Practical dietary interventions to prevent cardiovascular disease suitable for implementation in primary care: an ADAPTE-guided systematic review of international clinical guidelines.

PURPOSE: Cardiovascular diseases (CVD) are the leading cause of death globally. The current model of care for high-income countries involves preventive medication and highly trained healthcare professionals, which is expensive and not transposable to low-income countries. An innovative, effective approach adapted to limited human, technical, and financial resources is required. Measures to reduce CVD risk factors, including diet, are proven to be effective. The survey "Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa" aims to develop non-pharmacological cardiovascular prevention and control programs in primary care and community settings in high, middle, and low-income countries. This review aims to identify the existing, validated dietary interventions for primary CVD prevention from national and international clinical guidelines that can be implemented in primary care and communities. METHODS: A systematic review of CVD prevention guidelines was conducted between September 2017 and March 2023 using the Turning Research Into Practice medical database, the Guidelines International Network, and a purposive search. The ADAPTE procedure was followed. Two researchers independently conducted the searches and appraisals. Guidelines published after 01/01/2012 addressing non-pharmacological, dietary interventions for primary CVD prevention or CVD risk factor management, in the adult general population in primary care or in community settings were included and appraised using the Appraisal of Guidelines Research and Evaluation II score. Individual dietary recommendations and the studies supporting them were extracted. Then supporting data about each specific dietary intervention were extracted into a matrix. RESULTS: In total, 1375 guidelines were identified, of which 39 were included. From these, 383 recommendations, covering 10 CVD prevention themes were identified. From these recommendations, 165 studies for effective dietary interventions for CVD prevention were found. Among these, the DASH diet was the most effective on multiple CVD risk factors. Combining diet with other interventions such as exercise and smoking cessation increased efficacy. No guidelines provided detailed implementation strategies. CONCLUSION: The DASH diet combined with other interventions was the most effective on an individual basis. However, expansion in the wider population seems difficult, without government support to implement regulations such as reducing salt content in processed food. TRIAL REGISTRATION: Clinical Trials NCT03886064.

Heart disease is the leading cause of death around the world. Strategies to prevent heart disease in high-income countries rely on medications and the skills of highly trained healthcare professionals. However, this is expensive and unsuitable for low-income countries. Consequently, an innovative, effective approach, which can be adapted to countries with limited human, technical and financial resources is needed. A program called SPICES was developed to identify strategies other than medication to prevent and control heart disease. This program reviewed the evidence for smoking cessation, physical activity, and dietary strategies, which may be useful to prevent heart disease in communities with limited resources.In this review, the investigators searched online databases to find clinical guidelines that recommended dietary strategies to manage heart disease worldwide. The information found from this search revealed that the DASH diet, inspired by the Mediterranean diet, helps with weight loss, and improves blood pressure and cholesterol levels making it the most effective diet for preventing heart disease. It is even more effective if it is combined with other strategies such as exercise, stopping smoking or reducing the amount of alcohol consumed. However, this works well for individuals but is difficult to expand to the wider population. Therefore, government support is needed to implement regulations such as reducing salt content in processed food.

Screening for cardiovascular risk in the general population: The SPICES implementation survey.

Background: In 2019, cardiovascular diseases (CVD) caused 32% of deaths worldwide. The SPICES survey involved five countries in an international primary CVD prevention implementation study in the general population. The French SPICES survey was implemented in the Centre Ouest Bretagne area (COB), which is a rural, economically deprived, medically underserved territory with high cardiovascular mortality. A CVD screening in the general population was needed to select the implementation population without overburdening family practitioner (FP) workforces. The efficacy and the replicability of such a screening were unknown. The aims of this study were to identify the characteristics of the individuals undergoing CVD risk assessment with the Non-Laboratory Interheart risk score (NL-IHRS), and to identify barriers and explore facilitators when screening the general population. Methods: An implementation study combining a cross-sectional descriptive study with qualitative interviews was undertaken. The NL-IHRS was completed by trained screeners selected from health students, pharmacists, nurses, and physiotherapists in the area with a dedicated e-tool in sport and cultural events and public places. After the screening, all screener groups were interviewed until theoretical saturation for each group. Thematic analysis was performed using double-blind coding. Results: In 5 months, 3,384 assessments were undertaken in 60 different places, mostly by health students. A total of 1,587, 1,309, and 488 individuals were at low, moderate, and high CVD risk. Stressed or depressed individuals were remarkably numerous (40.1 and 24.5% of the population, respectively). Forty-seven interviews were conducted. The main facilitators were willingness of the population, trust between screeners and the research team, and media publicity. The main barriers were lack of motivation of some screeners, some individuals at risk, some stakeholders and difficulties in handling the e-tool. Conclusion: The efficacy of CVD risk screening while using mostly health students was excellent and preserved the FP workforce. Replicability was highly feasible if research teams took great care to establish and maintain trust between screeners and researchers. The e-tools should be more user-friendly.

