Dietary Approaches to Prevent Hypertension Comprehensive lifestyle modification and blood pressure control: a review of the PREMIER trial. Effects of Comprehensive Lifestyle Modification on Diet, Weight, Physical Fitness, and Blood Pressure Control: 18-Month Results of a Randomized Trial The PREMIER intervention helps participants follow the Dietary Approaches to Stop Hypertension dietary pattern and the current Dietary Reference Intakes recommendations. A dietary approach to prevent hypertension: A review of the dietary approaches to stop hypertension (DASH) study Indirect comparisons of competing interventions. Short-term effects of nitrate-rich green leafy vegetables on blood pressure and arterial stiffness in individuals with high-normal blood pressure. Mixed treatment comparison analysis provides internally coherent treatment effect estimates based on overviews of reviews and can reveal inconsistency. Effects of the Dietary Approaches to Stop Hypertension Diet, Exercise, and Caloric Restriction on Neurocognition in Overweight Adults With High Blood Pressure Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions. Effect of polyphenol-rich grape seed extract on ambulatory blood pressure in subjects with pre- and stage I hypertension. Sources of evidence for systematic reviews of interventions in diabetes. Can we rely on the best trial? A comparison of individual trials and systematic reviews Hypertension Intervention Pooling Project. Absence of an effect of high nitrate intake from beetroot juice on blood pressure in treated hypertensive individuals: a randomized controlled trial. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial Self-efficacy as a predictor of weight change and behavior change in the PREMIER trial. Dietary Approaches to Stop Hypertension: a summary of study results. DASH Collaborative Research Group. Sugammadex: when should we be giving it? Effects of Diet and Sodium Intake on Blood Pressure: Subgroup Analysis of the DASH-Sodium Trial Effect of the DASH Diet on Pre- and Stage 1 Hypertensive Individuals in a Free-Living Environment A road map for efficient and reliable human genome epidemiology Cardiorespiratory Fitness in Childhood and Adolescence Affects Future Cardiovascular Risk Factors: A Systematic Review of Longitudinal Studies Effects of dietary patterns on blood pressure: subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial. No Association between Dietary Patterns and Risk for Cognitive Decline in Older Women with 9-Year Follow-Up: Data from the Women's Health Initiative Memory Study. The dietary approaches to stop hypertension (DASH) clinical trial: implications for lifestyle modifications in the treatment of hypertensive patients. Effect of lifestyle modifications on blood pressure by race, sex, hypertension status, and age The 2007 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy. Dietary approaches to the reduction of blood pressure: the independence of weight and sodium/potassium interventions. Dietary approach to hypertension based on low glycaemic index and principles of DASH (Dietary Approaches to Stop Hypertension): a randomised trial in a primary care service. The influence of a physician and patient intervention program on dietary intake. DASH (Dietary Approaches to Stop Hypertension) Diet and Risk of Subsequent Kidney Disease. Impact of dietary and lifestyle factors on the prevalence of hypertension in Western populations. Effects of the PREMIER Interventions on Health-Related Quality of Life Seeing the forests and the trees—innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol Empirical Evidence of the Importance of Comparative Studies of Diagnostic Test Accuracy Global Risk Assessment to Guide Blood Pressure Management in Cardiovascular Disease Prevention Dietary Approaches to Stop Hypertension (DASH) diet: applicability and acceptability to a UK population. The DASH diet and diet costs among ethnic and racial groups in the United States. Effects of the Dietary Approaches to Stop Hypertension (DASH) Diet on the Pressure-Natriuresis Relationship Lifestyle Interventions Reduce Coronary Heart Disease Risk: Results From the PREMIER Trial Interpractice audit of diagnosis and management of hypertension in primary care: educational intervention and review of medical records Chocolate and Prevention of Cardiovascular Disease: A Systematic Review Efficacy and safety of acupuncture for hypertension: An overview of systematic reviews. Addressing Dichotomous Data for Participants Excluded from Trial Analysis: A Guide for Systematic Reviewers Reporting of prognostic markers: current problems and development of guidelines for evidence-based practice in the future A dietary fibre supplement in the treatment of mild hypertension. A randomized, double-blind, placebo-controlled trial Long-Term Weight Loss and Changes in Blood Pressure: Results of the Trials of Hypertension Prevention, Phase II Dietary fiber, glycemic index, glycemic load and renal cell carcinoma risk. Food Omega-3 Fatty Acid Intake of Individuals (Total, Linolenic Acid, Long-Chain) and Their Blood Pressure: INTERMAP Study Systematic review of interventions in the management of overweight and obese children which include a dietary component Systematic review of interventions in the management of overweight and obese children which include a dietary component. Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology. Sodium reduction for hypertension prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol
Elevated blood pressure arises from a combination of environmental and genetic factors and the interactions of these factors . A substantial body of evidence from animal studies , epidemiologic studies , meta-analyses , and r and omized controlled trials has demonstrated that certain dietary patterns and individual dietary elements play a prominent role in the development of hypertension . Changes in diet can lower blood pressure , prevent the development of hypertension , and reduce the risk of hypertension-related complications . Dietary strategies for the prevention of hypertension include reducing sodium intake , limiting alcohol consumption , increasing potassium intake , and adopting an overall dietary pattern such as the DASH ( Dietary Approaches to Stop Hypertension ) diet or a Mediterranean diet . In order to reduce the burden of blood pressure-related complications , efforts that focus on environmental and individual behavioral changes that encourage and promote healthier food choices are warranted The PREMIER trial assessed the aggregate effect on blood pressure ( BP ) of nationally recommended lifestyle modifications in free-living adults with high-normal ( stage 1 ) hypertension . Participants ( N=810 ) were r and omized to the advice-only group ; the established group ( consisting of weight loss , increased physical activity , and reduced sodium and alcohol intake ) ; or the established plus Dietary Approaches to Stop Hypertension ( DASH ) diet group ( consisting of the established interventions in addition to the DASH dietary pattern ) . The primary outcome was change in systolic BP at 6 months . Net of advice only , mean systolic BP declined by 3.7 mm Hg for members of the established group ( p<0.001 ) and 4.3 mm Hg for the established plus DASH group ( p<0.001 ) . The prevalence of hypertension decreased from a baseline of 38 % to 17 % in the established group ( p=0.01 ) and to 12 % in the established plus DASH group ( p<0.001 ) compared with a decrease to 26 % in the advice-only group . The PREMIER trial demonstrated that persons with above-optimal BP and stage 1 hypertension can make multiple lifestyle changes leading to better control of BP Context Can adults make sustained changes in unhealthy lifestyle behaviors ? Content In this multicenter trial , 810 adult volunteers with prehypertension or stage 1 hypertension were r and omly assigned to a multicomponent behavioral intervention group , a group combining the behavioral intervention plus the Dietary Approaches to Stop Hypertension ( DASH ) diet , or an advice only group . At 18 months , participants in both behavioral intervention groups had less hypertension , more weight loss , and better reduction in sodium and fat intake than those receiving advice only . The participants in the DASH diet group also increased their intake of fruits , vegetables , and fiber . Implication s Motivated adults can sustain several lifestyle changes over 18 months , which might reduce their risk for cardiovascular disease . The Editors The public health burden of chronic diseases related to suboptimal diet and physical inactivity is enormous . It has been estimated that these lifestyle factors contribute to approximately 20 % of deaths in the United States ( 1 ) . Incidence of atherosclerotic cardiovascular disease , overweight and obesity , elevated blood pressure and lipid levels , diabetes , osteoporosis , and cancer is increased by unhealthy lifestyles ( 2 - 8 ) . Multiple lifestyle factors , such as physical inactivity ; excessive intake of calories , sodium , saturated fat , and cholesterol ; and inadequate intake of fruits , vegetables , and low-fat dairy products , are etiologically related to the development of these diseases ( 4 , 5 , 8 - 10 ) . To reduce the burden of chronic disease , increased physical activity and changes in diet are needed , yet few intervention studies have attempted to achieve many lifestyle changes simultaneously . The PREMIER r and omized trial tested the effects of 2 multicomponent behavioral interventions on blood pressure ( 11 ) . Both interventions promoted increased physical activity , weight loss , and reduced sodium intake , each of which is recommended by the 2005 Dietary Guidelines Scientific Advisory Committee ( 12 ) . One intervention also added the Dietary Approaches to Stop Hypertension ( DASH ) diet ( 13 ) . This diet , which is high in fruits , vegetables , and low-fat dairy products and low in saturated fat , total fat , and cholesterol , meets each of the major nutrient recommendations that were established by the Institute of Medicine ( 14 - 18 ) . We report the effects of the PREMIER interventions on lifestyle changes and blood pressure status at 18 months . The main results of PREMIER , namely change in blood pressure at 6 months , were reported previously ( 11 ) . Methods The PREMIER study design and rationale ( 19 ) and intervention methods ( 11 ) have been described previously . The institutional review boards at each clinical center ; an external protocol review committee appointed by the National Heart , Lung , and Blood Institute ( NHLBI ) ; and the NHLBI review ed and approved the protocol ( available at www.kpchr.org/public/premier/intervention/default.asp ) . The NHLBI also appointed a data and safety monitoring board to monitor the trial . Each participant provided written informed consent . The trial was conducted from January 2000 through November 2002 . Study Participants Participants were generally healthy adults , age 25 years or older , who had prehypertension or stage 1 hypertension and met the Joint National Committee VI ( JNC VI ) criteria for a 6-month trial of nonpharmacologic therapy ( 2 ) . Targeted recruitment methods were used to ensure adequate representation of clinical ly important subgroups , in particular , African-American persons . Specific methods varied from site to site but included direct mailings , radio and newspaper advertisements , and networking within the local African-American communities . Eligibility criteria included not taking antihypertensive medication and having a systolic blood pressure of 120 to 159 mm Hg and a diastolic blood pressure of 80 to 95 mm Hg , based on the average of 3 screening visits . Persons with prehypertension ( systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg ) were included because of the excess risk for cardiovascular disease in those with blood pressure within this range ( 20 ) . Major exclusion criteria were a body mass index less than 18.5 kg/mg2 or greater than 45.0 kg/m2 , use of antihypertensive drugs or other drugs that affect blood pressure , JNC VI risk category C ( target organ damage or diabetes ) , use of prescription weight loss medications , previous cardiovascular event , congestive heart failure , angina , cancer , and consumption of more than 21 alcoholic drinks per week . Trial Conduct Eligible participants were r and omly assigned , with equal probability , to 1 of 3 groups : an advice only comparison group ( advice only ) ; an intervention group that targeted established , guideline -recommended lifestyle recommendations ( established ) ( 2 ) ; or an intervention group targeting the established recommendations and adding the DASH dietary pattern ( established plus DASH ) ( 13 ) . Computer-generated treatment assignments were stratified by clinic and hypertension status and were assigned in blocks of varying sizes to provide balance over time . The actual assignments were administered by using a password-protected , Web-based application developed by the coordinating center and accessible only by authorized individuals . All clinic measurement staff were blinded to treatment assignment , and all intervention staff were blinded to clinic measurements . Hypertension was defined by using the JNC VI criteria for hypertension treatment : an average systolic blood pressure of 140 mm Hg , a diastolic blood pressure greater than 90 mm Hg , or use of antihypertensive medication . Normal blood pressure was defined as systolic blood pressure less than 120 mm Hg , diastolic blood pressure less than 80 mm Hg , and no use of antihypertensive medication ( 21 ) ( Figure ) . Intervention was provided by master 's degreelevel counselors ( dietitians and health educators trained in behavioral methods ) . The counselors were central ly trained before the start of the study , attended annual 3-day training sessions , and participated in monthly conference calls . Figure . Flow diagram of enrollment , measurements , and visit completion . Advice Only  Group Participants in the advice group  received advice to follow the National High Blood Pressure Education Program lifestyle recommendations for blood pressure control ( 2 ) . Lifestyle recommendations included reducing weight ( if overweight ) , following a reduced-sodium diet , engaging in regular moderate-intensity physical activity , and eating a heart-healthy diet , including the DASH diet . This advice was provided in two 30-minute individual sessions , 1 immediately after r and om assignment and 1 after the 6-month data collection visit . A PREMIER counselor review ed the guidelines with the participant and provided printed educational material s and information about community re sources . This intervention did not include advice to keep a food or exercise diary . Behavioral Interventions in the Established and Established plus DASH Groups Participant goals for the established and established plus DASH groups included weight loss of at least 6.8 kg ( 15 lb ) for those with a body mass index of 25 kg/m2 or greater , at least 180 minutes per week of moderate-intensity physical activity , no more than 100 mmol per day of dietary sodium , and alcohol consumption of no more than 30 mL ( 1 oz ) per day ( 2 drinks ) for men and 15 mL ( 0.5 ) oz per day ( 1 drink ) for women . Participants assigned to the established plus DASH group ( but not those in the established group ) also received counseling on the DASH diet , with goals for increased consumption of fruits and vegetables ( 9 to 12 servings/d ) and low-fat dairy products ( 2 to 3 servings/d ) and reduced consumption of saturated fat ( 7 % of energy ) and total fat ( 25 % of energy ) . The intervention format , contact pattern , and behavior change strategies for the established and established plus DASH groups were identical . During the first 6 months , participants in both behavioral intervention groups attended 14 group sessions and 4 individual sessions ; during months 7 to 18 , they attended monthly group sessions supplemented with 3 individual counseling sessions . Throughout the trial , participants in the established and established plus DASH groups ( but not those in the advice group ) kept food diaries , monitored dietary calorie and sodium intakes , and recorded minutes of physical activity . Self-monitoring was used to provide individualized feedback , reinforcement , problem solving , and support . Social support for initial behavior changes and maintenance of change was provided during the group sessions . More detailed descriptions of the behavorial intervention methods are available ( 22 ) . Measurements Blood pressure was assessed twice at each measurement , and systolic and diastolic blood pressures were calculated by using the mean of all available measurements ( 4 sets before r and om assignment , 3 sets at 6 and 18 months , and 1 set at 3 and 12 months ) . For 4 participants who were started on antihypertensive drug therapy between the 12- and 18-month visits , we obtained an official set of blood pressure measurements before initiation of therapy and used these as our 18-month blood pressure values for analysis . A similar procedure was used to obtain the 6-month blood pressure value for the 1 participant who began taking antihypertensive drugs between the 3- and 6-month visits . Two 24-hour dietary recalls , 1 obtained on a weekday and the other obtained on a weekend , were collected at baseline and at 6 and 18 months by telephone interview ( 23 ) . Intakes of nutrients and food groups were calculated by using the Nutrition