Publications by authors named "Ângela Cristine Bersch-Ferreira"

18 Publications

  • Page 1 of 1

Effects of a Brazilian cardioprotective diet and nuts on cardiometabolic parameters after myocardial infarction: study protocol for a randomized controlled clinical trial.

Trials 2021 Sep 1;22(1):582. Epub 2021 Sep 1.

Instituto Nacional de Cardiologia (INC), Rio de Janeiro, Rio de Janeiro, Brazil.

Background: Nut consumption has been related to improvements on cardiometabolic parameters and reduction in the severity of atherosclerosis mainly in primary cardiovascular prevention. The objective of this trial is to evaluate the effects of the Brazilian Cardioprotective Diet (DIeta CArdioprotetora Brasileira, DICA Br) based on consumption of inexpensive locally accessible foods supplemented or not with mixed nuts on cardiometabolic features in patients with previous myocardial infarction (MI).

Methods: DICA-NUTS study is a national, multicenter, randomized 16-week follow-up clinical trial. Patients over 40 years old with diagnosis of previous MI in the last 2 to 6 months will be recruited (n = 388). A standardized questionnaire will be applied to data collection and blood samples will be obtained. Patients will be allocated in two groups: Group 1: DICA Br supplemented with 30 g/day of mixed nuts (10 g of peanuts, 10 g of cashew, 10 g of Brazil nuts); and Group 2: only DICA Br. The primary outcome will consist of LDL cholesterol means (in mg/dL) after 16 weeks of intervention. Secondary outcomes will consist of other markers of lipid profile, glycemic profile, and anthropometric data.

Discussion: It is expected that DICA Br supplemented with mixed nuts have superior beneficial effects on cardiometabolic parameters in patients after a MI, when compared to DICA Br.

Trial Registration: ClinicalTrials.gov Identifier NCT03728127 . First register: November 1, 2018; Last update: June 16, 2021. World Health Organization Universal Trial Number (WHO-UTN): U1111-1259-8105.
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http://dx.doi.org/10.1186/s13063-021-05494-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411551PMC
September 2021

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

Br J Nutr 2021 May 11:1-10. Epub 2021 May 11.

Graduate Program in Health Sciences (Cardiology), Instituto de Cardiologia/Fundação Universitária de Cardiologia do Rio Grande do Sul (IC/FUC), 395 Princesa Isabel Avenue, 90040-371 Porto Alegre, Rio Grande do Sul, Brazil.

The consumption of nuts and extra-virgin olive oil has been associated with suppression of inflammatory pathways that contribute to atherosclerosis, but its role on the modulation of the inflammatory profile in patients with established coronary artery disease (CAD) is unclear. The aim of this study was to evaluate the effects of adding pecan nuts or extra-virgin olive oil to a healthy diet on inflammatory markers in patients with stable CAD. In this randomised clinical trial, 204 patients were enrolled to three study groups: sixty seven to control group (CG: healthy diet), sixty eight to pecan nuts group (PNG: 30 g/d of pecans + healthy diet) and sixty nine to extra-virgin olive oil group (OOG: 30 ml/d of extra-virgin olive oil + healthy diet). High-sensitivity C-reactive protein (hs-CRP, in mg/l), fibrinogen (mg/dl), IL 2, 4, 6, 10 (pg/ml) and interferon-γ (IFN-γ, in pg/ml), IL-6/IL-10, IL-2/IL-4 and IFN-/γIL-4 ratios were evaluated at baseline and after the follow-up (12 weeks). As main results, after adjustment for sex, statin used and relative body weight variation, there were no differences between groups regarding inflammatory markers at the end of the study. IL-6 levels (primary outcome) were reduced in 12 weeks when compared with baseline in all study groups (CG: difference: -0·593 (se = 0·159) pg/dL; PNG: difference: -0·335 (se = 0·143) pg/dl; OOG: IL-6 difference: -0·325 (se = 0·143) pg/dl). In conclusion, there was no significant effect of including pecan nuts or extra virgin olive oil to a healthy diet on inflammatory markers in individuals with CAD.
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http://dx.doi.org/10.1017/S0007114521001513DOI Listing
May 2021

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

Int J Food Sci Nutr 2021 Apr 11:1-10. Epub 2021 Apr 11.

Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Brazil.

The consumption of ultra-processed foods (UPF) has been associated with cardiometabolic risk factors. However, there is scarce literature on the association between UPF consumption, cardiovascular events, and cardiometabolic risk factors in subjects undergoing secondary care for cardiovascular diseases (CVD). Thus, we aimed to evaluate the association between UPF consumption, CVD, and cardiometabolic risk factors in subjects with established CVD. Baseline data from 2,357 subjects participating in a Brazilian multicenter study were analysed finding a mean UPF consumption of 18.7% of their energy intake. Higher figures of UPF consumption were founded associated with an increased presence of high waist circumference, overweight, peripheral arterial disease, and with a decreased odds of the simultaneous presence of coronary arterial disease, peripheral arterial diseases, and stroke when comparing among tertiles of UPF contribution to energy intake. These associations were observed when analyzing the whole sample and women but not men. Thus, these findings should help improve strategies for CVD patients in secondary care.
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http://dx.doi.org/10.1080/09637486.2021.1908963DOI Listing
April 2021

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

Nutrition 2021 09 19;89:111140. Epub 2021 Feb 19.

Laboratory of Energy Metabolism and Body Composition, Department of Nutrition and Health, Universidade Federal de Viçosa, Viçosa, Minas Gerais, Brazil. Electronic address:

Objectives: Dietary total antioxidant capacity (dTAC) has been introduced as a useful tool to quantify the antioxidant content of a diet. However, few studies have evaluated the association of dTAC with cardiovascular disease (CVD) occurrence and cardiometabolic risk factors in people with established CVD events. Thus, we aimed to investigate the presence of an association between dTAC values, cardiovascular events, and cardiometabolic risk factors in individuals with previous CVD in a Brazilian multicenter study.

Methods: This study has a cross-sectional design. We evaluated baseline data from the Brazilian Cardioprotective Nutritional Program Trial. Sociodemographic, anthropometric, clinical, and food-consumption data were collected in face-to-face interviews. We estimated dTAC from the mean of two 24-h dietary recalls by values of ferric-reducing antioxidant power.

Results: We evaluated 2346 participants, most of whom were men (58.4%), older adults (64.2%), and overweight (68.6%), and had coronary artery disease (92.4%). The mean dTAC was equal to 5.6 (interquartile range, 3.9-7.8) mmol/1000 kcal. Participants in the third dTAC tertile (9.2 mmol/1000 kcal) had a 22%, 59%, and 69% lower chance, respectively, of having hypertriglyceridemic waist phenotype, abdominal aortic aneurysm, and amputation due to arterial disease in comparison to the first tertile (3.4 mmol/1000 kcal).

Conclusions: The dTAC was inversely associated with hypertriglyceridemic waist phenotype, abdominal aortic aneurysm, and amputation due to arterial disease in individuals undergoing secondary care for CVD. Our results can guide strategies for the prevention of new CVD and its consequences.
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http://dx.doi.org/10.1016/j.nut.2021.111140DOI Listing
September 2021

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

Int J Obes (Lond) 2021 04 15;45(4):914-917. Epub 2021 Feb 15.

Research Institute, Heart Hospital (HCor), São Paulo, Brazil.

Background: Most of the evidence on bariatric surgery on obstructive sleep apnea (OSA) is based on observational studies and/or short-term follow-up in patients with obesity grade 3.

Subjects/methods: This randomized study compared the effects of roux-en-Y gastric bypass (RYGB) or usual care (UC) on OSA severity in patients with obesity grade 1-2. Mild, moderate, and severe OSA was defined by the apnea-hypopnoea index (AHI): 5-14.9; 15-29.9, and ≥30 events/h, respectively. OSA remission was defined by converting any form of OSA into normal AHI (<5 events/h).

Results: After 3-year of follow-up, the body-mass index increased in the UC while decreased in the RYGB group: +1.7 (-1.9; 2.7) versus -10.6 (-12.7; -9.2) kg/m, respectively. The AHI increased by 5 (-4.2; 12.7) in the UC group while reduced in the RYGB group to -13.2 (-22.7; -7) events/h. UC significantly increase the frequency of moderate OSA (from 15.4 to 46.2%). In contrast, RYGB had a huge impact on reaching no OSA status (from 4.2 to 70.8%) in parallel to a decrease of moderate (from 41.7 to 8.3%) and severe OSA (from 20.8 to 0%).

