5/22/25, 1:22 AM Dietary fibre in hypertension and cardiovascular disease management: systematic review and meta-analyses - PMC

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BMC Med. 2022 Apr 22;20:139. doi: 10.1186/s12916-022-02328-x

Dietary fibre in hypertension and cardiovascular disease

management: systematic review and meta-analyses
Andrew N Reynolds 1,2,✉, Ashley Akerman 1, Shiristi Kumar 1, Huyen Tran Diep Pham 1, Sean Coffey 1, Jim
Mann 1,2

Author information Article notes Copyright and License information

PMCID: PMC9027105 PMID: 35449060

Abstract

Background

Higher dietary fibre intakes are associated with a reduced risk of developing cardiovascular
disease (CVD), and increasing intake has been shown to reduce blood pressure and other
cardiometabolic risk factors. The extent to which dietary fibre can further reduce risk for those
with CVD and treated with cardioprotective drugs has not been clearly established. We have
examined the evidence for dietary fibre as adjunct therapy in those with CVD or hypertension.

Methods

Ovid MEDLINE, Embase, PubMed, and CENTRAL were searched to June 2021. Prospective
observational studies reporting on fibre intakes and mortality in those with pre-existing CVD
and controlled trials of increasing fibre intakes on cardiometabolic risk factors in those with
CVD or hypertension were eligible. Outcomes were mortality (studies) and cardiometabolic

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risk factors (trials). Data synthesis was with random effects and dose response. Certainty of
evidence was assessed using GRADE.

Results

Three prospective studies including 7469 adults with CVD, and 12 trials of 878 adults with CVD
or hypertension were identified. Moderate certainty evidence indicates reduced all-cause
mortality (relative risk, RR0.75 (95% confidence interval, CI 0.58–0.97)) when comparing
higher with lower fibre intakes. Low certainty evidence from trials of adults with
cardiovascular disease indicates increasing fibre intakes reduced total (mean difference, MD −
0.42 mmol/L (95%CI − 0.78 to − 0.05) and low-density lipoprotein (LDL) cholesterol (MD −
0.47mmol/L (95%CI − 0.85 to − 0.10)). High certainty evidence from trials of adults with
hypertension indicates increasing fibre intakes reduces systolic (MD 4.3 mmHg (95% CI 2.2 to
5.8)) and diastolic blood pressure (MD 3.1 mmHg (95% CI 1.7 to 4.4)). Moderate and low
certainty evidence indicated improvements in fasting blood glucose (MD 0.48 mmol/L (− 0.91
to − 0.05)) and LDL cholesterol (MD 0.29 mmol/L (95% CI 0.17 to 0.40)). Benefits were
observed irrespective of cardioprotective drug use.

Conclusions

These findings emphasise the likely benefits of promoting greater dietary fibre intakes for
patients with CVD and hypertension. Further trials and cohort analyses in this area would
increase confidence in these results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12916-022-02328-x.

Keywords: Coronary artery disease, Hypertension, Meta-analysis, Epidemiology, Medical

education

Background

Cardiovascular disease (CVD) is the leading global cause of morbidity and mortality [1].
Insufficient intake of foods high in dietary fibre has been identified as one of the leading dietary
risk factors that contribute to the burden of non-communicable diseases [2]. Our systematic
review and meta-analyses [3] provide convincing evidence from prospective cohort studies and
clinical trials that a high dietary fibre intake can reduce cardiometabolic events and premature

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mortality in generally healthy populations. We have identified comparable benefits in the

management of adults with type 1 and type 2 diabetes [4]. Active pharmacological management
of cardiometabolic risk in patients with established cardiovascular disease has reduced the risk
of further cardiovascular events and improved survival [5]. The extent to which dietary fibre
can further reduce risk for those with CVD and treated with cardioprotective drugs following
an acute event has not been clearly established.

We have addressed this gap in the literature by conducting a systematic review and meta-
analysis of the available data. We have identified prospective observational studies reporting on
fibre intakes in those with pre-existing CVD and trials in which the effects of increasing fibre on
cardiovascular risk factors have been examined in people with established CVD. We have also
considered trials in which the effects of dietary fibre have been examined in hypertensive
individuals because they are a readily identifiable group at high risk of developing CVD [6]. As
many of those with diagnosed CVD or hypertension are likely to be treated on cardioprotective
medications, this research is intended to determine the extent to which dietary fibre is a useful
adjunct to the pharmacological management of this high risk group of patients.