Data System for Research , version NDS-R 1998 ( University of Minnesota , Minneapolis , Minnesota ) . Urinary excretion of sodium ( reflecting salt intake ) and potassium ( reflecting fruit and vegetable intake ) was obtained from 24-hour urinary collection s at baseline OBJECTIVE To examine the influence of the PREMIER study lifestyle interventions on dietary intakes and adherence to the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern and the Dietary Reference Intakes ( DRI ) . DESIGN An 18-month multicenter , r and omized controlled trial comparing two multicomponent lifestyle intervention programs to an advice only control group . SUBJECTS/ SETTING A total of 810 participants were recruited from local communities and r and omized into the study . Individuals were eligible if they were aged 25 years or older , had body mass index between 18.5 and 45.0 , not taking antihypertensive medication , and had prehypertension or stage 1 hypertension ( systolic blood pressure 120 to 159 mm Hg and diastolic blood pressure 80 to 95 mm Hg ) . INTERVENTION The two active intervention programs were a behavioral lifestyle intervention that implements established recommendations , and an established intervention plus the DASH dietary pattern . Both interventions consisted of intensive group and individual counseling sessions . The control group received a brief advice session after r and omization and again after 6 months of data collection . Dietary intakes were collected by two r and om 24-hour recalls at baseline , 6 months , and 18 months . MAIN OUTCOME MEASURES The primary outcome of the PREMIER study was change in systolic blood pressure at 6 months . The main outcomes examined here include dietary variables collected by 24-hour recall at each time point . STATISTICAL ANALYSES Nutrient intakes were calculated and compared among the time points and the three intervention groups using mixed models with repeated measures at 6 and 18 months . Proportion of participants who met or achieved the original DASH nutrient intake levels and the DRIs were calculated and compared among the three intervention groups . P<0.01 was considered statistically significant . RESULTS Participants in both the established intervention and established intervention plus DASH dietary pattern groups substantially reduced energy , total fat , saturated fat , and sodium intake and these reductions persisted throughout the study . Established intervention plus DASH dietary pattern group participants increased intakes of fruits , vegetables , dairy , and many vitamins and minerals ; these increases were significantly greater than that of the control and established intervention groups . A majority of established intervention plus DASH dietary pattern group participants achieved at least two thirds of the DRI recommendations for most nutrients at 6 months , despite their reduction in total energy intake . Some but relatively small recidivism occurred at 18 months . CONCLUSIONS Both the established intervention and established intervention plus DASH dietary pattern group intervention were effective in helping participants follow established recommendations to control blood pressure . The advice-only control group also made some behavior changes , mainly decreasing energy and sodium intake . Only the established intervention plus DASH dietary pattern group significantly increased intakes of DASH-specific food groups , including fruits , vegetables , and dairy products , and nutrients , including protein , fiber , calcium , potassium , and magnesium . Most of the increases did not reach the levels consumed in the original DASH feeding studies . Whereas the established intervention plus DASH dietary pattern group intervention provides a useful platform to achieve the DASH dietary pattern and current DRI recommendations , intervention enhancements , including a greater emphasis on nutrient-dense foods , would likely improve this intervention Background : Population s eating mainly vegetarian diets have lower blood pressure levels than those eating omnivorous diets . Epidemiologic findings suggest that eating fruits and vegetables lowers blood pressure OBJECTIVES To survey the frequency of use of indirect comparisons in systematic review s and evaluate the methods used in their analysis and interpretation . Also to identify alternative statistical approaches for the analysis of indirect comparisons , to assess the properties of different statistical methods used for performing indirect comparisons and to compare direct and indirect estimates of the same effects within review s. DATA SOURCES Electronic data bases . REVIEW METHODS The Data base of Abstract s of Review s of Effects ( DARE ) was search ed for systematic review s involving meta- analysis of r and omised controlled trials ( RCTs ) that reported both direct and indirect comparisons , or indirect comparisons alone . A systematic review of MEDLINE and other data bases was carried out to identify published methods for analysing indirect comparisons . Study design s were created using data from the International Stroke Trial . R and om sample s of patients receiving aspirin , heparin or placebo in 16 centres were used to create meta-analyses , with half of the trials comparing aspirin and placebo and half heparin and placebo . Methods for indirect comparisons were used to estimate the contrast between aspirin  and  heparin . The whole process was repeated 1000 times and the results were compared with direct comparisons and also theoretical results . Further detailed case studies comparing the results from both direct and indirect comparisons of the same effects were undertaken . RESULTS Of the review s identified through DARE , 31/327 ( 9.5 % ) included indirect comparisons . A further five review s including indirect comparisons were identified through electronic search ing . Few review s carried out a formal analysis and some based analysis on the naive addition of data from the treatment arms of interest . Few method ological papers were identified . Some valid approaches for aggregate data that could be applied using st and ard software were found : the adjusted indirect comparison , meta-regression and , for binary data only , multiple logistic regression ( fixed effect models only ) . Simulation studies showed that the naive method is liable to bias and also produces over-precise answers . Several methods provide correct answers if strong but unverifiable assumptions are fulfilled . Four times as many similarly sized trials are needed for the indirect approach to have the same power as directly r and omised comparisons . Detailed case studies comparing direct and indirect comparisons of the same effect show considerable statistical discrepancies , but the direction of such discrepancy is unpredictable . CONCLUSIONS Direct evidence from good- quality RCTs should be used wherever possible . Without this evidence , it may be necessary to look for indirect comparisons from RCTs . However , the results may be susceptible to bias . When making indirect comparisons within a systematic review , an adjusted indirect comparison method should ideally be used employing the r and om effects model . If both direct and indirect comparisons are possible within a review , it is recommended that these be done separately before considering whether to pool data . There is a need to evaluate methods for the analysis of indirect comparisons for continuous data and for empirical research into how different methods of indirect comparison perform in cases where there is a large treatment effect . Further study is needed into when it is appropriate to look at indirect comparisons and when to combine both direct and indirect comparisons . Research into how evidence from indirect comparisons compares to that from non-r and omised studies may also be warranted . Investigations using individual patient data from a meta- analysis of several RCTs using different protocol s and an evaluation of the impact of choosing different binary effect measures for the inverse variance method would also be useful Evidence for a beneficial effect of dietary nitrate , through the nitrate-nitrite-NO pathway , on measures of cardiovascular function in healthy individuals is accumulating . It is less clear whether increased dietary nitrate intake from green leafy vegetables would have similar beneficial vascular effects in those at increased risk of developing hypertension . Our aim was to assess the effects of short-term regular consumption of increased nitrate from green leafy vegetables on blood pressure and arterial stiffness in individuals with high-normal blood pressure . Thirty-eight men and women ages 30 - 70 years with systolic blood pressure 120 to 139 mm Hg were recruited to a r and omized controlled crossover trial . The effects of a 7-day high-nitrate diet intervention ( increased nitrate intake by at least 300 mg/day from green leafy vegetables ) were compared to a 7-day low-nitrate diet intervention . Outcome measures included pre- and postintervention salivary and plasma nitrate and nitrite concentrations ; ambulatory , home , and office blood pressure ; augmentation index ; and carotid-femoral pulse wave velocity . The high-nitrate diet intervention result ed in at least a fourfold increase in salivary and plasma nitrate and nitrite ( P<0.001 ) . Ambulatory , home , and office blood pressure and arterial stiffness were not different between the high-nitrate diet and the low-nitrate diet . Increasing dietary nitrate intake in those with high-normal blood pressure and at increased risk of hypertension may not be an effective short-term strategy to lower blood pressure OBJECTIVES To propose methods for mixed treatment comparisons ( MTC ) based on pooled summaries of the type produced in overviews of review s. STUDY DESIGN AND SETTING Overviews of review s ( umbrella review s ) summarize the results of multiple systematic review s into a single document . They report the summary estimates from the original pairwise meta-analyses and discuss them in narrative form , with the intention of identifying the most effective treatment . We present methods for MTC synthesis , tailored for use with overviews of review s. These generate a single internally consistent summary of all the relative treatment effects and assessment s of whether the summary is consistent with the data . These methods are applied to a published overview of treatments for childhood nocturnal enuresis . We apply the methods to both fixed-effect ( FE ) and r and om-effects ( RE ) meta-analyses of the original trials . RESULTS The summary relative risks based on FE meta-analyses , as originally published , were highly inconsistent . Those based on RE meta-analyses were consistent and could , given st and ard assumptions on comparability of treatment effects in meta- analysis , form a basis for coherent decision making . CONCLUSION Along with the summaries from systematic review s , MTC methods should be used in overviews to provide a single coherent analysis of all treatment comparisons and to check for evidence consistency High blood pressure increases the risks of stroke , dementia , and neurocognitive dysfunction . Although aerobic exercise and dietary modifications have been shown to reduce blood pressure , no r and omized trials have examined the effects of aerobic exercise combined with dietary modification on neurocognitive functioning in individuals with high blood pressure ( ie , prehypertension and stage 1 hypertension ) . As part of a larger investigation , 124 participants with elevated blood pressure ( systolic blood pressure 130 to 159 mm Hg or diastolic blood pressure 85 to 99 mm Hg ) who were sedentary and overweight or obese ( body mass index : 25 to 40 kg/m2 ) were r and omized to the Dietary Approaches to Stop Hypertension ( DASH ) diet alone , DASH combined with a behavioral weight management program including exercise and caloric restriction , or a usual diet control group . Participants completed a battery of neurocognitive tests of executive function-memory-learning and psychomotor speed at baseline and again after the 4-month intervention . Participants on the DASH diet combined with a behavioral weight management program exhibited greater improvements in executive function-memory-learning ( Cohen 's D=0.562 ; P=0.008 ) and psychomotor speed ( Cohen 's D=0.480 ; P=0.023 ) , and DASH diet alone participants exhibited better psychomotor speed ( Cohen 's D=0.440 ; P=0.036 ) compared with the usual diet control . Neurocognitive improvements appeared to be mediated by increased aerobic fitness and weight loss . Also , participants with greater intima-medial thickness and higher systolic blood pressure showed greater improvements in executive function-memory-learning in the group on the DASH diet combined with a behavioral weight management program . In conclusion , combining aerobic exercise with the DASH diet and caloric restriction improves neurocognitive function among sedentary and overweight/obese individuals with prehypertension and hypertension BACKGROUND Systematic review s may be compromised by selective inclusion and reporting of outcomes and analyses . Selective inclusion occurs when there are multiple effect estimates in a trial report that could be included in a particular meta- analysis ( e.g. from multiple measurement scales and time points ) and the choice of effect estimate to include in the meta- analysis is based on the results ( e.g. statistical significance , magnitude or direction of effect ) . Selective reporting occurs when the reporting of a subset of outcomes and analyses in the systematic review is based on the results ( e.g. a protocol -defined outcome is omitted from the published systematic review ) . OBJECTIVES To summarise the characteristics and synthesis e the results of empirical studies that have investigated the prevalence of selective inclusion or reporting in systematic review s of r and omised controlled trials ( RCTs ) , investigated the factors ( e.g. statistical significance or direction of effect ) associated with the prevalence and quantified the bias . SEARCH METHODS We search ed the Cochrane Methodology Register ( to July 2012 ) , Ovid MEDLINE , Ovid EMBASE , Ovid PsycINFO and ISI Web of Science ( each up to May 2013 ) , and the US Agency for Healthcare Research and Quality ( AHRQ ) Effective Healthcare Program 's Scientific Re source Center ( SRC ) Methods Library ( to June 2013 ) . We also search ed the abstract books of the 2011 and 2012 Cochrane Colloquia and the article alerts for method ological work in research synthesis published from 2009 to 2011 and compiled in Research Synthesis Methods . SELECTION CRITERIA We included both published and unpublished empirical studies that investigated the prevalence and factors associated with selective inclusion or reporting , or both , in systematic review s of RCTs of healthcare interventions . We included empirical studies assessing any type of selective inclusion or reporting , such as investigations of how frequently RCT outcome data is selectively included in systematic review s based on the results , outcomes and analyses are discrepant between protocol and published review or non-significant outcomes are partially reported in the full text or summary within systematic review s. DATA COLLECTION AND ANALYSIS Two review authors independently selected empirical studies for inclusion , extracted the data and performed a risk of bias assessment . A third review author resolved any disagreements about inclusion or exclusion of empirical studies , data extraction and risk of bias . We contacted authors of included studies for additional unpublished data . Primary outcomes included overall prevalence of selective inclusion or reporting , association between selective inclusion or reporting and the statistical significance of the effect estimate , and association between selective inclusion or reporting and the direction of the effect estimate . We combined prevalence estimates and risk ratios ( RRs ) using a r and om-effects meta- analysis model . MAIN RESULTS Seven studies met the inclusion criteria . No studies had investigated selective inclusion of results in systematic review s , or discrepancies in outcomes and analyses between systematic review registry entries and published systematic review s. Based on a meta- analysis of four studies ( including 485 Cochrane Review s ) , 38 % ( 95 % confidence interval ( CI ) 23 % to 54 % ) of systematic review s added , omitted , up grade d or down grade d at least one outcome between the protocol and published systematic review . The association between statistical significance and discrepant outcome reporting between protocol and published systematic review was uncertain . The meta-analytic estimate suggested an increased risk of adding or upgrading ( i.e. changing a secondary outcome to primary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.43 , 95 % CI 0.71 to 2.85 ; two studies , n = 552 meta-analyses ) . Also , the meta-analytic estimate suggested an increased risk of downgrading ( i.e. changing a primary outcome to secondary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.26 , 95 % CI 0.60 to 2.62 ; two studies , n = 484 meta-analyses ) . None of the included studies had investigated whether the association between statistical significance and adding , upgrading or downgrading of outcomes was modified by the type of comparison , direction of effect or type of outcome ; or whether there is an association between direction of the effect