Conclusions: RYGB is an attractive strategy for mid-term OSA remission or decrease moderate-to-severe forms of OSA in patients with obesity grade 1-2.
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http://dx.doi.org/10.1038/s41366-021-00752-2DOI Listing
April 2021

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

Public Health Nutr 2021 Aug 5;24(11):3331-3340. Epub 2020 Nov 5.

Department of Nutrition and Health, Universidade Federal de Viçosa, Avenida PH Rolfs s/n, Viçosa, Minas Gerais36570-900, Brazil.

Objective: To evaluate the association of dietary inflammatory index (DII®) with the occurrence of cardiovascular events, cardiometabolic risk factors and with the consumption of processed, ultra-processed, unprocessed or minimally processed foods and culinary ingredients.

Design: This was a cross-sectional study that analysed the baseline data from 2359 cardiac patients. Data on socio-demographic, anthropometric, clinical and food consumption were collected. Energy-adjusted food intake data were used to calculate DII, and the foods were classified according to the NOVA classification. Furthermore, the patients were grouped according to the number (1, 2 or ≥ 3) of manifested cardiovascular events. The data were analysed using linear and multinomial logistic regression.

Settings: Multicentre study from Brazil.

Participants: Patients with established cardiovascular events from the Brazilian Cardioprotective Nutritional Program Trial evaluated at baseline.

Results: Most of the patients were male (58·8 %), older adults (64·2 %) and were overweight (68·8 %). Patients in the third tertile of DII (DII > 0·91) had were more likely to have 2 (OR 1·27, 95 % CI: 1·01-1·61) and ≥ 3 (OR 1·39, 95 % CI: 1·07-1·79) cardiovascular events, with poor cardiometabolic profile. They also were more likely to consume a higher percentage of processed, ultra-processed and culinary ingredients foods consumption compared with the patients in the first DII tertile (DII ≤ 0·91).

Conclusion: A more pro-inflammatory diet is associated with a greater chance of having 2 and ≥ 3 cardiovascular events and cardiometabolic risk factors and were more likely to consume processed, ultra-processed and culinary ingredients compared to those with a more anti-inflammatory diet.
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http://dx.doi.org/10.1017/S136898002000378XDOI Listing
August 2021

[Quality of diet and daily spending on food by adults with cardiovascular disease in Brazil].

Cad Saude Publica 2020 2;36(10):e00225019. Epub 2020 Oct 2.

Universidade de São Paulo, São Paulo, Brasil.

Adherence to a healthy diet depends on factors such as food prices, while studies in developed countries have identified higher costs of more nutritional foods. The current study aimed to assess the direct food expenditures by adults with cardiovascular disease in Brazil, investigating the relationship between cost and quality of diet. The study used data from a randomized clinical trial, the BALANCE Program. The current study is a cross-sectional baseline analysis of participants with high adherence to the trial, conducted in 35 sites in all five major geographic regions of Brazil. Food consumption by 1,160 individuals was collected with a 24-hour dietary recall (24HR), quality of diet was measured with the Diet Quality Index Revised (DQI-R), and direct food costs were estimated from market prices. No significant differences were observed between tertiles of adherence in the direct costs of food or individual characteristics. When all the 24HR were analyzed, there was no correlation between cost and quality of diet (r = 0.38; p = 0.17), while analysis by tertiles showed a weak correlation in the lowest tertile of adherence (r = -0.112; p = 0.03). The study showed absence of differences between direct costs of healthy versus unhealthy foods, a finding that can serve as an incentive for adherence to food recommendations in Brazil, thereby minimizing barriers to the adoption of healthy lifestyles.
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http://dx.doi.org/10.1590/0102-311X00225019DOI Listing
March 2021

Mindfulness Practice for Glycemic Control: Could it be a New Strategy for an Old Problem? A Systematic Review and Meta-Analysis.

Curr Diabetes Rev 2021 ;17(7):e081020184730

HCor Research Institute (IP-HCor), Hospital do Coração (HCor), São Paulo, Brazil.