Methods

We followed Cochrane guidelines [7] for conducting systematic reviews, World Health
Organization protocols for guideline development [8], and PRISMA reporting standards for
systematic reviews and meta-analyses [9]. The protocol for this systematic review was
prospectively registered CRD42018089176.

Study eligibility

This systematic review and meta-analyses were conducted to address the question “what is the
role of high fibre diets in CVD and hypertension management”. Prospective observational
studies of adults with CVD that reported fibre intakes and all-cause or CVD mortality were
considered eligible. Controlled trials of increasing fibre intakes in those with CVD or
hypertension (SBP >130 mmHg) reporting on cardiometabolic risk factors were also identified.
We included parallel and crossover trials of at least 6 weeks duration where the intervention
was an increase in dietary fibre. Eligible trials included those in which participants were
provided with foods or were given dietary advice relating to an increase in dietary fibre with no
further advice regarding macronutrients or energy intake. Trials comparing between different
types or sources of fibre were not included. Trials with additional lifestyle change, such as
advice to increase physical activity, were not included.

Literature search
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We identified eligible observational studies and trials from the same online search. This
strategy required publications to have a term for the patient population of interest, the dietary
exposure, an outcome of interest, and the study design. The list of possible terms for the
outcome was broad in order to identify a wide range of CVD outcomes and potential risk factors
including both standard and exploratory measures of cardiovascular function. Details of the
search procedure are provided in Additional file 1.

Ovid MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were
searched up to 10 June 2021. The online search was augmented by hand searching of reference
lists to identify other potentially eligible publications. No date or language restrictions were
applied to the searches. Commercially available software was used to remove duplicates and
aid screening [10]. At least two reviewers independently screened all articles identified by the
search strategy, with disagreements resolved through discussion with a third reviewer.

Data extraction and risk of bias assessment

Data from eligible studies were extracted by one reviewer into an Excel spreadsheet template
used in a previous review [4], with a second reviewer then checking each cell. An audit of 10%
of cells selected at random was also undertaken by a third reviewer. The most adjusted values
for effect size were extracted for cohort studies, while baseline and post-intervention data were
extracted for controlled trials. Risk of bias in eligible studies was assessed with the Newcastle-
Ottawa scale [11], trials were assessed with the Cochrane risk of bias tool [12] by two
reviewers independent of each other. A description of eligible studies and trials is shown in
Additional files 2, 3 and 4.

Statistical analyses and assessment of evidence certainty

For prospective cohort studies, we considered the relationship between fibre intake and all-
cause or cardiovascular disease-related mortality by comparing the highest intake quantile
with the lowest intake quantile [13]. Dose response relationships were considered with
restricted cubic splines in a two-stage, random effects model [14] after testing for linearity
(Wald test). This process uses all available quantile values for exposure (grams of fibre per day)
and outcome (relative risk of mortality). For controlled trials, we analysed the mean difference
between intervention and control groups with generic inverse variance models and random
effects [7]. For trials with more than one eligible intervention, the control group sample size
was split accordingly to avoid unit of analysis error [7]. Additional analysis combining
intervention arms before pooling multiple studies did not change the direction or significance
of the results, nor reduce initial heterogeneity. Correlation coefficients were obtained from

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publications when reported or taken from a previous review with a larger pool of trials on
increasing dietary fibre intakes [4].

We considered heterogeneity between the reported results of individual studies and trials with
the I2 statistic [15] and the Q test [16], However because these are overall measures unable to
provide insight on sources of heterogeneity, we applied meta-regression analyses and analyses
of effect sizes standardised to the same dose to consider potential heterogeneity sources for
outcomes with four or more trial arms pooled. The variables considered were dose of fibre in
the intervention, intervention duration, geographical region, if placebo-controlled, if eligibility
criteria included an elevated BMI, if participants were on antihypertensive medication, and if
the fibre were from foods, oats, or psyllium. Small study effects, such as potential publication
bias, were assessed with Egger’s test [17] and if likely, the trim and fill method to consider the
direction and impact of the effect [18]. Each analysis of four or more studies was considered
with an influence analysis where each study or trial was removed from the pooled estimate one
at a time to consider if they substantially changed the reported result. In pools of four or more
point estimates, the effect size per study was standardised to 5 g of dietary fibre per day by
dividing the reported effect size by the reported daily fibre dose then multiplying by five. This
process assumes linearity of association in normal population intakes of fibre and the health
outcomes reported on. Analyses were performed in Stata statistical software (version 15) using
the metan, metabias, metatrim, metainf, and metareg commands. After producing the pooled
estimate for each outcome, we used Grading of Recommendations Assessment, Development
and Evaluation (GRADE) protocols [19] to calculate absolute risk reductions from prospective
observational study data, and evaluate the certainty of the body of evidence for each outcome.
Full details of the analyses are shown in Additional file 5. The evidence per outcome was graded
as either high, moderate, low, or very low according to the potential risk of bias and the chance
that further data might change the reported results. Full GRADE tables are shown in Additional
file 6.