estimate and discrepant outcome reporting . Several secondary outcomes were reported in the included studies . Two studies found that reasons for discrepant outcome reporting were infrequently reported in published systematic review s ( 6 % in one study and 22 % in the other ) . One study ( including 62 Cochrane Review s ) found that 32 % ( 95 % CI 21 % to 45 % ) of systematic review s did not report all primary outcomes in the abstract . Another study ( including 64 Cochrane and 118 non-Cochrane review s ) found that statistically significant primary outcomes were more likely to be completely reported in the systematic review abstract than non-significant primary outcomes ( RR 2.66 , 95 % CI 1.81 to 3.90 ) . None of the studies included systematic review s published after 2009 when reporting st and ards for systematic review s ( Preferred Reporting Items for Systematic review s and Meta-Analyses ( PRISMA ) Statement , and Method ological Expectations of Cochrane Intervention Review s ( MECIR ) ) were disseminated , so the results might not be generalisable to more recent systematic review s. AUTHORS ' CONCLUSIONS Discrepant outcome reporting between the protocol and published systematic review is fairly common , although the association between statistical significance and discrepant outcome reporting is uncertain . Complete reporting of outcomes in systematic review abstract s is associated with statistical significance of the results for those outcomes . Systematic review outcomes and analysis plans should be specified prior to seeing the results of included studies to minimise post-hoc decisions that may be based on the observed results . Modifications that occur once the review has commenced , along with their justification , should be clearly reported . Effect estimates and CIs should be reported for all systematic review outcomes regardless of the results . The lack of research on selective inclusion of results in systematic review s needs to be addressed and studies that avoid the method ological weaknesses of existing research are also needed Dietary polyphenols , such as those from grape products , may exert beneficial effects on cardiovascular health , including anti-hypertensive effects . We investigated the effect of a specific grape seed extract ( GSE ) rich in low-molecular-weight polyphenolic compounds on ambulatory blood pressure ( ABP ) in untreated subjects with pre- and stage I hypertension . In addition , potential mechanisms that could underlie the hypothesised effect of GSE on blood pressure ( BP ) , and platelet aggregation , were explored . The study was design ed as a double-blind , placebo-controlled , r and omised , parallel-group intervention study including seventy healthy subjects with systolic BP between 120 and 159 mmHg . A 1-week run-in period was followed by an 8-week intervention period , during which subjects consumed capsules containing either 300 mg/d of GSE or a placebo ( microcrystalline cellulose ) . Before and after the intervention , daytime ABP readings , 24 h urine sample s and fasting and non-fasting blood sample s were taken . The mean baseline systolic BP was 135.8 ( SE 1.3 ) mmHg and diastolic BP was 81.5 ( SE 0.9 ) mmHg . BP values were modestly , but not significantly , affected by the polyphenol-rich GSE treatment v. placebo with an effect of - 3.0 mmHg for systolic BP ( 95 % CI - 6.5 , 0.5 ) and - 1.4 mmHg for diastolic BP ( 95 % CI - 3.5 , 0.6 ) . Vasoactive markers including endothelin-1 , NO metabolites and asymmetric dimethylarginine , plasma renin activity and platelet aggregation were not affected by the GSE intervention . Our findings show that consumption of polyphenol-rich GSE does not significantly lower ABP in untreated subjects with pre- and stage I hypertension AIMS To analyse the effect on systematic review s in diabetes interventions of including only trials that are indexed in medline , and to assess the impact of adding trials from other data bases and the grey literature . METHODS All systematic review s of diabetes interventions which included a meta- analysis of r and omized controlled trials , and were published since 1996 , were selected . The impact on the meta- analysis of including only those trials indexed in medline , and the effect of then adding trials from other sources , was assessed . Where possible this was measured quantitatively , by redoing the meta- analysis , otherwise a qualitative estimate was made . RESULTS Forty-four systematic review s met our inclusion criteria . There were 120 articles reporting trial data which were not indexed in medline . These came from 52 % of the review s. In 34 % of the review s , basing a meta- analysis on a search of only medline would miss trials that could affect the result . Sources of non- medline data which had the biggest effect on the meta-analyses were journal articles from central and embase ( mainly in Diabetes , Nutrition and Metabolism ) and unpublished data ( mainly from industry ) . The exceptions were journal articles on herbal medicine , mostly indexed in Chinese language data bases . CONCLUSIONS A search of only the medline data base is insufficient for systematic review s of diabetes , because in about 34 % of review s the missed trials could affect the results of the meta- analysis . It is recommended that central ( on the Cochrane Library ) also be search ed . Scanning meeting abstract s , and seeking unpublished data are also recommended if the intervention has only recently been introduced Background The ideal evidence to answer a question about the effectiveness of treatment is a systematic review . However , for many clinical questions a systematic review will not be available , or may not be up to date . One option could be to use the evidence from an individual trial to answer the question ? Methods We assessed how often ( a ) the estimated effect and ( b ) the p-value in the most precise single trial in a meta- analysis agreed with the whole meta- analysis . For a r and om sample of 200 completed Cochrane Review s ( January , 2005 ) we identified a primary outcome and extracted : the number of trials , the statistical weight of the most precise trial , the estimate and confidence interval for both the highest weighted trial and the meta- analysis overall . We calculated the p-value for the most precise trial and meta- analysis . Results Of 200 review s , only 132 provided a meta- analysis of 2 or more trials , with a further 35 effect estimates based on single trials . The average number of trials was 7.3 , with the most precise trial contributing , on average , 51 % of the statistical weight to the summary estimate from the whole meta- analysis . The estimates of effect from the most precise trial and the overall meta-analyses were highly correlated ( rank correlation of 0.90).There was an 81 % agreement in statistical conclusions . Results from the most precise trial were statistically significant in 60 of the 167 evaluable review s , with 55 of the corresponding systematic review s also being statistically significant . The five discrepant results were not strikingly different with respect to their estimates of effect , but showed considerable statistical heterogeneity between trials in these meta-analyses . However , among the 101 cases in which the most precise trial was not statistically significant , the corresponding meta-analyses yielded 31 statistically significant results . Conclusions Single most precise trials provided similar estimates of effects to those of the meta-analyses to which they contributed , and statistically significant results are generally in agreement . However , " negative " results were less reliable , as may be expected from single underpowered trials . For systematic review ers we suggest that : ( 1 ) key trial(s ) in a review deserve greater attention ( 2 ) systematic review ers should check agreement of the most precise trial and the meta analysis . For clinicians using trials we suggest that when a meta- analysis is not available , a focus on the most precise trial is reasonable provided it is adequately powered Data from 12 independently design ed and conducted r and omized trials of behavioral interventions for hypertension , consisting principally of variants of relaxation and biofeedback therapies , were aggregated to assess current progress of research in this area . Meta-analytical methods revealed a statistically significant decrease in diastolic blood pressure for nonmedicated patients at the end of intervention . No significant improvement was detected in medicated patients , but potential differential effectiveness of prescribed medications and differences in compliance among patients prohibits separation of changes due to behavioral treatments alone . The need to devise criteria for selection of patients , and to establish the most appropriate patient-treatment match is emphasized BACKGROUND Dietary nitrate , which is in green leafy vegetables and beetroot , decreases blood pressure through the enterosalivary nitrate-nitrite-nitric oxide pathway in healthy individuals . Whether similar effects would occur in individuals with treated hypertension and , therefore , at increased risk of cardiovascular disease is unclear . OBJECTIVE We assessed whether increased dietary nitrate intake by using beetroot juice for 1 wk lowers blood pressure in treated hypertensive men and women . DESIGN Participants ( n = 27 ) were recruited to a r and omized , placebo-controlled , double-blind crossover trial . The effect of 1-wk intake of nitrate-rich beetroot juice was compared with 1-wk intake of nitrate-depleted beetroot juice ( placebo ) . The primary outcome was blood pressure assessed by measuring home blood pressure during the intervention and 24-h ambulatory blood pressure on day 7 of the intervention . Other outcomes included nitrate metabolism assessed by measuring nitrate and nitrite in plasma , saliva , and urine . RESULTS Relative to the placebo , 1-wk intake of nitrate-rich beetroot juice result ed in a 3-fold increase in plasma nitrite and nitrate , a 7-fold increase in salivary nitrite , an 8-fold higher salivary nitrate , and a 4-fold increase in both urinary nitrite and nitrate ( P < 0.001 ) . However , no differences in home blood pressure and 24-h ambulatory blood pressure were observed with 1-wk intake of nitrate-rich beetroot juice in comparison with the placebo . CONCLUSION An increase in dietary nitrate intake may not be an effective short-term approach to further lower blood pressure in treated hypertensive subjects BACKGROUND Observational epidemiological studies have shown a positive association between hypertension and risk of incident dementia ; however , the effects of antihypertensive therapy on cognitive function in controlled trials have been conflicting , and meta-analyses of the trials have not provided clear evidence of whether antihypertensive treatment reduces dementia incidence . The Hypertension in the Very Elderly trial ( HYVET ) was design ed to assess the risks and benefits of treatment of hypertension in elderly patients and included an assessment of cognitive function . METHODS Patients with hypertension ( systolic pressure 160 - 200 mm Hg ; diastolic pressure < 110 mm Hg ) who were aged 80 years or older were enrolled in this double-blind , placebo-controlled trial . Participants were r and omly assigned to receive 1.5 mg slow release indapamide , with the option of 2 - 4 mg perindopril , or placebo . The target systolic blood pressure was 150 mm Hg ; the target diastolic blood pressure was 80 mm Hg . Participants had no clinical diagnosis of dementia at baseline , and cognitive function was assessed at baseline and annually with the mini-mental state examination ( MMSE ) . Possible cases of incident dementia ( a fall in the MMSE score to < 24 points or a drop of three points in 1 year ) were assessed by st and ard diagnostic criteria and expert review . The trial was stopped in 2007 at the second interim analysis after treatment result ed in a reduction in stroke and total mortality . Analysis was by intention to treat . The trial is registered with Clinical Trials.gov , number NCT00122811 . FINDINGS 3336 HYVET participants had at least one follow-up assessment ( mean 2.2 years ) and were included : 1687 participants were r and omly assigned to the treatment group and 1649 to the placebo group . Only five reports of adverse effects were attributed to the medication : three in the placebo group and two in the treatment group . The mean decrease in systolic blood pressure between the treatment and placebo groups at 2 years was systolic -15 mm Hg , p<0.0001 ; and diastolic -5.9 mm Hg , p<0.0001 . There were 263 incident cases of dementia . The rates of incident dementia were 38 per 1000 patient-years in the placebo group and 33 per 1000 patient-years in the treatment group . There was no significant difference between treatment and placebo groups ( hazard ratio [ HR ] 0.86 , 95 % CI 0.67 - 1.09 ) ; however , when these data were combined in a meta- analysis with other placebo-controlled trials of antihypertensive treatment , the combined risk ratio favoured treatment ( HR 0.87 , 0.76 - 1.00 , p=0.045 ) . INTERPRETATION Antihypertensive treatment  in elderly patients does not statistically reduce incidence of dementia . This negative finding might have been due to the short follow-up , owing to the early termination of the trial , or the modest effect of treatment . Nevertheless , the HYVET findings , when included in a meta- analysis , might support antihypertensive treatment to reduce incident dementia OBJECTIVES Determine whether self-efficacy independently predicted weight loss in a behavioral intervention and explore factors that influence the path between self-efficacy and weight change . DESIGN Secondary analysis of the PREMIER trial , a r and omized controlled trial testing effects of lifestyle interventions on blood pressure . SETTING Four academic medical centers . PARTICIPANTS PREMIER recruited adults ( n = 810 ) with pre-hypertension/stage 1 hypertension , not currently receiving medication . This analysis excluded participants in the control arm , result ing in n = 537 . INTERVENTIONS Participants were r and omly assigned to 1 of 3 groups : advice only , established lifestyle recommendations , or established lifestyle recommendations plus Dietary Approaches to Stop Hypertension dietary pattern . MAIN OUTCOME MEASURES Self-efficacy ( dietary self-efficacy [ DSE ] , exercise self-efficacy [ ESE ] ) , dietary intake , fitness . ANALYSIS Pearson correlations , 1-way analysis of variance , mediation analyses . RESULTS Despite an overall decrease in DSE/ESE , change in DSE/ESE significantly predicted weight change at 6 ( β = -.21 , P < .01 ; β = -.19 , P < .01 , respectively ) and 18 months ( β = -.19 , P < .01 ; β = -.35 , P < .01 ) . Change in percent calories from fat partially mediated the DSE/weight change relationship at 6 months . Change in fitness partially mediated the ESE/weight change relationship at 18 months . CONCLUSIONS AND IMPLICATION S Changes in DSE/ESE were not associated with behavior change as hypothesized . Additional research is needed to identify mediators between self-efficacy and adoption of behaviors that influence weight loss The Dietary Approaches to Stop Hypertension multicenter trial examined the impact of dietary patterns on blood pressure in 459 adults with blood pressure < 160 mm Hg systolic and 80 to 95 mm Hg diastolic . After a 3-week run-in period on a control diet low in fruits , vegetables , and dairy products , and with a fat content typical for Americans , participants were r and omized for 8 weeks to either the control diet , a diet rich in fruits and vegetables , or a combination diet that emphasized fruits , vegetables , and low-fat dairy products . Body weight and sodium intake were held constant , and physical activity did not change during the intervention . Baseline mean + /- st and ard deviation systolic and diastolic blood pressures were 131.3 + /- 10.8 mm Hg and 84.7 + /- 4.7 mm Hg , respectively . Relative to the control diet , the combination diet reduced blood pressure by 5.5 mm Hg and diastolic blood pressure by 3.0 mm Hg ( P < .001 ) . For those on the fruits and vegetables diet , blood pressure reductions relative to control were 2.8 mm Hg systolic ( P < .001 ) and 1.1 mm Hg diastolic ( P < .07 ) . In 133 participants with hypertension , the combination diet produced a net blood pressure reduction of 11.4 and 5.5 mm Hg systolic and diastolic , respectively ( P < .001 ) . In participants without hypertension ( n = 326 ) , the corresponding blood pressure reductions were 3.5 mm Hg systolic ( P < .001 ) and 2.1 mm Hg diastolic ( P < .003 ) . In other subgroup analyses , minorities showed relatively larger reductions in blood pressure than nonminorities ( P < .001 ) . We conclude that the dietary pattern reflected in the combination diet can substantially reduce blood pressure , and , accordingly , provides an additional lifestyle approach to preventing and treating hypertension 2011 ; 14 : 371–380 . 6 . Senn S , Gavini F , Magrez D , Scheen A. Issues in performing a network meta analysis . Statistical Methods in Medical Research 2013 ; 22 : 169–89 . 7 . Salanti G , Higgins JP , Ades A , Ioannidis JP . Evaluation of networks of r and omized trials . Statistical Methods in Medical Research 2008 ; 17 : 279– 301 . 8 . Song F , Clark A , Bachmann MO , Maas J. Simulation evaluation of statistical properties  of methods for indirect and mixed treatment comparisons . BMC Medical Research Methodology 2012 ; 12 : 1–14 . 