Background: The management of type 2 diabetes mellitus (T2DM) requires a complex and organized care that includes patient's lifestyle change. Additionally, emotional well-being is an important part of self-management, and it may impair the individual's adherence. Therefore, equipping the patients with the necessary coping and self-care techniques may be an important step in managing diabetes.

Objective: To evaluate the effect of interventions using established mindfulness-based protocols on glycemic control of individuals with T2DM.

Methods: Data sources: Two electronic databases (PubMed and EMBASE) were searched from inception to December 2019. We limited our search to published studies in English, Spanish and Portuguese languages.

Study Selection: Randomized clinical trials that assessed the effects of mindfulness in individuals with T2DM were selected.

Data Extraction: Two authors independently assessed the risk of bias and extracted data from the included trials. Data were pooled using inverse-variance random-effects meta-analyses. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results: Four randomized trials were included. There were no differences in blood glucose change (mean difference between groups (MD) -0.73mg/dl; 95% CI, -10.49; 9.02; I2 =0%; very low quality of evidence) or glycated hemoglobin (MD 0.05%; 95%CI -0.22 to 0.32; I2 =29%; very low quality of evidence).

Conclusion: Although the quality of current evidence is very low, our findings suggest that established protocols involving mindfulness have no effect on blood glucose or glycated hemoglobin in individuals with T2DM. Indeed, large-scale trials are needed to evaluate the contribution of mindfulness to glycemic control in clinical practice. PROSPERO Registration ID: RD42020161940.
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http://dx.doi.org/10.2174/1573399816666200810131055DOI Listing
September 2021

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

Cardiovasc Diabetol 2019 07 11;18(1):89. Epub 2019 Jul 11.

Department of Nutrition and Health, Universidade Federal de Viçosa, Avenida PH Rolfs s/n, Viçosa, Minas Gerais, 36570-900, Brazil.

Background: The triglyceride-glucose index (TyG index) is a tool for insulin resistance evaluation, however, little is known about its association with coronary artery disease (CAD), which is the major cardiovascular death cause, and what factors may be associated with TyG index.

Objective: To evaluate the association between the TyG index and the prevalence of CAD phases, as well as cardiovascular risk factors.

Methods: The baseline data of patients in secondary care in cardiology from Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program Trial) were analyzed. Anthropometric, clinical, socio-demographic and food consumption data were collected by trained professionals. The TyG index was calculated by the formula: Ln (fasting triglycerides (mg/dl) × fasting blood glucose (mg/dl)/2) and regression models were used to evaluate the associations.

Results: We evaluated 2330 patients, which the majority was male (58.1%) and elderly (62.1%). The prevalence of symptomatic CAD was 1.16 times higher in patients classified in the last tertile of the TyG index (9.9 ± 0.5) compared to those in the first tertile (8.3 ± 0.3). Cardiometabolic risk factors were associated with TyG index, with the highlight for higher carbohydrate and lower lipid consumption in relation to recommendations that reduced the chance of being in the last TyG index tertile.

Conclusion: The TyG index was positively associated with a higher prevalence of symptomatic CAD, with metabolic and behavioral risk factors, and could be used as a marker for atherosclerosis. Trial registration ClinicalTrials.gov identifier: NCT01620398. Registered 15 June, 2012.
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http://dx.doi.org/10.1186/s12933-019-0893-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625050PMC
July 2019

Effects of Bariatric Surgery Versus Medical Therapy on the 24-Hour Ambulatory Blood Pressure and the Prevalence of Resistant Hypertension.

Hypertension 2019 03;73(3):571-577

Hypertension Unit, Renal Division (S.d.B., L.F.D.), University of São Paulo Medical School, Brazil.