Patient and public involvement

It was not appropriate or possible to involve patients or the public in the design, conduct,
reporting, or dissemination plans of our research.

Results

The process of identifying eligible studies is shown in Fig. 1. Of the initial 16,921 titles
identified, we found fifteen peer-reviewed publication that met the eligibility criteria. We
identified three publications relating to four prospective observational cohort studies including
7,469 participants with CVD who were followed for a mean duration of 8.6 years. These studies

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were conducted in the UK [20], the USA [21], and Taiwan [22]. We also identified three eligible
trials involving 230 participants with CVD [23–25], and 9 trials involving 648 participants with
hypertension [26–34]. The increase in fibre intake ranged between 5.6 and 12 g per day. Trials
were conducted in Asia (4), Europe (4), North America (3), and Australia (1). Eight of the trials
provided fibre as supplements (tablets or powder), four trials provided oat products to increase
participant fibre intake.

Fig. 1.

🔍
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Flowchart illustrating the identification of controlled trials and prospective studies.

Legend: 2020 PRISMA template of the search process undertaken to identify eligible
trials and studies, with numbers of records considered or excluded at each stage of the
process

Dietary fibre and premature mortality from observational studies of patients with
CVD

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Extreme quantile analyses from cohort data are shown in Table 1. A 25% reduction in all-cause
mortality was observed for those consuming the most fibre when compared with those
consuming the least. In terms of absolute risk, this translated into 60 fewer deaths per 1000
participants (7 to 101 fewer) for higher fibre consumers. The dose response curve for fibre and
all-cause mortality is shown in Fig. 2, with an inverse relationship evident. Assuming linearity,
there was a 14% risk reduction (1–26%) for every additional 10 g of fibre consumed. Risk
reduction for premature mortality with higher fibre intakes was evident from data that
controlled for medication use, indicating the observed benefits were independent of what is
achieved in pharmacological management. The evidence for total dietary fibre intake and all-
cause mortality for adults with cardiovascular disease was considered of moderate certainty
following GRADE protocols. Table 1 also shows non-statistically significant decreases in
mortality with higher total or cereal fibre intakes, with this body of evidence considered of
very low certainty following GRADE protocols.

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Table 1.

Effects of higher compared with lower fibre intake on all-cause and cardiovascular
mortality in adults with established cardiovascular disease

Exposure Cohorts Cases Person RR (95% Absolute risk Grade

years CI) (95%CI)
All-cause mortality
Dietary 2 1133 41,688 0.75 (0.58 60 fewer per 1000 (7 Moderate
fibre to 0.97) to 101 fewer)
Cereal 3 2216 62,831 0.90 (0.62 33 fewer per 1000 Very low
fibre to 1.30) (125 fewer to 98
more)
Cardiovascular mortality
Dietary 2 558 41,688 0.86 (0.60 17 fewer per 1000 Very low
fibre to 1.24) (47 fewer to 28
more)
Cereal 4 1309 64,406 0.91 (0.64 16 fewer per 1000 Very low
fibre to 1.31) (63 fewer to 54
more)

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Fig. 2.

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Dose-response relationship between total dietary fibre and all-cause mortality based on
data from prospective studies. Legend: cubic spline and linear dose response models of
total dietary fibre and relative risk of all-cause mortality in those with established heart
disease. Long-dash lines are the 95% confidence intervals around the spline model risk
estimate. Individual quantile data shown as circles with the larger circles having a
greater influence on the model than smaller circles

Dietary fibre and cardiometabolic risk factors in trials of patients with CVD

Meta-analyses for mean difference in cardiometabolic risk factors when increasing dietary fibre
in CVD management are shown in Table 2. The available data indicate increasing fibre intakes
improved measures of total and LDL cholesterol, blood pressure, blood glucose control, and
body weight. Although there was high initial heterogeneity, there were insufficient data to
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explore with meta-regression, so the certainty of evidence for each outcome was downgraded
once for Inconsistency. Further information on these analyses are shown in Additional file 5:
Figs. 1-4

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Table 2.