9 . Jansen JP , Naci H. Is network meta- analysis as valid as st and ard pairwise meta- analysis ? It all depends on the distribution of effect modifers . BMC Medicine 2013 ; 11 : 1 . 10 . The Guidelines Manual . London : National Institute for Health and Clinical Excellence . 2012 . https://www . nice.org.uk/process/pmg6/chapter/6 review ing-the- evidence ( accessed 27/ 05/2017 ) . 11 . Kanters S , Ford N , Druyts E , et al. Use of network meta- analysis  in clinical guidelines . Bulletin of the World Health Organization 2016 ; 94 : 782–4 . 12 . Kiefer C , Sturtz S , Bender R. Indirect comparisons and network meta-analyses : estimation of effects in the absence of head-to-head trials . Deutsches € Arzteblatt International 2015 ; 112 : 803–8 . 13 . Imberger G , Gluud C , Boylan J , Wetterslev J. Systematic review s of anesthesiologic interventions reported as statistically significant : problems with power , precision , and type 1 error protection . Anesthesia and Analgesia 2015 ; 121 : 1611–22 . 14 . Afshari A , Wetterslev J , Smith AF . Can systematic review s with sparse data be trusted ? Anaesthesia 2017 ; 72 : 12–6 . 15 . Jakobsen JC , Wetterslev J , Lange T , Gluud C. Viewpoint : taking into account risks of r and om errors when analysing multiple outcomes in systematic review s. Cochrane Data base of Systematic Review s 2016 ; 3 : ED000111 . 16 . Jakobsen JC , Wetterslev J , Winkel P , Lange T , Gluud C. Thresholds for statistical and clinical significance in systematic review s with meta-analytic methods . BMC Medical Research Methodology 2014 ; 14 : 120 . 17 . Wetterslev J , Jakobsen JC , Gluud C. Trial Sequential Analysis in systematic review s with meta- analysis . BMC Medical Research Methodology 2017 ; 17 : 39 . 18 . Smith AF , Carlisle JC . Review s , systematic review s and Anaesthesia . Anaesthesia 2015 ; 70 : 644–70 . 19 . Cook TM , Kelly FE . The Difficult Airway Society 2015 guidelines and the sacred cows of routine airway management . Anaesthesia 2016 ; 71 : 466–7 . 20 . Schmitz S , Adams R , Walsh C. Incorporating data from various trial design s into a mixed treatment comparison model . Statistics in Medicine 2013 ; 32 : 2935–49 . 21 . Marshall SD , P and it JJ . Radical evolution : the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation . Anaesthesia 2016 ; 71 : 131–7 . 22 . Black AE , Flynn PE , Smith HL , Thomas ML , Wilkinson KA . Association of Pediatric Anaesthetists of Great Britain and Irel and . Development of a guideline for the management of the unanticipated difficult airway in pediatric practice . Pediatric Anaesthesia 2015 ; 25 : 346–62 . 23 . Hagberg CA , Gabel JC , Connis RT . Difficult Airway Society 2015 guidelines for the management of unanticipated difficult intubation in adults : not just another algorithm . British Journal of Anaesthesia 2015 ; 115 : 812–4 . 24 . Martin-Castro C , Montero A.  Flexible laryngeal mask as an alternative to reinforced tracheal tube for upper chest , head and neck oncoplastic surgery . European Journal of Anaesthesiology 2008 ; 25 : 261–6 . 25 . Maclennan A , Smith AF . An analysis of critical incidents relevant to paediatric anaesthesia reported to the UK National Reporting and Learning System , 2006 - 2008 . Pediatric Anesthesia 2011 ; 21 : 841–7 . 26 . P and it JJ , Popat MT , Cook TM , et al. The Difficult Airway Society ‘ ADEPT ’ Guidance on selecting airway devices : the basis of a strategy for equipment evaluation . Anaesthesia 2011 ; 66 : 726–37 Although epidemiologic data show a direct relation between dietary sodium intake and blood pressure at the population level ( 1 , 2 ) , some experts question the universality of the findings and oppose public health recommendations to decrease sodium intake in the general population ( 3 ) . Certainly , results from reports on the relationship between sodium and blood pressure among major subgroups vary considerably . Several studies suggest that African Americans and older adults have heightened salt sensitivity ( greater blood pressure response to sodium intake ) ( 4 - 6 ) . Some evidence also indicates increased salt sensitivity in women ( 7 ) , although other studies do not support this cl aim ( 4 , 5 ) . The association of sodium intake with cardiovascular morbidity and mortality varies by overweight status ( 8) , perhaps reflecting a differential effect of sodium on blood pressure in overweight persons . Finally , higher dietary intakes of potassium and calcium have been shown to blunt the pressor effects of dietary sodium ( 9 , 10 ) . Dietary factors other than sodium also directly affect blood pressure , and these effects also appear to vary across subgroups . In the Dietary Approaches to Stop Hypertension ( DASH ) Trial , for example , a diet that had reduced total and saturated fat and was rich in fruits , vegetables , and low-fat dairy foods ( the DASH diet ) substantially decreased blood pressure compared with a more typical U.S. diet , in the absence of weight change and at sodium intakes approximating current U.S. consumption ( 11 , 12 ) . These effects persisted across all subgroups and were especially pronounced among hypertensive persons , African Americans , and persons who did not drink alcohol ( 13 ) . The DASH-Sodium Trial examined the effects of reduced sodium intake in the context of the DASH diet and a more typical U.S. diet ( 14 ) . In that study , highly significant decreases in blood pressure were observed with decreased sodium intake in participants following either diet , and the DASH diet decreased blood pressure at sodium intakes well below the current U.S. average . These results were observed overall and in subgroups defined by ethnicity , sex , and hypertension status ( 15 ) . We report on more detailed subgroup analyses from the DASH-Sodium Trial , including results for subgroups defined by age , obesity , waist circumference , alcohol intake , and baseline sodium intake . We also report the results of multivariate analyses that demonstrate how these effects vary across subgroups defined jointly by age , ethnicity , sex , and hypertension status . Methods Study Design The DASH-Sodium Trial was a multicenter , r and omized feeding trial comparing the effects on blood pressure of three levels of sodium intake and two dietary patterns . The 412 participants were 22 years of age or older and had systolic blood pressures of 120 to 159 mm Hg and diastolic blood pressures of 80 to 95 mm Hg ( 15 ) . The three levels of sodium intake ( lower , intermediate , and higher ) varied according to energy intake in a ratio of 1:2:3 ; target intakes were 50 , 100 , and 150 mmol/d , respectively , for a 2100-kcal diet . The dietary patterns were a control diet , typical of what many Americans eat , and the DASH diet , which emphasizes fruits , vegetables , and low-fat dairy foods ; includes whole grains , poultry , fish , and nuts ; and is reduced in fats , red meat , sweets , and sugar-containing beverages ( 11 , 14 ) . Participants were recruited in four separate feeding cohorts and were r and omly assigned to one of the two dietary patterns by using a parallel-group design . They then ate their assigned diet for three consecutive 30-day intervention feeding periods , during which sodium intake varied among the three levels by a r and omly assigned sequence ( Figure ) . Participants ate the control diet at the higher sodium intake during a 2-week run-in period . During the three intervention periods , participants received all their food in the context of the study and were asked not to eat any non study food . Individual energy intake was adjusted to keep body weight stable . Figure . Design of the Dietary Approaches to Stop Hypertension (DASH)-Sodium Trial . Exclusion criteria were heart disease , renal insufficiency , poorly controlled hyperlipidemia or diabetes mellitus , diabetes requiring insulin , special dietary requirements , intake of more than 14 alcoholic drinks/wk , or use of antihypertensive drugs or other medications that would affect blood pressure or nutrient metabolism . The study was approved by the human subjects committees of the clinical centers and coordinating center , and participants gave informed consent . Measurement Protocol Trained staff measured blood pressure at each of three screening visits , on 2 days during the run-in period , and on 5 of the last 9 days of each intervention feeding period . Interim blood pressures were assessed once during each of the first 3 weeks of each intervention feeding period . During screening and the last week of each intervention feeding period , a 24-hour urine collection was obtained . Height and weight were measured , and body mass index was calculated . Baseline physical activity was measured by using a 7-day physical activity recall interview ( 16 ) . Information on education level , income , alcohol consumption , and family history was obtained by using a question naire . Baseline blood pressure was defined as the average of the five preintervention blood pressures . End-of-feeding blood pressures were defined as the average of the five blood pressures at the end of each 30-day intervention feeding period . If no end-of-feeding blood pressure values were available ( 49 of 1236 possible cases ) , interim ( n = 9 ) or screening ( n = 40 ) blood pressures were used to impute end-of-feeding blood pressures . Definitions of Subgroups Ethnicity was categorized as African American versus other ( primarily non-Hispanic white ) . Participants were considered hypertensive if their untreated baseline systolic blood pressure was 140 mm Hg or greater and their diastolic blood pressure was 90 mm Hg or greater . ( Use of antihypertensive agents was an exclusion criterion [ 17 ] . ) Obesity was defined as body mass index of 30 kg/m2 or greater , and high-risk waist circumference was defined as greater than 102 cm in men and greater than 88 cm in women ( 18 ) . Age , physical activity , baseline alcohol intake , baseline 24-hour urinary sodium level , and family income were dichotomized at the approximate median . Level of education was dichotomized as high school or less versus more than high school . Statistical Analysis The data were analyzed on an intention-to-treat basis . Given the differential effects of sodium on blood pressure observed in previous analyses among participants eating the DASH diet versus the control diet ( 15 ) and because power for subgroup analyses is more limited than for overall analysis , we focused our comparisons on the maximum contrasts ( higher versus lower sodium intake with the control diet , DASH diet versus control diet at the higher sodium intake , and the combined effect of DASH diet and lower sodium intake versus control diet and higher sodium intake ) . We used generalized estimating equations ( 19 ) to fit linear models that predicted baseline and end-of-feeding blood pressures as a function of diet ( DASH vs. control ) , sodium level , and subgroup indicators . Different ways of modeling the dietsodium effects and their interactions with the subgroup indicators were used to test specific hypotheses . In particular , two-way interactions of the various dietsodium effects with ethnicity , sex , hypertension status , and age were analyzed to determine the incremental effect on blood pressure in each of these subgroups while controlling for the main and incremental effects of the other subgroups . This model allowed us to estimate various diet-sodium contrasts for each of the 16 subgroups defined by hypertension status , ethnicity , sex , and age . A second set of models examined subgroup variables in a bivariate manner and did not assume simple additivity of subgroup effects . Finally , unadjusted subgroup analyses included main effects and interactions for a single subgroup indicator . All analyses were performed by using the xtgee procedure in Stata software , version 5 ( Stata Corp. , College Station , Texas ) ( 20 ) and included adjustment for baseline blood pressure , site , feeding cohort , and carryover effects . An exchangeable covariance matrix was assumed for the repeated measurements for each participant . Unless otherwise stated , a P value less than 0.05 was significant , and all confidence intervals are 95 % confidence intervals . Because subgroup analyses were planned to interpret and eluci date the overall study results , they are not adjusted for multiple comparisons . Results Of the 412 participants who underwent r and omization , 390 ( 95 % ) completed the 12-week intervention feeding period . Adherence to the study diets seemed excellent , and body weight remained stable over time ( 15 ) . Table 1 shows baseline characteristics of the 412 participants .  Mean urinary sodium excretion at screening was 155 mmol/d , a value higher than that found while participants ate higher-sodium diets ( 142 mmol/d ) . Table 1 . Characteristics of Study Sample Several key subgroups were highly interrelated . Women made up 70 % of African-American participants but only 39 % of non-African-American participants . Women were more likely to be hypertensive than were men . The percentage of both men and women with hypertension increased sharply with age among non-African-American participants ( 21 % of those 45 years of age vs. 47 % of those > 45 years of age ) but was equally high among older and younger African Americans ( 43 % of those 45 years of age vs. 45 % of those > 45 years of age ) . These correlations highlight the potential for confounding in our results and , hence , the importance of the multivariate-adjusted analyses . Effects of the DASH Diet Table 2 shows the effect on systolic blood pressure of the DASH diet compared with the control diet Background Dietary Approaches to Stop Hypertension ( DASH ) has been shown to successfully reduce systolic ( SBP ) and diastolic blood pressure ( DBP ) when evaluated in clinical ly controlled environments but there is a lack of information regarding the efficacy of the original DASH diet when it is applied in a free-living environment . Purpose To provide descriptive data as to the changes in blood pressure individuals could expect to achieve when following the DASH diet in a free-living environment for 4-weeks with no additional behavioral modifications . Methods Twenty , pre- and stage 1 hypertensive participants were r and omly split into 2 groups ; DASH ( males N = 5 , females N = 5 , age = 38.5 ± 10.8 ) and control ( males N = 7 , females N = 3 , age = 38.1 ± 11.1 ) . The DASH group was instructed on how to follow the DASH diet on their own for 4-weeks while the control group continued their normal diet  . SBP , DBP , body weight , 3-day food diaries and physical activity recall question naire data were collected pre and post intervention using a traditional person-to-person instructional technique . Results Two-way ANOVA demonstrated that there was a significant group ( DASH , control ) by time ( pre , post ) interaction for SBP ( P = 0.003 ) and no significant effects for DBP . The interaction was due to a significant reduction ( P < 0.001 ) in SBP in the DASH group ( pre : 141.3 ± 11.3 mmHg vs. post : 130.7 ± 9.1 mmHg ) over the course of the intervention with no change in SBP in the control group ( pre : 133.5 ± 6.6 mmHg vs. post : 131.9 ± 8.9 mmHg ) . Pearson 's correlation analyses revealed that changes in potential moderators of blood pressure including body weight , BMI , sodium intake and total kilocalories were each not associated with changes in SBP ( r ≤ 0.14 , P ≥ 0.5 ) or DBP ( r < 0.10 , P ≥ 0.6 ) pre- to post-treatment . Chi-square demonstrated no significant differences in the number of participants per group ( n = 4 DASH , n = 1 control ) who indicated increasing physical activity during the intervention . Conclusion DASH diet followed in a free-living environment significantly reduced SBP but not DBP . However , the changes in SBP and DBP were very similar to those noted in controlled clinical feeding evaluations of the DASH diet . Presently , none of the potential moderators of blood pressure that were assessed were independently associated with the observed changes in blood pressure which may be due to our small sample size or the possibility that it is the combined change in multiple factors that lead to reductions in blood pressure when following the DASH diet Networks of investigators have begun sharing best practice s , tools and methods for analysis of associations between genetic variation and common diseases . A Network of Investigator Networks has been set up to drive the process , sponsored by the Human Genome Epidemiology Network . A workshop is planned to develop consensus guidelines for reporting results of genetic association studies . Published literature data bases will be integrated , and unpublished data , including ' negative ' studies , will be captured by online journals and through investigator networks . Systematic review s will be exp and ed to include more meta-analyses of individual-level data and prospect i ve meta-analyses . Field synopses will offer regularly up date d overviews Background Although cardiorespiratory fitness ( CRF ) in childhood and adolescence may be linked to future cardiovascular health , there is currently limited evidence for a longitudinal association . Objectives To provide a systematic review on the prospect i ve association between CRF in childhood and adolescence and cardiovascular disease ( CVD ) risk factors at least 2 years later . Methods Using a systematic search of Medline , Embase , and SPORTD iscus , relevant articles were identified by the following criteria : generally healthy children and adolescents between 3 and 18 years of age with CRF assessed at baseline , and a follow-up period of ≥ 2 years . The outcome measures were CVD risk factors . We appraised quality of the included articles with STROBE and QUIPS checklists . Results After screening 7524 titles and abstract s , we included 38 articles , assessing 44,169 children and adolescents followed up for a median of 6 years . Eleven articles were of high quality . There was considerable heterogeneity in methodology , measurement of CRF , and outcomes , which hampered meta- analysis . In approximately half of the included articles higher CRF in childhood and adolescence was associated with lower body mass index ( BMI ) , waist circumference , body fatness and lower prevalence of metabolic syndrome in later life . No associations between CRF in childhood and adolescence and future waist-to-hip ratio , blood pressure , lipid profile , and glucose homeostasis were observed . Conclusion Although about half of the included articles reported inverse associations between CRF in childhood and adolescence and future BMI , body fatness , and metabolic syndrome , evidence for other CVD risk factors was unconvincing . Many articles did not account for important confounding factors such as adiposity . Recommendations for future research include st and ardizing the measurement of CRF , i.e. by reporting VO2max , using st and ardized outcome assessment s , and performing individual patient data meta-analyses OBJECTIVE To determine the effects of dietary patterns on blood pressure in subgroups . METHODS Dietary Approaches to Stop Hypertension ( DASH ) was a r and omized controlled feeding study conducted at 4 academic medical centers . Participants were 459 adults with untreated systolic blood pressure less than 160 mm Hg and diastolic blood pressure 80 to 95 mm Hg . For 3 weeks , participants were fed a " control " diet . They were then r and omized to 8 weeks of ( 1 ) control diet ; ( 2 ) a diet rich in fruits and vegetables ; or ( 3 ) a combination diet rich in fruits , vegetables , and low-fat dairy foods , and reduced in saturated fat , total fat , and cholesterol ( the DASH combination diet ) . Weight and salt intake were held constant . Change in diastolic blood pressure was the primary outcome variable , and systolic blood pressure a secondary outcome . Subgroups analyzed included race , sex , age , body mass index , years of education , income , physical activity , alcohol intake , and hypertension status . RESULTS The combination diet significantly lowered systolic blood pressure in all subgroups ( P<.008 ) , and significantly lowered diastolic blood pressure ( P<.01 ) in all but 2 subgroups . The fruits- and -vegetables diet also reduced blood pressure in the same subgroups , but to a lesser extent . The combination diet lowered systolic blood pressure significantly more in African Americans ( 6.8 mm Hg ) than in whites ( 3.0 mm Hg ) , and in hypertensive subjects ( 11.4 mm Hg ) than in nonhypertensive subjects ( 3.4 mm Hg ) ( P<.05 for both interactions ) . CONCLUSIONS The DASH combination diet , without sodium reduction or weight loss , significantly lowered blood pressure in virtually all subgroups examined , and was particularly effective in African Americans and those with hypertension . The DASH combination diet may be an effective strategy for preventing and treating hypertension in a broad cross section of the population , including segments of the population at highest risk for blood pressure-related cardiovascular disease BACKGROUND Data on the association between dietary patterns and  age-related cognitive decline  are inconsistent . OBJECTIVE To determine whether dietary patterns assessed by the alternate Mediterranean diet score ( aMED ) , the Healthy Eating Index-2010 ( HEI-2010 ) , the Alternate Healthy Eating Index 2010 ( AHEI-2010 ) , or the Dietary Approach to Stop Hypertension ( DASH ) diet score are associated with  cognitive decline in older women , and to examine whether dietary patterns modify the risk for  cognitive decline in women with hypertension . DESIGN Prospect i ve , longitudinal cohort study . Food frequency question naires were used to derive dietary patterns at baseline . Hypertension was defined as self-report of current drug therapy for hypertension or clinic measurement of systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg . PARTICIPANTS AND SETTING Postmenopausal women ( N=6,425 ) aged 65 to 79 years who participated in the Women 's Health Initiative Memory Study and were cognitively intact at baseline . MAIN OUTCOME MEASURES Cognitive decline was defined as cases of mild cognitive impairment ( MCI ) or probable dementia ( PD ) . Cases were identified through rigorous screening and expert adjudication . STATISTICAL ANALYSES PERFORMED Cox proportional hazards models with multivariable adjustment were used to estimate the relative risk for developing MCI or PD . RESULTS During a median follow-up of 9.11 years , we documented 499 cases of MCI and 390 of PD . In multivariable analyses we did not detect any statistically significant relationships across quintiles of aMED , HEI-2010 , DASH , and AHEI-2010 scores and MCI or PD ( P values for trend=0.30 , 0.44 , 0.23 , and 0.45 ) . In women with hypertension , we found no significant association between dietary patterns and cognitive decline ( P values for trend=0.19 , 0.08 , 0.07 , and 0.60 ) . CONCLUSIONS Dietary patterns characterized by the aMED , HEI-2010 , AHEI-2010 , or DASH dietary score were not associated with cognitive decline in older women . Adherence to a healthy dietary pattern did not modify the risk for cognitive decline in women with hypertension Lifestyle modifications , such as weight loss , sodium restriction , and limiting alcohol consumption , are important components of the initial treatment of hypertensive patients . The Dietary Approaches to Stop Hypertension ( DASH ) study investigated the effects of dietary patterns on blood pressure in individuals with diastolic blood pressure between 80 - 95 mmHg . Two different dietary patterns were tested in this feeding study . A diet enriched in fruits and vegetables and a diet enriched in fruits , vegetables , and low-fat dairy products and low in total and saturated fat ( combination diet ) were compared with a control diet . Dietary intake was adjusted so that participants did not lose weight , and all study diets had comparable sodium intake ( approximately 3 grams/day ) . All meals were provided for 459 participants for an 11-week period . Those r and omized to the combination diet ( n = 151 ) had a significant change in systolic ( -5.5 mmHg ; p < 0.001 ) and diastolic blood pressure ( -3.0 mmHg ; p < 0.001 ) after subtracting the response to the control diet ( n = 154 ) . The fruits- and -vegetables diet ( n = 154 ) produced a significant but lesser decrease in blood pressure ( systolic , -2.8 mmHg ; p < 0.001 and diastolic , -1.1 mmHg ; p = 0.07 ) . Hypertensive individuals and African Americans had particularly favorable responses with blood pressure reductions , which were significantly greater than other subgroups . The combination diet was well-accepted and adherence to the diet was high ( > 90 % ) for all participants . The DASH combination diet is an effective lifestyle modification for lowering blood pressure in patients with high-normal or Stage 1 hypertension Recommendations for control of high blood pressure ( BP ) emphasize lifestyle modification , including weight loss , reduced sodium intake , increased physical activity , and limited alcohol consumption . The Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern also lowers BP . The PREMIER r and omized trial tested multicomponent lifestyle interventions on BP in demographic and clinical subgroups . Participants with above-optimal BP through stage 1 hypertension were r and omized to an Advice Only group or one of two behavioural interventions that implement established recommendations ( Est ) or established recommendations plus DASH diet ( Est plus DASH ) . The primary outcome was change in systolic BP at 6 months . The study population was 810 individuals with an average age of 50 years , 62 % women , 34 % African American ( AA ) , 95 % overweight/obese , and 38 % hypertensive . Participants in all the three groups made lifestyle changes . Mean net reductions in systolic ( S ) BP in the Est intervention were 1.2 mmHg in AA women , 6.0 in AA men , 4.5 in non-AA women , and 4.2 in non-AA men . The mean effects of the  Est Plus DASH intervention were 2.1 , 4.6 , 4.2 , and 5.7 mmHg in the four race – sex subgroups , respectively . BP changes were consistently greater in hypertensives than in nonhypertensives , although interaction tests were nonsignificant . The Est intervention caused statistically significant BP reductions in individuals over and under age 50 . The Est Plus DASH intervention lowered BP in both age groups , and significantly more so in older individuals . In conclusion , diverse groups of people can adopt multiple lifestyle changes that can lead to improved BP control and reduced CVD risk OBJECTIVE To provide up date d , evidence -based recommendations for the prevention and management of hypertension in adults . OPTIONS AND OUTCOMES For lifestyle and pharmacological interventions , evidence was review ed from r and omized controlled trials and systematic review s of trials . Changes in cardiovascular morbidity and mortality were the primary outcomes of interest . However , for lifestyle interventions , blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field . For treatment of patients with kidney disease , the progression of kidney dysfunction was also accepted as a clinical ly relevant primary outcome . EVIDENCE A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to up date the 2006 Canadian Hypertension Education Program recommendations . In addition , reference lists were scanned and experts were contacted to identify additional published studies . All relevant articles were review ed and appraised independently by both content and method ological experts using prespecified levels of evidence . RECOMMENDATIONS Dietary lifestyle modifications for prevention of hypertension , in addition to a well-balanced diet , include a dietary sodium intake of less than 100 mmol/day . In hypertensive patients , the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day . Other lifestyle modifications for both normotensive and hypertensive patients include : performing 30 min to 60 min of aerobic exercise four to seven days per week ; maintaining a healthy body weight ( body mass index of 18.5 kg/m2 to 24.9 kg/m2 ) and waist circumference ( less than 102 cm in men and less than 88 cm in women ) ; limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women ; following a diet reduced in saturated fat and cholesterol , and one that emphasizes fruits , vegetables and low-fat dairy products , dietary and soluble fibre , whole grains and protein from plant sources ; and considering stress management in selected individuals with hypertension . For the pharmacological management of hypertension , treatment thresholds and targets should take into account each individual 's global atherosclerotic risk , target organ damage and any comorbid conditions : blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease . Most patients require more than one agent to achieve these blood pressure targets . In adults without compelling indications for other agents , initial therapy should include thiazide diuretics ; other agents appropriate for first-line therapy for diastolic and /or systolic hypertension include angiotensin-converting enzyme ( ACE ) inhibitors ( except in black patients ) , long-acting calcium channel blockers ( CCBs ) , angiotensin receptor blockers ( ARBs ) or beta-blockers ( in those younger than 60 years of age ) . First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs . Certain comorbid conditions provide compelling indications for first-line use of other agents : in patients with angina , recent myocardial infa rct ion , or heart failure , beta-blockers and ACE inhibitors are recommended as first-line therapy ; in patients with cerebrovascular disease , an ACE inhibitor plus diuretic combination is preferred ; in patients with nondiabetic chronic kidney disease , ACE inhibitors are recommended ; and in patients with diabetes mellitus , ACE inhibitors or ARBs ( or , in patients without albuminuria , thiazides or dihydropyridine CCBs ) are appropriate first-line therapies . All hypertensive patients with dyslipidemia should be treated using the thresholds , targets and agents outlined in the Canadian Cardiovascular Society position statement ( recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease ) . Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy . Once blood pressure is controlled , acetylsalicylic acid therapy should be considered . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence -Based Recommendations Task Force . All recommendations reported here achieved at least 95 % consensus . These guidelines will continue to be up date d annually This study was design ed to determine the feasibility of teaching mildly hypertensive individuals to select a diet , using normally available food products , that either would produce a 5 % reduction in percentage of overweight ( without altering sodium ( Na ) , potassium ( K ) , or Na : K ratio ) or would decrease Na to less than 70 mEq and increase K to greater than 100 mEq ( without affecting weight ) and to compare the result ing changes in blood pressure .  Fifty-two participants with mild hypertension were r and omly assigned to either a weight-loss or a Na : K intervention .  Blood pressure , weight , 3-day diaries , and 24-h urinary excretion of Na and K were measured before and after an 8-week intervention . Participants in the weight-loss intervention had significantly greater changes in weight and calorie intake than those in the Na : K intervention , while changes in Na : K ratio were greatest in the intervention targeted for that change . The percentage of participants who were able to meet the dietary goals is presented and the implication s of these data for the selection of dietary goals are discussed Hypertension is one of the leading causes of morbidity and mortality in Brazil .  Diet may play an important role in reducing blood pressure ( BP ) , as has been shown for diets high in fruits , vegetables and low-fat dairy products and low in salt ( Dietary Approaches to Stop Hypertension (DASH)-Na ) . A low-glycaemic index Brazilian diet combined with the principles of the DASH-Na diet was evaluated in a r and omised study of 206 individuals who were followed for 6 months . In the control group ( CG ) , counselling was based on st and ard care and mainly focused on salt intake reduction . An intention-to-treat analysis showed that , after 6 months , systolic BP was reduced by 14·4 mmHg and diastolic BP by 9·7 mmHg in the experimental group ( EG ) , compared with 6·7 and 4·6 mmHg , respectively , in the CG . After adjusting for body weight , BP at baseline and age , these changes were 12·1 and 7·9 mmHg , respectively . Urinary Na excretion was also reduced by 43·4 mEq/24 h in the EG . Food intake was modified accordingly during the intervention with an increase in the consumption of vegetables  ( 2·97 - 5·85 frequency of consumption measured in three non-consecutive days ) , fruits ( 4·09 - 7·18 ) , beans ( 1·94 - 3·13 ) and fish ( 1·80 - 2·74 ) by the EG . The present study showed the feasibility of a Brazilian dietary approach to treating hypertension by reducing urinary Na excretion and BP , changes that may have a great impact on public health and promote the benefits of controlling hypertension BACKGROUND Efficient dietary interventions for patients with hypertension in clinical setting s are needed . OBJECTIVE To assess the separate and combined influence of a physician intervention ( MD-I ) and a patient intervention ( PT-I ) on dietary intakes of patients with hypertension . DESIGN A nested 2 × 2 design , r and omized controlled trial conducted over 18 months . PARTICIPANTS A total of 32 physicians and 574 out patients with hypertension . INTERVENTION MD-I included training modules addressing the Seventh Report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure hypertension management guidelines and lifestyle modification . PT-I included lifestyle coaching to adopt the Dietary Approaches to Stop Hypertension ( DASH ) eating pattern , reduce sodium intake , manage weight , increase exercise , and moderate alcohol intake . MAIN OUTCOME MEASURES Dietary intakes were measured by the Block Food Frequency Question naire . Concordance with the DASH dietary pattern was estimated by a DASH score . STATISTICAL ANALYSES The main effects of MD-I and PT-I , and their interaction , were evaluated using analysis of covariance . RESULTS After 6 months of intervention , MD-I participants significantly increased intakes of potassium , fruits , juices , and carbohydrate ; decreased intake of fat ; and improved overall dietary quality as measured by the Healthy Eating Index . PT-I intervention result ed in increased intakes of carbohydrate , protein , fiber , calcium , potassium , fruits and fruit juices , vegetables , dairy and Healthy Eating Index score , and decreased intakes in fat , saturated fat , cholesterol , sodium , sweets , and added fats/oils/sweets . In addition , PT-I improved overall DASH concordance score . The change in DASH score was