Bariatric surgery is an effective strategy for blood pressure (BP) reduction, but most of the evidence relies on office BP measurements. In this study, we evaluated the impact of bariatric surgery on 24-hour BP profile, BP variability, and resistant hypertension prevalence. This is a randomized trial including obese patients with grade 1 and 2 using at least 2 antihypertensive drugs at maximal doses or >2 at moderate doses. Patients were allocated to either Roux-en-Y Gastric Bypass (RYGB) combined with medical therapy or medical therapy alone for 12 months. The primary outcome was the 24-hour BP profile and variability (average real variability of daytime and night time BP). We evaluated the nondipping status and prevalence of resistant hypertension as secondary end points. We included 100 patients (76% female, body mass index, 36.9±2.7 kg/m). The 24-hour BP profile (including nondipping status) was similar after 12 months, but the RYGB group required less antihypertensive classes as compared to the medical therapy alone (0 [0-1] versus 3 [2.5-4] classes; P<0.01). The average real variability of systolic nighttime BP was lower after RYGB as compared to medical therapy (between-group difference, -1.63; 95% CI, -2.91 to -0.36; P=0.01). Prevalence of resistant hypertension was similar at baseline (RYGB, 10% versus MT, 16%; P=0.38), but it was significantly lower in the RYGB at 12 months (0% versus 14.9%; P<0.001). In conclusion, RYGB significantly reduced antihypertensive medications while promoting similar 24-hour BP profile and nondipping status. Interestingly, bariatric surgery improved BP variability and may decrease the burden of resistant hypertension associated with obesity. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT01784848.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.118.12290DOI Listing
March 2019

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

Nutr J 2018 05 4;17(1):49. Epub 2018 May 4.

Department of Nutrition, School of Public Health, University of São Paulo, Avenida Doutor Arnaldo, 715, São Paulo, SP, 01246904, Brazil.

Background: The diet of the Brazilian Cardioprotective Nutritional Program (BALANCE) classifies food into four groups and sets the daily amount to be consumed. The dietary approach of BALANCE is different from other dietary recommendations; therefore, it is not possible to use existing dietary indexes (DI) to assess patient's adequacy to BALANCE diet. For this reason, it is important to develop a specific dietary index based on BALANCE diet. This study aims to describe the development of the BALANCE DI, evaluate its internal consistency, construct and content validity and population characteristics associated with the index.

Methods: We analyzed baseline data from the BALANCE randomized clinical trial ( https://www.clinicaltrials.gov/ ; NCT01620398). The four food groups of the diet were adopted as index components. Points ranging from 0 to 10 were given to each index component. Internal consistency was evaluated by correlation coefficients between total score and component scores, as well as Cronbach's Alpha. Content and construct validity were assessed by checking how nutrients are associated with the index and if the index could distinguish between groups with known differences in diet, respectively. Crude and adjusted linear regression analyses were performed to evaluate population characteristics associated with the index.

Results: The analysis included 2044 subjects (58.6% men). The average of the total index was higher among women (p < 0,05). The components of the index showed low correlations with each other. The correlations between each individual component with the total index were > 0.40. Cronbach's alpha coefficient was 0.66. High scores in the index were inversely associated (p < 0,05) with energy, total fat, monounsaturated fat (MUFA) and cholesterol; they were positively associated (p < 0,05) with carbohydrates and fiber. Hypertensive men and diabetic women had higher scores, while male smokers had lower scores.

Conclusions: The BALANCE DI showed reliability and construct validity similar to other DI. It also detected characteristics of individuals that are associated with higher or lower index scores.
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http://dx.doi.org/10.1186/s12937-018-0359-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935976PMC
May 2018

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

Nutr J 2018 02 21;17(1):26. Epub 2018 Feb 21.

Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil.

Background: Proinflammatory biomarkers levels are increased among patients with cardiovascular disease, and it is known that both the presence of insulin resistance and diet may influence those levels. However, these associations are not well studied among patients with established cardiovascular disease. Our objective is to compare inflammatory biomarker levels among cardiovascular disease secondary prevention patients with and without insulin resistance, and to evaluate if there is any association between plasma fatty acid levels and inflammatory biomarker levels among them.

Methods: In this cross-sectional sub-study from the BALANCE Program Trial, we collected data from 359 patients with established cardiovascular disease. Plasma fatty acids and inflammatory biomarkers (interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12, high sensitive C-reactive protein (hs-CRP), adiponectin, and tumor necrosis factor (TNF)-alpha) were measured. Biomarkers and plasma fatty acid levels of subjects across insulin resistant and not insulin resistant groups were compared, and general linear models were used to examine the association between plasma fatty acids and inflammatory biomarkers.