Effects of increasing dietary fibre intakes on cardiometabolic risk factors in patients with
established CVD

Outcome Trials Participants Initial MD (95% CI) Grade

(I/C) I2

Total cholesterol 3 117/110 99% − 0.42 (− 0.78 to Low

(mmol/L) − 0.05)
LDL cholesterol 3 117/110 99% − 0.47 (− 0.85 to Low
(mmol/L) − 0.10)
HDL cholesterol 3 117/110 99% 0.08 (− 0.02 to Low
(mmol/L) 0.17)
Triglycerides (mmol/L) 3 117/110 91% − 0.03 (− 0.15 to Low
0.08)
Systolic blood pressure 1 38/38 - − 1.2 (− 2.0 to − Very
(mmHg) 0.4) low
Diastolic blood pressure 1 38/38 - − 3.6 (− 4.0 to − Very
(mmHg) 3.2) low
Body weight (kg) 1 61/53 - − 0.20 (− 0.37 to Very
− 0.04) low
BMI (kg/m2) 2 99/91 98% − 0.30 (− 0.69 to Low
0.09)
Waist circumference 1 61/53 - − 0.5 (− 0.6 to − Very
(cm) 0.4) low
Fasting plasma glucose 2 99/91 100% − 1.23 (− 2.13 to Low
(mmol/L) − 0.33)
Fasting plasma insulin 1 38/38 - − 10.8 (− 13.2 to Very
(pmol/L) − 8.4) low

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Dietary fibre and cardiometabolic risk factors in trials of patients with

hypertension

The mean difference in cardiometabolic risk factors from trials of increasing dietary fibre in
patients with hypertension is shown in Table 3. Results indicated improvements in systolic and
diastolic blood pressure, LDL cholesterol and triglycerides and fasting plasma and insulin
concentrations. The data for blood pressure improvements were consistent, with no evidence of
small study effects or that other factors, including the use of anti-hypertensives, mediated the
observed results. Influence analysis for both systolic and diastolic blood pressure indicated one
study appreciably influenced each of the pooled results, with greater improvements seen in
analyses with these studies removed (data available in Additional file 5: Figs. 15-18). Sensitivity
analyses could not account for any one factor contributing to the initial heterogeneity; however,
each point estimate within the meta-analyses indicated a benefit with higher fibre intake,
suggesting heterogeneity was likely due to the specificity of point estimates rather than any
known underlying factor. Benefits remained when standardising the fibre dose to 5 g per day,
with a − 2.8 (− 3.8 to − 1.8) reduction in systolic and a − 2.1 (− 3.0 to − 1.2) reduction in diastolic
blood pressure. The certainty of evidence for dietary fibre improving systolic and diastolic
blood pressure was graded as high.

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Table 3.

Effects of increasing dietary fibre intakes on cardiometabolic risk factors in patients with
established hypertension

Outcome Trial Participants Initial MD (95% CI) Grade

arms (I/C) I2

Systolic blood 9 281/250 99% − 4.3 (− 5.8 to − High

pressure (mmHg) 2.8)
Diastolic blood 9 281/250 99% − 3.1 (− 4.4 to − High
pressure (mmHg) 1.7)
Total cholesterol 5 190/144 98% − 0.22 (− 0.45 Low
(mmol/L) to 0.01)
LDL cholesterol 3 137/88 97% − 0.29 (− 0.40 Low
(mmol/L) to − 0.17)
HDL cholesterol 4 169/119 93% 0.02 (− 0.01 to Low
(mmol/L) 0.05)
Triglycerides 4 169/119 99% − 0.19 (− 0.30 Low
(mmol/L) to − 0.08)
Body weight (kg) 3 137/88 99% − 0.14 (− 1.36 Low
to 1.08)
BMI (kg/m2) 2 92/45 99% − 1.3 (− 2.1 to − Low
0.5)
HbA1c (%) 1 32/31 - 0.3 (0.20 to Very low
0.40)
Fasting plasma 5 195/153 99% − 0.48 (− 0.91 Moderate
glucose (mmol/L) to − 0.05)
Fasting plasma insulin 4 150/110 97% − 3.5 (− 5.5 to − Low
(pmol/L) 1.6)