significantly associated with the changes in blood pressure and weight at 6 months . At 18 months , most changes reversed back toward baseline levels , including the DASH score . CONCLUSIONS Both MD-I and PT-I  improved eating patterns at 6 months with some sustained effects at 18 months . Even though all dietary changes observed were consistent with the DASH nutrient targets or food group guidelines , only the PT-I intervention was effective in improving the overall DASH concordance score . This finding affirms the role of medical nutrition therapy in long-term intensive interventions for hypertension risk reduction and weight management and underlines the need for development of maintenance strategies . Furthermore , this study emphasizes the importance of collaborations among physicians , registered dietitians and other dietetics practitioners , and lay health advisors while assisting patients to make healthy behavior changes BACKGROUND There are established guidelines for recommended dietary intake for hypertension treatment and cardiovascular disease prevention . Evidence is lacking for effective dietary patterns for kidney disease prevention . STUDY DESIGN Prospect i ve cohort study . SETTING & PARTICIPANTS Atherosclerosis Risk in Communities ( ARIC ) Study participants with baseline estimated glomerular filtration rate ( eGFR ) ≥ 60mL/min/1.73m2 ( N=14,882 ) . PREDICTOR The Dietary Approaches to Stop Hypertension ( DASH ) diet score was calculated based on self-reported dietary intake of red and processed meat , sweetened beverages , sodium , fruits , vegetables , whole grains , nuts and legumes , and low-fat dairy products , averaged over 2 visits . OUTCOMES Cases were ascertained based on the development of eGFRs<60mL/min/1.73m2 accompanied by ≥25 % eGFR decline from baseline , an  International Classification of Diseases , Ninth/Tenth Revision code for a kidney disease-related hospitalization or death , or end-stage renal disease from baseline through 2012 . RESULTS 3,720 participants developed kidney disease  during a median follow-up of 23 years . Participants with a DASH diet score in the lowest tertile were 16 % more likely to develop kidney disease than those with the highest score tertile ( HR , 1.16 ; 95 % CI , 1.07 - 1.26 ; P for trend < 0.001 ) , after adjusting for sociodemographics , smoking status , physical activity , total caloric intake , baseline eGFR , overweight/obese status , diabetes status , hypertension status , systolic blood pressure , and antihypertensive medication use . Of the individual components of the DASH diet score , high red and processed meat intake was adversely associated with kidney disease and high nuts , legumes , and low-fat dairy products intake was associated with reduced risk for kidney disease . LIMITATIONS Potential measurement error due to self-reported dietary intake and lack of data for albuminuria . CONCLUSIONS Consuming a DASH-style diet was associated with lower risk for kidney disease independent of demographic characteristics , established kidney risk factors , and baseline kidney function . Healthful dietary patterns such as the DASH diet may be beneficial for kidney disease prevention BACKGROUND Data on the impact of the many dietary and lifestyle factors on the prevalence of  hypertension  in Western societies are lacking . This study quantified the contributions of body weight , physical inactivity and dietary factors to the prevalence of hypertension in Finl and , Italy , the Netherl and s , United Kingdom ( UK ) and USA . METHODS Distributions of blood pressure ( BP ) and risk factors in Western population s were obtained from nationwide surveys . The effect of risk factors on BP was assessed by meta-regression analysis of r and omized trials , published between 1966 and March 2001 . Population attributable risk percentages ( PAR% ) for hypertension ( i.e. systolic BP > or = 140 mmHg ) were computed for all risk factors in the five countries . RESULTS Being overweight made the largest contribution to hypertension , with PAR% between 11 % ( Italy ) and 25 % ( USA ) . PAR% were 5 - 13 % for physical inactivity , 9 - 17 % for high sodium intake , 4 - 17 % for low potassium intake and 4 - 8 % for low magnesium intake . The impact of alcohol was small ( 2 - 3 % ) in all population s. PAR% varied among population s for inadequate intake of calcium ( 2 - 8 % ) , magnesium ( 4 - 8 % ) , coffee ( 0 - 9 % ) and fish fatty acids ( 3 - 16 % ) . CONCLUSIONS Diet and lifestyle have a substantial impact on  hypertension  in Western societies , with being overweight , physical inactivity , high sodium intake and low potassium intake being the main contributors . The relative significance of different risk factors varies among population s , which is important for preventative strategies Background Health-related quality of life ( HRQOL ) is an important aspect of well-being that may improve with health behavior interventions . However , health behavior change is difficult with pressure to maintain status quo . Purpose This report examines the effects of two lifestyle interventions and an advice-only condition on HRQOL . Effects of meeting behavioral goals and weight loss also were examined . Methods Participants were 295 men and 467 women ( 34 % African American ) with pre-hypertension or stage 1 hypertension from the PREMIER trial .  HRQOL was assessed by the Short Form-36 . Participants were assigned r and omly to ( 1 ) advice only ( ADVICE ) , ( 2 ) established guidelines for blood pressure control ( EST ) , or ( 3 ) established guidelines plus the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern ( EST + DASH ) . Results Assignment to EST result ed in improvement in three HRQOL subscales at 6 months and one at 18 months relative to ADVICE . EST + DASH improved in two subscales at 6 and 18 months compared with ADVICE . Across conditions , total fat , saturated fat , fruit , and vegetable intake change , along with ≥4-kg weight loss , result ed in HRQOL improvements at 6 and 18 months . No improvement was found for change in physical activity , and only a few HRQOL subscales were associated with change in sodium and low-fat dairy intake . Conclusions Intensive lifestyle interventions can result in improvements in HRQOL . Change in dietary intake and weight loss is also important Background To improve quality of care and patient outcomes , health system decision-makers need to identify and implement effective interventions . An increasing number of systematic review s document the effects of quality improvement programs to assist decision-makers in developing new initiatives . However , limitations in the reporting of primary studies and current meta- analysis methods ( including approaches for exploring heterogeneity ) reduce the utility of existing syntheses for health system decision-makers . This study will explore the role of innovative meta- analysis approaches and the added value of enriched and up date d data for increasing the utility of systematic review s of complex interventions . Methods / Design We will use the data set from our recent systematic review of 142 r and omized trials of diabetes quality improvement programs  to evaluate novel approaches for exploring heterogeneity . These will include exploratory methods , such as multivariate meta-regression analyses and all-subsets combinatorial meta- analysis . We will then up date our systematic review to include new trials and enrich the data set by surveying authors of all included trials . In doing so , we will explore the impact of variables not , reported in previous publications , such as details of study context , on the effectiveness of the intervention . We will use innovative analytical methods on the enriched and up date d data set to identify key success factors in the implementation of  quality improvement interventions  for diabetes . Decision-makers will be involved throughout to help identify and prioritize variables to be explored and to aid in the interpretation and dissemination of results . Discussion This study will inform future systematic review s of complex interventions and describe the value of enriching and updating data for exploring heterogeneity in meta- analysis . It will also result in an up date d comprehensive systematic review of diabetes quality improvement interventions that will be useful to health system decision-makers in developing interventions to improve outcomes for people with diabetes . Systematic review registration PROSPERO registration no. BACKGROUND Systematic review s that " compare " the accuracy of 2 or more tests often include different sets of studies for each test . PURPOSE To investigate the availability of direct comparative studies of test accuracy and to assess whether summary estimates of accuracy differ between meta-analyses of noncomparative and comparative studies . DATA SOURCES Systematic review s in any language from the Data base of Abstract s of Review s of Effects and the Cochrane Data base of Systematic Review s from 1994 to October 2012 . STUDY SELECTION 1 of 2 assessors selected review s that evaluated at least 2 tests and identified meta-analyses that included both noncomparative studies and comparative studies . DATA EXTRACTION 1 of 3 assessors extracted data about review and study characteristics and test performance . DATA SYNTHESIS 248 review s compared test accuracy ; of the 6915 studies , 2113 ( 31 % ) were comparative . Thirty-six review s ( with 52 meta-analyses ) had adequate studies to compare results of noncomparative and comparative studies by using a hierarchical summary receiver-operating characteristic meta-regression model for each test comparison . In 10 meta-analyses , noncomparative studies ranked tests in the opposite order of comparative studies . A total of 25 meta-analyses showed more than a 2-fold discrepancy in the relative diagnostic odds ratio between noncomparative and comparative studies . Differences in accuracy estimates between noncomparative and comparative studies were greater than expected by chance ( P < 0.001 ) . LIMITATION A paucity of comparative studies limited exploration of direction in bias . CONCLUSION Evidence derived from noncomparative studies often differs from that derived from comparative studies . Robustly design ed studies in which all patients receive all tests or are r and omly assigned to receive one or other of the tests should be more routinely undertaken and are preferred for evidence to guide test selection . PRIMARY FUNDING SOURCE National Institute for Health Research ( United Kingdom ) Elevated blood pressure ( BP ) is a causal risk factor for cardiovascular disease ( CVD ) . Epidemiological analyses have established the grade d and continuous association between higher BP and CVD . Moreover , r and omized clinical trials among individuals with hypertension have demonstrated , in aggregate , a reduction in CVD events by 20 % , coronary heart disease ( CHD ) by 17 % , stroke by 27 % , and heart failure by 28 % for every 10 mm Hg systolic BP ( SBP ) lowering with medical therapy.1 Therefore , prevention , detection , treatment , and control of elevated BP , and its clinical correlate hypertension , is an important public health priority and a primary target for CVD prevention . Although national health surveys have demonstrated improvements in hypertension awareness and treatment , strategic opportunities to improve the efficiency and efficacy of applying BP-lowering therapy in patients most likely to benefit remain.2 Global CVD risk assessment , using multivariable prediction models that estimate absolute CVD risk from routinely measured clinical variables , has been promulgated in several CVD prevention guidelines for cholesterol management to target the most intensive preventive therapies to those at highest absolute CVD risk.3–5 Hypertension guidelines , however , have instead relied solely on isolated BP thresholds and BP goals to guide treatment initiation and intensity . In this review , we provide a rationale for incorporating global CVD risk assessment in BP treatment decision-making and propose a framework to guide its implementation in future CVD prevention guidelines . Epidemiological analyses have firmly established that CVD is a multifactorial condition and that modest increases of several CVD risk factors can often lead to greater overall risk than a severe elevation of a BACKGROUND The Dietary Approaches to Stop Hypertension ( DASH ) diet is widely promoted in the USA for the prevention and treatment of high blood pressure . It is high in fruit and vegetables , low-fat dairy and wholegrain foods and low in saturated fat and refined sugar . To our knowledge , the use of this dietary pattern has not been assessed in a free-living UK population . METHODS The DASH diet was adapted to fit UK food preferences and portion sizes . Fourteen healthy subjects followed the adapted DASH diet for 30 days in which they self-selected all food and beverages .  Dietary intake was assessed by 5-day food diaries completed before and towards the end of the study . Blood pressure was measured at the beginning and end of the study to assess compliance to the DASH style diet . RESULTS The DASH diet was easily adapted to fit with UK food preferences . Furthermore , it was well tolerated and accepted by subjects . When on the DASH style diet , subjects reported consuming significantly ( P < 0.01 ) more carbohydrate and protein and less total fat ( 5 % , 6 % and 9 % total energy , respectively ) . Sodium intakes decreased by 860 mg day(-1 ) ( P < 0.001 ) . Systolic and diastolic blood pressure decreased significantly ( P < 0.05 ) by 4.6 and 3.9 mmHg , respectively when on the DASH style diet . CONCLUSIONS The DASH style diet was well accepted and was associated with a decrease in blood pressure in normotensive individuals and should be considered when giving dietary advice to people with elevated blood pressure in the UK The Dietary Approaches to Stop Hypertension ( DASH ) diet is perhaps the best example of how a nutrient dense dietary pattern can prevent chronic disease . In r and omized trials , DASH dietary patterns lowered blood pressure  in hypertensive individuals.1 Subsequent trials and observational studies have consistently found that DASH-type diets reduced cardiovascular and metabolic Abstract —Blood pressure-lowering mechanisms of the Dietary Approaches to Stop Hypertension ( DASH ) diet , rich in fruits , vegetables , and low-fat dairy foods , were analyzed based on the pressure-natriuresis relationship . Participants ( n=375 ) were r and omly assigned to control or DASH diet groups by using a parallel-group design . They then ate their assigned diet for 3 consecutive 30-day intervention feeding periods , during which sodium intake varied among 3 levels by a r and omly assigned sequence . Urinary sodium excretion rate and mean arterial pressure were measured at the end of each sodium intake level . Mean arterial pressure and urinary sodium excretion were plotted on x and y axes , respectively , for participants eating control and DASH diets and were modeled as linear relationships for simplicity to allow the estimation of the extrapolated x-intercept and slope of the relationships . The DASH diet steepened the slope of the relationship ( 29.5±3.4 vs 64.9±13.1 [mmol/d]/mm Hg , P = 0.0002 ) without significantly shifting the x-intercept ( 94.1±0.5 vs 93.2±0.6 mm Hg , NS ) of the relationship . These data suggest a natriuretic action of the DASH diet Background — Although trials of lifestyle interventions generally focus on cardiovascular disease risk factors rather than hard clinical outcomes , 10-year coronary heart disease ( CHD ) risk can be estimated from the Framingham risk equations . Our objectives were to study the effect of 2 multicomponent lifestyle interventions on estimated CHD risk relative to advice alone and to evaluate whether differences can be observed in the effects of the lifestyle interventions among subgroups defined by baseline variables . Methods and Results — A total of 810 healthy adults with untreated prehypertension or stage I hypertension were r and omized to 1 of 3 intervention groups : An “ advice-only ” group , an “ established ” group that used established lifestyle recommendations for blood pressure control ( sodium reduction , weight loss , and increased physical activity ) , or an “ established-plus-DASH ” group that combined established lifestyle recommendations with the DASH ( Dietary Approaches to Stop Hypertension ) diet . The primary outcome was 10-year CHD risk , estimated from follow-up data collected at 6 months . A secondary outcome was 10-year CHD risk at 18 months . Of the 810 participants , 62 % were women and 34 % were black . Mean age was 50 years , mean systolic/diastolic blood pressure was 135/85 mm Hg , and median baseline Framingham risk was 1.9 % . The relative risk ratio comparing 6-month to baseline Framingham risk was 0.86 ( 95 % confidence interval 0.81 to 0.91 , P<0.001 ) in the established group and 0.88 ( 95 % confidence interval 0.83 to 0.94 , P<0.001 ) in the established-plus-DASH group relative to advice alone . Results were virtually identical in sensitivity analyses , in each major subgroup , and at 18 months . Conclusions — The observed reductions of 12 % to 14 % in estimated CHD risk are substantial and , if achieved , should have important public health benefits Abstract Objective : To determine whether peer review medical audit in a primary care setting changes clinical behaviour in relation to the management of hypertension . Design : Review of medical records in general practice s to identify hypertensive patients followed up by assessment of the pre-educational and post-educational management of interventions . Setting : Six general practice s in north west London picked at r and om within defined criteria of geography and size . Subjects : 740 hypertensive patients managed by 25 different general practitioners . Main outcome measures : Improved level of care in terms of better diagnosis by having at least three blood pressure readings before the start of drug treatment , better level of recordings of lifestyle parameters as shown by the level of recordings of body mass index and total lipid values , and better control of blood pressure and harm minimisation as shown by the level of recordings of urea and electrolyte values . Results : Improvement was noted in the level of recordings of body mass index , total lipid concentrations , and urea and electrolyte values but not in better diagnosis or blood pressure control . Conclusion : Clinical behaviour of general practitioners can be changed by peer review but more complex behavioural changes which require the cooperation of the patients and cognitive actions by the general practitioners need further investigation . Key messages Peer review can significantly change the clinical behaviour of general practitioners with respect to undertaking simple diagnostic procedures , recording lifestyle variables , and carrying out laboratory measurements Attempts to improve control of blood pressure by general practitioners is a target less easily achieved A primary care study has shown that despite an active education programme over two years the proportion of treated patients whose blood pressure was controlled to < 160/90 mm Hg remained at only one Background Consumption of chocolate has been often hypothesized to reduce the risk of cardiovascular disease ( CVD ) due to chocolate 's high levels of stearic acid and antioxidant flavonoids . However , debate still lingers regarding the true long term beneficial cardiovascular effects of chocolate overall . Methods We review ed English- language MEDLINE publications from 1966 through January 2005 for experimental , observational , and clinical studies of relations between cocoa , cacao , chocolate , stearic acid , flavonoids ( including flavonols , flavanols , catechins , epicatechins , and procynadins ) and the risk of cardiovascular disease ( coronary heart disease ( CHD ) , stroke ) . A total of 136 publications were selected based on relevance , and quality of design and methods . An up date d meta- analysis of flavonoid intake and CHD mortality was also conducted . Results The body of short-term r and omized feeding trials suggests cocoa and chocolate may exert beneficial effects on cardiovascular risk via effects on lowering blood pressure , anti-inflammation , anti-platelet function , higher HDL , decreased LDL oxidation . Additionally , a large body of trials of stearic acid suggests it is indeed cholesterol-neutral . However , epidemiologic studies of serum and dietary stearic acid are inconclusive due to many method ologic limitations . Meanwhile , the large body of prospect i ve studies of flavonoids suggests the flavonoid content of chocolate may reduce risk of cardiovascular mortality . Our up date d meta- analysis indicates that intake of flavonoids may lower risk of CHD mortality , RR = 0.81 ( 95 % CI : 0.71–0.92 ) comparing highest and lowest tertiles . Conclusion Multiple lines of evidence from laboratory experiments and r and omized trials suggest stearic acid may be neutral , while flavonoids are likely protective against CHD mortality . The highest priority now is to conduct larger r and omized trials to definitively investigate the impact of chocolate consumption on long-term cardiovascular outcomes BACKGROUND AND PURPOSE Acupuncture is widely used in the treatment of hypertension , yet its efficacy and safety for hypertension remain controversial . This overview aim ed to summarize the evidence on acupuncture for hypertension . METHODS Eight data bases were search ed . The Assessment of Multiple Systematic Review s ( AMSTAR ) tool and the Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach were performed . RESULTS Fifteen systematic review s ( SRs ) were identified . Method ological quality and quality of evidence were unsatisfactory . Acupuncture combined with Western medicine ( WM ) was superior to WM in systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) , efficacy rate , and traditional Chinese medicine ( TCM ) syndrome .  Acupuncture was more effective in treating SBP and DBP than sham acupuncture plus WM . Evidence regarding the benefit of acupuncture alone for SBP and DBP , efficacy rate and TCM syndrome was inconsistent . No serious adverse effects were identified . CONCLUSION High- quality SRs and r and omized controlled trials ( RCTs ) are required Introduction Systematic review er authors intending to include all r and omized participants in their meta-analyses need to make assumptions about the outcomes of participants with missing data . Objective The objective of this paper is to provide systematic review er authors with a relatively simple guidance for addressing dichotomous data for participants excluded from analyses of r and omized trials . Methods This guide is based on a review of the Cochrane h and book and published method ological research . The guide deals with participants excluded from the analysis who were considered ‘ non-adherent to the protocol ’ but for whom data are available , and participants with missing data . Results Systematic review er authors should include data from ‘ non-adherent ’ participants excluded from the primary study authors ' analysis but for whom data are available . For missing , unavailable participant data , authors may conduct a complete case analysis ( excluding those with missing data ) as the primary analysis . Alternatively , they may conduct a primary analysis that makes plausible assumptions about the outcomes of participants with missing data . When the primary analysis suggests important benefit , sensitivity meta-analyses using relatively extreme assumptions that may vary in plausibility can inform the extent to which risk of bias impacts the confidence in the results of the primary analysis . The more plausible assumptions draw on the outcome event rates within the trial or in all trials included in the meta- analysis . The proposed guide does not take into account the uncertainty associated with assumed events . Conclusions This guide proposes methods for h and ling participants excluded from analyses of r and omized trials . These methods can help in establishing the extent to which risk of bias impacts meta- analysis results Prognostic markers help to stratify patients for treatment by identifying patients with different risks of outcome ( e.g. recurrence of disease ) , and are important tools in the management of cancer and many other diseases . Systematic review and meta-analytical approaches to identifying the most valuable prognostic markers are needed because ( sometimes conflicting ) evidence relating to markers is often published across a number of studies . To investigate the practicality of this approach , an empirical investigation of a systematic review of  tumour markers for neuroblastoma was performed ; 260 studies of prognostic markers were identified , which considered 130 different markers . The reporting of these studies was often inadequate , in terms of both statistical analysis and presentation , and there was considerable heterogeneity for many important clinical /statistical factors . These problems restricted both the extraction of data and the meta- analysis of results from the primary studies , limiting feasibility of the evidence -based approach . Guidelines for reporting the results of primary prognostic marker studies in cancer , and other diseases , are given in order to facilitate both the interpretation of individual studies and the undertaking of systematic review s , meta- analysis and , ultimately , evidence -based practice . General availability of full individual patient data is a necessary step forward and would overcome the majority of problems encountered , including poorly reported summary statistics and variability in cutoff level , outcome assessed and adjustment factors used . It would also limit the problem of reporting bias , although publication bias will remain a concern until studies are prospect ively registered . Such changes in practice would help important evidence -based review s to be conducted in order to establish the most appropriate prognostic markers for clinical use , which should ultimately improve patient care Objective : To study the effects of a dietary fibre supplement given as monotherapy upon blood pressure in mildly hypertensive patients . Design : The investigation was performed as a prospect i ve r and omized , double-blind , placebo-controlled trial for 3 months . Setting : Patients attending an outpatient hypertension clinic in a hospital . Patients : Hypertensive patients with a minimum of two diastolic blood pressure ( DBP ) readings > 90mmHg during a 2-week run-in period were included . Of the 65 patients enrolled , 63 were r and omized ( 32 fibre , 31 placebo )  . Six patients did not complete the trial . Intervention : Patients were treated with either fibre ( 7 g/day ) or matching placebo . Main outcome measure : Based on previous studies , the a priori hypothesis was that dietary fibre supplementation could reduce blood pressure in hypertensive patients . Results : Body weight was significantly reduced in the fibre group . Dietary fibre  significantly reduced DBP and fasting serum insulin . However , no correlation between changes in body weight and systolic blood pressure or DBP was found . Conclusion : A dietary fibre supplement can lower DBP in mildly hypertensive patients independent of changes in body weight Approximately one fourth of the U.S. adult population nearly 50 million peoplehas hypertension ( 1 , 2 ) . Taking a broader perspective , more than half of the adult population has higher than optimal blood pressure ( 1 ) , defined as systolic blood pressure greater than 120 mm Hg and diastolic blood pressure greater than 80 mm Hg ( 2 ) . These persons are at significantly increased risk for cardiovascular disease and stroke ( 3 ) . Although pharmacologic treatment for hypertension significantly reduces morbidity and mortality from cardiovascular diseases ( 4 , 5 ) , long-term pharmacologic therapy can have undesirable side effects and requires the expense of continuing medical supervision . Furthermore , pharmacologic therapy is not usually initiated when blood pressure is higher than optimal yet below diagnostic thresholds for hypertension . Thus , lifestyle interventions for primary prevention and initial treatment of high blood pressure remain a vital strategy for controlling this highly prevalent condition ( 2 ) . Weight loss has been shown to reduce blood pressure in overweight hypertensive patients ( 6 - 9 ) and in overweight persons with high-normal blood pressure ( 10 - 12 ) . Two review s of r and omized trials of weight reduction to reduce blood pressure examined the results of nine studies ( 13 , 14 ) . Most of these trials were small , only one had more than 500 participants ( 11 ) , and most had short-term follow-up ( 1 year or less ) . Only three studies had follow-up of 3 to 5 years ( 8 , 10 , 11 ) . Compared with controls ,  weight loss  averaged nearly 7 kg in the short-term trials and approximately 3 kg in the three longer-term trials . In almost all trials , systolic blood pressure and diastolic blood pressure were reduced in the intervention groups . Since these review s were published , the Trials of Hypertension Prevention ( TOHP ) Phase I reported mean weight reduction of 3.9 kg at 18 months in 564 overweight participants with high-normal blood pressure , result ing in significant decreases in systolic blood pressure and diastolic blood pressure compared with a usual care control group ( 12 , 15 ) . To investigate whether nonpharmacologic interventions can prevent hypertension over the long term , TOHP II was initiated . This was a r and omized , controlled trial examining the effects of  weight loss and dietary sodium reduction , alone and in combination , in reducing blood pressure in overweight adults with high-normal diastolic blood pressure ( 16 ) . This target population is at high risk for hypertension as they age . The primary outcome paper from this trial ( 17 ) provided only a brief overview of the effects of weight loss on blood pressure . Here , we provide more detailed analysis of weight loss and blood pressure in TOHP II . Of special interest are the long-term effects of weight loss on blood pressure , the magnitude of the doseresponse relationship at 36 months , the effect of patterns of weight loss on blood pressure , and the predictors of weight loss and blood pressure response . Methods Participants Participants in TOHP II were overweight adults with nonmedicated diastolic blood pressure of 83 to 89 mm Hg and systolic blood pressure less than 140 mm Hg . Other eligibility criteria included age 30 to 54 years and a body mass index of 26.1 to 37.4 kg/m2 for men and 24.4 to 37.4 kg/m2 for women , approximately 110 % to 165 % of ideal weight ( 18 ) . Principal exclusion criteria were current treatment with medications that might affect blood pressure , clinical or laboratory evidence of cardiovascular disease , diabetes mellitus , renal insufficiency ( serum creatinine concentration 150 mol/L [ 1.7 mg/dL ] for men and 132 mol/L [ 1.5 mg/dL ] for women ) , and current or planned pregnancy . Detailed descriptions of recruitment and participant characteristics have been published elsewhere ( 19 , 20 ) . The study was review ed and approved by the institutional review boards at all nine TOHP centers and the coordinating center , and all participants signed informed consent forms . Design Eligible participants were r and omly assigned with equal probability to one of four groups : weight loss only , sodium reduction only , combined weight loss and sodium reduction , or usual care ( controls ) . Measurements Age , sex , ethnicity , and years of education were obtained by question naire . Baseline blood pressure measurements were taken at three screening visits , each separated by 7 to 45 days . At each visit , three readings of systolic blood pressure and diastolic blood pressure were obtained and averaged . Certified staff obtained measurements in seated participants by using a Hawksley r and om-zero sphygmomanometer ( 21 ) . Body weight was measured to the nearest 0.2 kg ( 0.5 lb ) by using a calibrated balance-beam scale ; participants wore indoor clothing ( without shoes ) . Blood pressure and weight were measured every 6 months after r and omization to the end of follow-up at 36 , 42 , or 48 months , depending on r and omization date . Clinic staff who were blinded to study group assignment made these assessment s. Blood pressure measurements were obtained during a single visit at all follow-up points except for 18 and 36 months , when measurements were taken at a series of three visits approximately 1 week apart . Multiple measurements were taken at 18 and 36 months to provide a more precise assessment of average blood pressures at these primary outcome points . Dietary intake was assessed by 24-hour recall , and physical activity was assessed by question naire . Intervention Participants assigned to the weight loss intervention group sought to lose at least 4.5 kg ( 10 lb ) during the first 6 months of the intervention and to maintain their weight loss for the remainder of the trial . A brief description of the intervention methods is presented here ; a more detailed description has been published elsewhere ( 22 ) . The intervention started with an individual counseling session , followed by 14 weekly group meetings led by dietitians or health educators . After this 14-week intensive phase , participants attended six biweekly group meetings and then monthly group meetings . Beginning in the 18th month , participants were offered a variety of options to keep them involved in the intervention , including individual counseling sessions and special group sessions focused on selected weight loss topics . The intervention focused on self-directed behavior change ( behavioral self-management ) , nutrition education , information on physical activity , and social support for making and maintaining behavior changes . Specific behavior change techniques included self-monitoring ( food diaries and graphs of minutes of physical activity per day ) , setting explicit short-term goals and developing specific action plans to achieve those objectives , and developing alternative strategies for situations that trigger problem eating . The dietary intervention focused on reducing caloric intake by decreasing consumption of excess fat , sugar , and alcohol . Keeping daily food diaries was emphasized for monitoring intake and assessing progress . With experience , the participants determined the caloric intake that produced moderate weight loss for them . It was suggested that men not consume less than 1500 kcal/d and women not less than 1200 kcal/d . Weight loss of more than 0.9 kg ( 2 lb ) per week was discouraged . The physical activity goal was to gradually increase activity to 30 to 45 minutes per day , four to five days per week . Exercise intensity was moderate , approximately 40 % to 