Results: Subjects with insulin resistance had a higher concentration of hs-CRP (p = 0.002) and IL-6 (p = 0.002) than subjects without insulin resistance. Among subjects without insulin resistance there was a positive association between stearic fatty acid and IL-6 (p = 0.032), and a negative association between alpha-linolenic fatty acid and pro-inflammatory biomarkers (p < 0.05). Among those with insulin resistance there was a positive association between monounsaturated fatty acids and arachidonic fatty acid and adiponectin (p < 0.05), and a negative association between monounsaturated and polyunsaturated fatty acids and pro-inflammatory biomarkers (p < 0.05), as well as a negative association between polyunsaturated fatty acids and adiponectin (p < 0.05). Our study has not found any association between hs-CRP and plasma fatty acids.

Conclusions: Subjects in secondary prevention for cardiovascular disease with insulin resistance have a higher concentration of hs-CRP and IL-6 than individuals without insulin resistance, and these inflammatory biomarkers are positively associated with saturated fatty acids and negatively associated with unsaturated fatty acids.
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http://dx.doi.org/10.1186/s12937-018-0342-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5822607PMC
February 2018

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

Circulation 2018 03 13;137(11):1132-1142. Epub 2017 Nov 13.

Research Institute (C.A.S., A.C.B.-F., E.V.S., J.D.O., C.R.T., P.T.B., J.C.F., R.N.F., L.P.D., A.B.C., O.B.).

Background: Recent research efforts on bariatric surgery have focused on metabolic and diabetes mellitus resolution. Randomized trials designed to assess the impact of bariatric surgery in patients with obesity and hypertension are needed.

Methods: In this randomized, single-center, nonblinded trial, we included patients with hypertension (using ≥2 medications at maximum doses or >2 at moderate doses) and a body mass index between 30.0 and 39.9 kg/m. Patients were randomized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. The primary end point was reduction of ≥30% of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure <140 mm Hg and 90 mm Hg, respectively, at 12 months.

Results: We included 100 patients (70% female, mean age 43.8±9.2 years, mean body mass index 36.9±2.7 kg/m2), and 96% completed follow-up. Reduction of ≥30% of the total number of antihypertensive medications while maintaining controlled blood pressure occurred in 41 of 49 patients from the gastric bypass group (83.7%) compared with 6 of 47 patients (12.8%) from the control group with a rate ratio of 6.6 (95% confidence interval, 3.1-14.0; <0.001). Remission of hypertension was present in 25 of 49 (51%) and 22 of 48 (45.8%) patients randomized to gastric bypass, considering office and 24-hour ambulatory blood pressure monitoring, respectively, whereas no patient submitted to medical therapy was free of antihypertensive drugs at 12 months. A post hoc analysis for the primary end point considering the SPRINT (Systolic Blood Pressure Intervention Trial) target reached consistent results, with a rate ratio of 3.8 (95% confidence interval, 1.4-10.6; =0.005). Eleven patients (22.4%) from the gastric bypass group and none in the control group were able to achieve SPRINT levels without antihypertensives. Waist circumference, body mass index, fasting plasma glucose, glycohemoglobin, low-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, and 10-year Framingham risk score were lower in the gastric bypass than in the control group.

Conclusions: Bariatric surgery represents an effective strategy for blood pressure control in a broad population of patients with obesity and hypertension.

Clinical Trial Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT01784848.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.032130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865494PMC
March 2018

Association between polyunsaturated fatty acids and inflammatory markers in patients in secondary prevention of cardiovascular disease.

Nutrition 2017 May 28;37:30-36. Epub 2016 Dec 28.

Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil. Electronic address:

Objective: The aim of this study was to assess the association between polyunsaturated fatty acids (PUFAs) and inflammatory biomarkers among patients in secondary prevention of cardiovascular disease (CVD).

Methods: In this cross-sectional substudy from BALANCE Program Trial, we have collected data from 364 patients with established CVD. Twenty-four-hour dietary recalls and plasma FA concentrations were analyzed to estimate the FA intake. Inflammatory biomarkers measurement consisted of interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12, C-reactive protein, adiponectin, and tumor necrosis factor-α. After log-transformation of inflammatory biomarkers, multivariate-adjusted general linear model was used to examine the effect of FA intake. The association was adjusted for body mass index, waist circumference, energy, smoking status, age, total cholesterol, low-density lipoprotein cholesterol, physical activity, and calcium channel blockers.

