability analyses were performed, including principal component analyses, association with selected nutrients, means differences between groups (for example, smokers vs. non-smokers), Cronbach's alpha, and linear regression analyses between CHDI and overall dietary quality. The mean CHDI was 57.1 points (95% CI 47.9:66.0). The CHDI had four dimensions; in addition, it was associated with nutrients related to cardiovascular health, and the points were significantly (p < 0.001) lower in smokers (52.1) than in non-smokers (57.8). Cronbach's alpha value was 0.50. After age and sex adjustment, the CHDI score remained associated with a higher overall dietary quality (ß 0.87, 95%CI 0.84:0.89, p < 0.001). The CHDI proved to be valid and reliable for use, in addition to being associated with higher overall dietary quality. The use of CHDI is expected to assess the population's compliance with dietary recommendations for promoting cardiovascular health and preventing cardiovascular disease.

Tracking of Dietary Patterns in the Secondary Prevention of Cardiovascular Disease after a Nutritional Intervention Program-A Randomized Clinical Trial.

Individuals with a history of previous cardiovascular events have an increased risk of mortality and morbidity, so adherence to a healthy dietary pattern is essential. We aimed to evaluate and compare dietary patterns between the control and the experimental group from the BALANCE Program. A total of 2360 individuals aged 45 years or older with previous cardiovascular disease were included. The individuals were randomized into two groups: intervention (dietary prescription with nutritional recommendations, nutritional education program based on playful strategies, suggestions of typical and accessible Brazilian foods and intensive monitoring) and control (conventional nutritional counseling). The dietary patterns were identified using factor analysis with the principal component extraction method, and the t-Student tests and ANOVA test were performed to evaluate the associated factors. Four dietary patterns were identified for both groups: "Traditional", "Snack", "Western", "Cardioprotective". There was an increase in the variances of the "Cardioprotective" pattern in both groups. Regarding the "Western" pattern, there was a significant reduction in the variances of the experimental group (10.63% vs. 8.14%). Both groups had improvements in eating habits, especially in the first year of follow-up. The greater increase in adherence to the traditional and cardioprotective pattern in the experimental group justifies the initiative of the BALANCE program.

Absolute and Relative Agreement between the Current and Modified Brazilian Cardioprotective Nutritional Program Dietary Index (BALANCE DI) and the American Heart Association Healthy Diet Score (AHA-DS) in Post Myocardial Infarction Patients.

The American Heart Association Diet Score (AHA-DS) defines the cardiovascular health, and the Brazilian Cardioprotective Nutritional Program Dietary Index (BALANCE DI) was designed to evaluate diet quality in secondary cardiovascular prevention settings. Our aim was to assess the absolute and relative agreement between both tools in Brazilian adults after a myocardial infarction (MI). In this cross-sectional study, 473 individuals were included and had their diet assessed by a 24 h food recall and a semi-quantitative Food Frequency Questionnaire. The weighted Kappa between BALANCE DI and primary AHA-DS was 0.66 (95% CI: 0.08-0.21), and between BALANCE DI and total AHA-DS was 0.70 (95% CI: 0.20-0.32). To improve the agreement between the tools, modifications were made to the BALANCE DI scoring system. The weighted Kappa between New BALANCE DI and primary AHA-DS was 0.77 (95% CI: 0.36-0.48), and between BALANCE DI and total AHA-DS was 0.76 (95% CI: 0.34-0.46). The mean bias observed between the New BALANCE DI as compared to the primary and total AHA-DS was -16% (-51 to 19) and -8% (-41 to 24), respectively. Our results suggest that the New BALANCE DI may be a useful tool to evaluate diet quality in post MI patients.

Dietary total antioxidant capacity is inversely associated with cardiovascular events and cardiometabolic risk factors: A cross-sectional study.

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.