Innovative cardiovascular primary prevention population-based strategies: a 2-year hybrid type 1 implementation randomised control trial (RCT) which evaluates behavioural change conducted by community champions compared with brief advice only from the SPICES project (scaling-up packages of interventions for cardiovascular disease prevention in selected sites in Europe and sub-Saharan Africa).

BACKGROUND: Cardiovascular diseases (CVD) caused 17.9 million deaths worldwide in 2016, being the world's leading cause of death. Prevention of CVD in high-income countries is expensive and fails to reach the population at risk. In low-income countries, it is under-developed. The SPICES project implements a community-based program to improve CVD prevention in 3 European countries and 2 Sub-Saharan countries, based on using community champions to effect behavioural changes. In France, the project operates in "Pays Centre Ouest Bretagne" (COB) which is the Central West Brittany area, and a vulnerable, rural setting. The aim of this study is to assess this innovative prevention strategy versus brief advice. METHODS: A two-step RCT hybrid type 1 implementation study will first of all screen a population using the Non-Laboratory INTERHEART Score (NL-IHRS) and will involve health-care students at public events in the COB area until 1000 participants have been recruited. Second, a RCT will be carried out. The research team will contact each participant with an intermediate NL-IHRS in order to include them. Participants will be over 18 years of age and work or live in the COB area. Participants will be equally randomised in two groups. The intervention group will receive brief advice plus behavioural change guidance carried out by community champions. The control group will receive brief advice only. The main objective for the RCT is to assess a difference of at least 15% in the NL-IHRS between the two groups after 24 months. The primary outcome will be analysed with intention to treat. Secondary outcomes for the RCT will be assessed using validated questionnaires: the WHOQOL-BREF, the DASH Q questionnaire, the IPAQ-short; smoking level will be assessed according to the NL-IHRS scoring system; a modified self-declared alcohol consumption questionnaire has been developed and gauges will be used to assess BMI. The implementation strategy will use mixed methods: qualitative research methods and quantitative epidemiological studies. DISCUSSION: A difference in the mean NL-IHRS of 15% will provide an argument in favour of reorganising prevention policies. A substantial change would favour relocating primary prevention from healthcare professionals to lay people and the community. TRIAL REGISTRATION: Clinical Trials NCT03886064 - the study was recorded on ClinicalTrials.gov , the 22nd of March 2019.

Inadequate conflict of interest policies at most French teaching hospitals: A survey and website analysis.

BACKGROUND: There are 32 teaching hospitals in France, including 30 University hospitals and two Regional teaching hospitals. Teaching hospitals have three roles: health care provision, training of healthcare professionals, and medical research. These roles lead to frequent interactions with pharmaceutical and medical device companies, inevitably raising risks of conflicts of interests. Therefore, policies to manage conflict of interests (COI) are crucial. This study aims to examine COI policies in French teaching hospitals. METHODS: All French teaching hospitals (n = 32) were included in this study. All hospitals websites were screened for institutional COI policies and curriculum on COI, using standardized keyword searches. More data were collected through a questionnaire addressed to each chief executive officer (CEO) of the teaching hospital. We used predefined criteria (n = 20) inspired by similar surveys on COI policies in French, US and Canadian medical schools, with some additions to reflect the local hospital context. A global score for each hospital, ranging from 0 to 60 (higher scores denoting stronger policies) was calculated by summing points obtained for each criterion. RESULTS: All 32 hospitals had websites; 21 hospitals listed policies or regulations on their websites or provided them on request. In December 2017, 17 (53.1%) had rules and regulations for some items only, four of which (12.5%) have considered implementing a policy, and only two (6.3%) have begun implementation. 15 (46.9%) had no evidence of COI policies and a null score. The maximum score was 24 out of 60. CONCLUSION: This is the first systematic assessment of COI policies in teaching hospitals in France. Such policies are needed to protect patients, clinicians and students from undue commercial influence. Despite public and political pressure for better management of COI, few teaching hospitals have implemented comprehensive and protective policies, and some hospitals lacked policies altogether. These results highlight the need for greater attention to management of COI within teaching hospitals. One potential solution would be to integrate COI policies into hospital accreditation procedures, in order to ensure a baseline of management at all teaching hospitals.