Results: PUFAs were inversely associated with C-reactive protein levels (P = 0.006) and with IL-1 β. The increase of 1 g/1000 kcal in PUFAs, omega-3, and omega-6 reduces, on average, 6%, 48%, and 8% respectively, the mean concentration of IL-1 β.

Conclusion: Omega-3 and omega-6 FA intakes are inversely associated with inflammatory biomarkers among CVD patients. Additional studies on omega-3 and omega-6 intake in relation to inflammatory biomarkers in patients in secondary prevention of CVD are needed, particularly regarding dietary patterns that are rich in some sources of PUFA.
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http://dx.doi.org/10.1016/j.nut.2016.12.006DOI Listing
May 2017

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

Am Heart J 2016 Jan 15;171(1):73-81.e1-2. Epub 2015 Aug 15.

Research Institute, Hospital do Coração (IP-HCor), São Paulo, SP, Brazil.

This article reports the rationale for the Brazilian Cardioprotective Nutritional Program (BALANCE Program) Trial. This pragmatic, multicenter, nationwide, randomized, concealed, controlled trial was designed to investigate the effects of the BALANCE Program in reducing cardiovascular events. The BALANCE Program consists of a prescribed diet guided by nutritional content recommendations from Brazilian national guidelines using a unique nutritional education strategy, which includes suggestions of affordable foods. In addition, the Program focuses on intensive follow-up through one-on-one visits, group sessions, and phone calls. In this trial, participants 45 years or older with any evidence of established cardiovascular disease will be randomized to the BALANCE or control groups. Those in the BALANCE group will receive the afore mentioned program interventions, while controls will be given generic advice on how to follow a low-fat, low-energy, low-sodium, and low-cholesterol diet, with a view to achieving Brazilian nutritional guideline recommendations. The primary outcome is a composite of death (any cause), cardiac arrest, acute myocardial infarction, stroke, myocardial revascularization, amputation for peripheral arterial disease, or hospitalization for unstable angina. A total of 2468 patients will be enrolled in 34 sites and followed up for up to 48 months. If the BALANCE Program is found to decrease cardiovascular events and reduce risk factors, this may represent an advance in the care of patients with cardiovascular disease.
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http://dx.doi.org/10.1016/j.ahj.2015.08.010DOI Listing
January 2016

Effects of gastric bypass surgery in patients with hypertension: rationale and design for a randomised controlled trial (GATEWAY study).

BMJ Open 2014 Sep 8;4(9):e005702. Epub 2014 Sep 8.

Research Institute HCor (Hospital do Coração, Heart Hospital) São Paulo, São Paulo, Brazil.

Introduction: Obesity and overweight are becoming progressively more prevalent worldwide and are independently associated with a significant increase in the risk of cardiovascular diseases. Systemic arterial hypertension is frequently found in association with obesity and contributes significantly to increased cardiovascular risk. We hypothesise that Roux-en-Y gastric bypass (RYGB) surgery, a procedure that effectively reduces body weight, can also positively impact blood pressure control in obese and hypertensive individuals.

Methods And Analysis: A unicentric, randomised, controlled, unblinded clinical trial. Sixty obese (body mass index between 30 and 39.9) and moderately well controlled hypertensive patients, in use of at least two antihypertensive medications at maximum doses or more than two in moderate doses, will be randomly allocated, using an online, electronic and concealed method, to receive either RYGB plus optimised clinical treatment (OCT) or OCT alone. The primary end point is the reduction of antihypertensive medication at 1 and 2 years of follow-up. Data analysis will primarily be conducted on an intention-to-treat basis.

Ethics And Dissemination: The study was approved by the local institutional review board that works in total compliance with the latest version of the Helsinki Declaration, the Good Clinical Practices (GCP), the 'America's Document' and the national regulatory laws. Before the beginning of any study-related activities, each study participant is asked to provide a signed informed consent.