55 % of heart rate reserve , and consisted primarily of brisk walking . Statistical Analysis Baseline characteristics of the weight loss and usual care groups were compared overall and by sex by using t-tests for means and chi-square tests for proportions . Although weight and blood pressure data were collected every 6 months , special efforts were made to achieve high follow-up rates at 18 and 36 months ; at each of these two time points , nine blood pressure readings were collected over three visits and were averaged . For participants prescribed antihypertensive medication , follow-up blood pressure for all subsequent visits was taken to be the last study blood pressure before therapy was started . Participants receiving medications that affect blood pressure for reasons other than hypertension or who became pregnant were treated as missing at that visit . We used two- sample t-tests to compare changes in weight and blood pressure from baseline in the  weight loss intervention and usual care groups overall , by sex , by ethnicity , and by sex and ethnicity . The effects of the intervention in terms of changes in weight and blood pressure were examined overall and in subgroups defined by sex , ethnicity , and sex and ethnicity . Subgroup differences were tested by using terms for the interaction of treatment group with sex and with ethnicity in multiple linear regression models . Regression analyses were also used to analyze the doseresponse relationship between change in weight and change in blood pressure , overall and within sex and ethnicity subgroups . Differences in dose response were tested by using interaction terms in linear regression models . All regressions were adjusted for age and baseline weight . We also adjusted for baseline blood pressure in the blood pressure regression models . Change in blood pressure was also examined in relation to quintile of weight loss . Quintiles were computed by using the distribution of weight change in the weight loss intervention group . Additional multiple regression analyses were performed in which weight loss participants were categorized according to patterns of weight loss at 6 and 36 months . The PROC MIXED function of SAS software ( SAS Institute , Inc. , Cary , North Carolina ) was used to perform repeated- measures analyses that tested differences over time by pattern of weight loss . Cox proportional-hazards models were used for survival analyses , with onset of hypertension as the outcome . Results Baseline Findings The baseline characteristics of participants assigned to Several epidemiological studies have investigated the potential association between dietary fiber , glycemic index ( GI ) or glycemic load ( GL ) , and renal cell carcinoma ( RCC ) risk with inconsistent results . The aim of this study was to systematic ally evaluate this issue with a meta- analysis approach . A comprehensive literature search up to March 2018 was performed in PubMed and Web of Science data bases . Summary relative risks ( RRs ) and 95 % confidence intervals ( CIs ) were estimated with a r and om-effects model . Twelve studies were finally included in this study ( eight for fiber analysis , five for GI and five for GL ) . A significant positive association was observed between GI and the risk of RCC ( summary RR 1.16 , 95 % CI 1.02 - 1.32 ) , and no significant heterogeneity was detected among studies ( I2 = 22.8 % , P = 0.262 ) . A significant inverse association was found between fiber intake and the risk of RCC ( summary RR 0.82 , 95 % CI 0.72 - 0.92 ) , and no significant heterogeneity was observed across studies ( I2 = 27.6 % , P = 0.218 ) . GL was not significantly associated with RCC risk ( summary RR 1.14 , 95 % CI 0.81 - 1.60 ) , and significant heterogeneity was found across studies ( I2 = 78.6 % , P < 0.001 ) . In conclusion , this systematic review and meta- analysis suggests that dietary GI and fiber may be associated with the risk of RCC . Further large prospect i ve cohort studies are still warranted to confirm our preliminary findings Findings from short-term r and omized trials indicate that dietary supplements of omega-3 polyunsaturated fatty acids ( PFA ) lower blood pressure of hypertensive persons , but effect size in nonhypertensive individuals is small and nonsignificant . Data are lacking on food omega-3 PFA and blood pressure in general population s. The International Study of Macro- and Micro-nutrients and Blood Pressure ( INTERMAP ) is an international cross-sectional epidemiologic study of 4680 men and women ages 40 to 59 from 17 population -based sample s in China , Japan , United Kingdom , and United States . We report associations of food omega-3 PFA intake ( total , linolenic acid , long-chain ) of individuals with blood pressure . Systolic and diastolic blood pressure were measured 8 times at 4 visits . With several models to control for possible confounders ( dietary , other ) , linear regression analyses showed inverse relationship of total omega-3 PFA from food ( percent kilocalories , from four 24-hour dietary recalls ) to systolic and diastolic blood pressures . With adjustment for 17 variables , estimated systolic blood pressure/diastolic blood pressure differences with 2 st and ard deviation higher ( 0.67 % kcal ) omega-3 PFA were −0.55/−0.57 mm Hg ( Z-score −1.33 , −2.00 ) ; for 2238 persons without medical or dietary intervention , −1.01/−0.98 mm Hg ( Z −1.63 , −2.25 ) ; for 2038 nonhypertensive persons from this sub-cohort , −0.91/−0.92 mm Hg ( Z −1.80 , −2.38 ) . For linolenic acid ( largely from vegetable foods ) , blood pressure differences were similar , eg , for the 2238 “ nonintervened ” individuals , −0.97/−0.87 mm Hg ( Z −1.52 , −1.95 ) ; blood pressure differences were −0.32/−0.45 mm Hg for long-chain omega-3 PFA ( largely from fish ) . In summary , food omega-3 PFA intake related inversely to blood pressure , including in nonhypertensive persons , with small estimated effect size . Food omega-3 PFA may contribute to prevention and control of adverse blood pressure levels Background The prevalence of overweight and obesity in children and adolescents is increasing at an alarming rate around the world and prevention has become a key public health objective . Treatment and management of those already overweight and obese must be aligned with the best available evidence on effectiveness , if the risk of obesity‐related morbidity and mortality is yet be reduced . Diet plays a pivotal role in successful treatment of obesity but to date , there is limited evidence on which to base practice . Objectives To identify and present the best available evidence on the optimal dietetic treatment and management of children and adolescent who are overweight or obese . Search strategy Published English language literature was search ed using the electronic data bases CINAHL , MEDLINE , PRE‐ MEDLINE , DARE , COCHRANE , EMBASE , AUSTROM , Current Concepts and Dissertation Abstract s. The data bases were limited to English Language from 1975 until 2003 . Government reports from the UK , USA and Australian were also search ed and a h and search performed for the Journal of the Dietitians Association of Australia , International Journal of Obesity and the Journal of Human Nutrition and Dietetics and the bibliographies of retrieved articles . Selection criteria ( i ) Interventions that evaluated the effectiveness of nutrition or dietary interventions to treat or manage overweight and obesity ; ( ii ) Children aged less than 18 years ; and ( iii ) Participants were defined as overweight or obese by relative weight or a measure of body weight status , studies that reported body weight per se were excluded . Data collection and analysis An experienced professional librarian search ed the data bases , and two trained research assistants independently identified studies for retrieval and assessed each article for inclusion . The included studies were critically appraised for method ological quality by two people independently . Data were extracted from the appropriate articles and when a discrepancy arose , a third party would arbitrate . Main results There were 116 articles that met the inclusion criteria . While 49 articles described r and omised controlled trials , they arose from 37 separate studies . There were 67 non‐r and omised trials . Meta‐analyses were performed on eight studies that included both a dietary intervention component and an adequate control group and on four studies that had follow‐up data . There was a high degree of heterogeneity between studies and this made comparisons between studies problematic . Interventions that include diet therapy generally result in significant weight loss , at least in the short term . Many studies were poorly design ed and had no or only minimal follow up . The details of the dietary intervention were often inadequately described and dietary outcomes rarely reported , making repetition of the studies difficult . Review ers ' conclusions There is an urgent need for high quality studies investigating the optimal dietary approach to management of paediatric  overweight and obesity . These studies require adequate follow up to ascertain if weight loss can be sustained in the long term . Details of the dietary prescription , adherence to the dietary intervention and diet‐specific outcomes need to be reported in order to inform best practice Background The prevalence of overweight and obesity in children and adolescents is increasing at an alarming rate around the world and prevention has become a key public health objective . Treatment and management of those already overweight and obese must be aligned with the best available evidence on effectiveness , if the risk of obesity-related morbidity and mortality is yet be reduced . Diet plays a pivotal role in successful treatment of obesity but to date , there is limited evidence on which to base practice . Objectives To identify and present the best available evidence on the optimal dietetic treatment and management of children and adolescent who are overweight or obese . Search strategy Published English language literature was search ed using the electronic data bases CINAHL , MEDLINE , PRE- MEDLINE , DARE , COCHRANE , EMBASE , AUSTROM , Current Concepts and Dissertation Abstract s. The data bases were limited to English Language from 1975 until 2003 . Government reports from the UK , USA and Australian were also search ed and a h and search performed for the Journal of the Dietitians Association of Australia , International Journal of Obesity and the Journal of Human Nutrition and Dietetics and the bibliographies of retrieved articles . Selection criteria ( i ) Interventions that evaluated the effectiveness of nutrition or dietary interventions to treat or manage overweight and obesity ; ( ii ) Children aged less than 18 years ; and ( iii ) Participants were defined as overweight or obese by relative weight or a measure of body weight status , studies that reported body weight per se were excluded . Data collection and analysis An experienced professional librarian search ed the data bases , and two trained research assistants independently identified studies for retrieval and assessed each article for inclusion . The included studies were critically appraised for method ological quality by two people independently . Data were extracted from the appropriate articles and when a discrepancy arose , a third party would arbitrate . Main results There were 116 articles that met the inclusion criteria . While 49 articles described r and omised controlled trials , they arose from 37 separate studies . There were 67 non-r and omised trials . Meta-analyses were performed on eight studies that included both a dietary intervention component and an adequate control group and on four studies that had follow-up data . There was a high degree of heterogeneity between studies and this made comparisons between studies problematic . Interventions that include diet therapy generally result in significant weight loss , at least in the short term . Many studies were poorly design ed and had no or only minimal follow up . The details of the dietary intervention were often inadequately described and dietary outcomes rarely reported , making repetition of the studies difficult . Review ers ' conclusions There is an urgent need for high quality studies investigating the optimal dietary approach to management of paediatric overweight and obesity . These studies require adequate follow up to ascertain if weight loss can be sustained in the long term . Details of the dietary prescription , adherence to the dietary intervention and diet-specific outcomes need to be reported in order to inform best practice CONTEXT The findings of systematic review s ( SRs ) and meta-analyses ( MAs ) are used for clinical decision making . The European Association of Urology has committed increasing re sources into the development of high quality clinical guidelines based on such SRs and MAs . OBJECTIVE In this paper , we have summarised the process of conducting SRs for underpinning clinical practice guidelines under the auspices of the European Association of Urology Guidelines Office . EVIDENCE ACQUISITION The process involves explicit methods and the findings should be reproducible . When conducting a SR , the essential first step is to formulate a clear and answerable research question . An extensive literature search lays the foundation for evidence synthesis . Data are extracted independently by two review ers and any disagreements are resolved by discussion or arbitration by a third review er . EVIDENCE SYNTHESIS In SRs , data for particular outcomes in individual r and omised controlled trials may be combined statistically in a meta- analysis to increase power when the studies are similar enough . Biases in studies included in a SR/MA can lead to either an over estimation or an under estimation of true intervention effect size , result ing in heterogeneity in outcome between studies . A number of different tools are available such as Cochrane Risk of Bias assessment tool for r and omised controlled trials . In circumstances where there is too much heterogeneity , or when a review has included nonr and omised comparative studies , it is more appropriate to conduct a narrative synthesis . The GRADE tool for assessing quality of evidence strives to be a structured and transparent system , which can be applied to all evidence , regardless of quality . A SR not only identifies , evaluates , and summarises the best available evidence , but also the gaps to be targeted by future studies . CONCLUSIONS SRs and MAs are integral in developing sound clinical practice guidelines and recommendations . PATIENT SUMMARY Clinical practice guidelines should be evidence based , and systematic review s and meta-analyses are essential in their production . We have discussed the key steps of conducting systematic review s and meta-analyses in this paper Sodium reduction is efficacious for primary prevention of hypertension , but the feasibility of achieving this effect is unclear . The objective of the paper is detailed analyses of adherence to and effects of the sodium reduction intervention among overweight adults in the Trials of Hypertension Prevention , Phase II . Sodium reduction ( comprehensive education and counselling about how to reduce sodium intake ) was tested vs no dietary intervention ( usual care ) for 36–48 months . A total of 956 white and 203 black adults , ages 30–54 years , with diastolic blood pressure 83–89 mmHg , systolic blood pressure ( SBP ) < 140 mmHg , and body weight 110–165 % of gender-specific st and ard weight were included in the study . At 36 months , urinary sodium excretion was 40.4 mmol/24 h ( 24.4 % ) lower in sodium reduction compared to usual care participants ( P<0.0001 ) , but only 21 % of sodium reduction participants achieved the targeted level of sodium excretion below 80 mmol/24 h. Adherence was positively related to attendance at face-to-face contacts . Net decreases in SBP at 6 , 18 , and 36 months of 2.9 ( P<0.001 ) , 2.0 ( P<0.001 ) , and 1.3 ( P=0.02 ) mmHg in sodium reduction vs usual care were associated with an overall 18 % lower incidence of hypertension ( P=0.048 ) ; were relatively unchanged by adjustment for ethnicity , gender , age , and baseline blood pressure , BMI , and sodium excretion ; and were observed in both black and white men and women . From these beneficial but modest results with highly motivated and extensively counselled individuals , sodium reduction sufficient to favourably influence the population blood pressure distribution will be difficult to achieve without food supply changes Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641
For most comparisons , the credibility of evidence was rated very low to moderate , with the exception for the DASH vs. the low-fat dietary approach for which the quality of evidence was rated high .
Conclusion : The present network meta- analysis suggests that the DASH dietary approach might be the most effective dietary measure to reduce blood pressure among hypertensive and pre-hypertensive patients based on high quality evidence
ABSTRACT Background : Pairwise meta-analyses have shown beneficial effects of individual dietary approaches on blood pressure but their comparative effects have not been established .
Objective : Therefore we performed a systematic review of different dietary intervention trials and estimated the aggregate blood pressure effects through network meta- analysis including hypertensive and pre-hypertensive patients .