Trial Registration Number: NCT01784848.
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http://dx.doi.org/10.1136/bmjopen-2014-005702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158200PMC
September 2014

Effects of Brazilian Cardioprotective Diet Program on risk factors in patients with coronary heart disease: a Brazilian Cardioprotective Diet randomized pilot trial.

Clinics (Sao Paulo) 2012 Dec;67(12):1407-14

Hospital do Coração (IEP-HCor), Research Institute, São Paulo/SP, Brazil.

Objective: To evaluate the effectiveness of the Brazilian Cardioprotective Diet Program in reducing blood pressures, fasting glucose levels and body mass indices in patients with established atherothrombotic disease.

Method: This randomized controlled pilot trial included outpatients who were over 45 years of age with atherothrombotic cardiovascular disease. Group A, who received the Brazilian Cardioprotective Diet Program, had weekly sessions with dietitians. Groups B and C received the usual dietary therapy that is given to patients with cardiovascular diseases as proposed by the Brazilian guidelines. This diet had the same nutrient profile as that given to Group A, but it was customized by the integration of typical Mediterranean foods. The difference between Groups B and C was the number of sessions with the dietitian. Group B received weekly sessions, while group C only had monthly sessions. ClinicalTrials.gov: NCT 01453166.

Results: There was a greater reduction in systolic (7.8%) and diastolic (10.8%) blood pressures in Group A compared with Group B (2.3% and 7.3%), and Group C (3.9% and 4.9%, respectively). Fasting glucose decreased by 5.3% and 2% in Groups A and B, respectively. Fasting glucose increased by 3.7% in Group C. The BMIs decreased by 3.5% and 3.3% in Groups A and B, respectively. Group C did not present with any changes in BMI. However, none of these data showed statistical differences between the groups, which is methodologically acceptable in pilot trials.

Conclusions: The Brazilian Cardioprotective Diet Program seems to be more effective in reducing blood pressures, fasting glucose levels, weights and BMIs in patients with previous cardiovascular disease compared with the diet that has been proposed by the Brazilian guidelines.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3521803PMC
http://dx.doi.org/10.6061/clinics/2012(12)10DOI Listing
December 2012

Adipose tissue distribution and quantification of PPARbeta/delta and PPARgamma1-3 mRNAs: discordant gene expression in subcutaneous, retroperitoneal and visceral adipose tissue of morbidly obese patients.

Obes Surg 2007 Jul;17(7):934-40

Departamento de Bioquímica-UFRGS, PUCRS, Porto Alegre, Brazil.

Background: Adipose tissue (AT) metabolism is altered in obese subjects, and the reestablishment of energy homeostasis requires the identification and regulation of genes with altered patterns. The aim of this study was to compare mRNA expression of PPARbeta/delta and PPARgamma1-3 in morbidly obese and nonobese patients. The expression pattern of these receptors in various abdominal adipose tissues, subcutaneous (SAT), retroperitoneal (RAT) and visceral (VAT), was also evaluated.

Methods: The AT depots were obtained by surgery. Total RNAs were extracted using TRIzol. PPARs reverse transcripts were determined by quantitative polymerase chain reaction (qRT-PCR).

Results: The amounts of PPARP/8 mRNA in different depots of morbidly obese AT showed a significant decrease in VAT (P < 0.05). In the non-obese group, the level of PPARbeta/delta was higher in SAT (P < 0.05), but PPARgamma1-3 was not differentially expressed in obese and non-obese depots. When comparing obese and non-obese, the results revealed a decrease in PPARPbeta/delta expression in SAT (P = 0.058) and VAT (P = 0.094) of the morbidly obese. PPARgamma1-3 mRNA expression was increased significantly in SAT (P = 0.022) and decreased in RAT (P = 0.034) in morbidly obese subjects. PPARbeta/delta expression in SAT and VAT correlated negatively with hip size and insulin serum respectively. PPARgamma1-3 expression in RAT correlated negatively with waist and hip circumference and in VAT correlated positively with waist size.

Conclusions: The present study demonstrates that PPARbeta/delta and PPARgamma1-3 mRNAs are quantitatively different in AT of morbidly obese individuals compared to non-obese, and that PPARbeta/delta mRNA levels are characteristic for each AT depot.
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http://dx.doi.org/10.1007/s11695-007-9172-5DOI Listing
July 2007
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