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There was evidence that increasing fibre intakes improved LDL cholesterol and triglyceride
concentrations. Small study effects and influence analysis did not appreciably alter any pooled
results. Meta-regression analyses indicated that the fibre source influenced the pooled result for
total cholesterol, with greater benefits from food sources rather than supplements (− 0.52 (−
0.78 to − 0.26) p 0.008) with the I2 reduced to 68%. Standardising the fibre dose to 5 g per day
indicated a beneficial reduction in total cholesterol (MD − 0.15 (− 0.29 to − 0.02)). The certainty
of evidence for blood lipids outcomes was assessed as low following downgrading for
Imprecision and Inconsistency. The data for an improvement in fasting blood glucose was
assessed as Moderate following a single downgrade for inconsistency, although all sensitivity
analyses indicated the finding was robust. Further information on sensitivity analyses is shown
in the Additional file 5: Figs. 5-14.

Discussion

We have considered the role of dietary fibre as a potential adjunct therapy alongside
cardioprotective drugs in the management of established cardiovascular disease and
hypertension. The findings indicate a reduced risk of premature mortality with higher fibre
intakes when compared with lower intakes, and an improvement in key cardiometabolic risk
factors when increasing fibre intakes. Risk reduction for premature mortality from the
prospective observational studies was evident from data that controlled for medication use,
while meta-regression from trials of adults with hypertension did not indicate anti-
hypertensive medication use was a determining factor in the reported outcomes. As such, the
current analyses indicate benefits with higher fibre intakes independent to what is achieved in
pharmacological management.

The consideration of data from both trials of increasing fibre intakes and studies of higher
intakes over time add confidence in the beneficial effects of dietary fibre intake, as the
improvements in blood pressure, blood lipids, and body weight would be expected to reduce
premature mortality, as was observed. There were more data available from trials of
participants with hypertension than CVD, these analyses support and add to what was observed
with CVD participants with improvements in blood pressure, blood lipids, bodyweight, and
glycaemic control observed.

Higher dietary fibre intakes have demonstrated previous benefit in evidence synthesis on the
prevention of premature mortality and non-communicable disease occurrence [3] and in
diabetes management [4]. This review however is the first meta-analysis to consider the role of
dietary fibre in the management of pre-existing hypertension and CVD. Furthermore, our
methodology included use of meta-regression analyses to explore initial heterogeneity
observed in trial data and increase confidence in the observed results. Although common, it is

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potentially misleading to report initial heterogeneity values without some further

consideration of where it is derived. As an example, all nine data points from trials of increased
dietary fibre and systolic blood pressure in patients with hypertension indicated a beneficial
effect; however, the initial I2 was high (99%). Meta-regression techniques did not identify a
single underlying reason for this heterogeneity, and standardisation of dose to 5g of fibre per
day still produced appreciable benefits. From this we conclude that the initial heterogeneity is
statistical heterogeneity due to the low variability around each point estimate, rather than
underlying differences between trials beyond the interventions delivered. Our use of GRADE
protocols to assess the certainty of evidence for dietary fibre intakes in these populations is a
further addition to the existing literature, and a key addition for guideline development and
clinical recommendations.

Current guidelines for CVD and hypertension management focus on pharmacological aides [35,
36] or if dietary, total dietary fat intake and fat quality [37]. Fewer guidelines recommend
dietary fibre as part of a cardioprotective dietary pattern [38] or in lipid management [39]. The
current work provides confirmation on the role of dietary fibre in human health, and the direct
translatability of the findings into dietary and clinical guidelines make it a substantial
contribution to the field.

Increasing dietary fibre intake led to high certainty of substantial improvements in blood
pressure in adults with hypertension. These improvements were observed regardless of the use
of antihypertensives. High blood pressure not only results in deleterious mechanical stress on
blood vessels but also on the myocardium, leading to the development of hypertensive heart
disease and congestive heart failure [1, 40]. Several pathways of action may explain this finding,
such as dietary fibre’s role in reducing LDL cholesterol and triglyceride uptake [41] improving
the elasticity of blood vessel walls to decrease vascular resistance and maintain adequate tissue
perfusion without requiring a subsequent rise in heart rate to maintain stroke volume [42]. As a
less direct mechanism, higher fibre intakes improved insulin sensitivity in this and previous
works [4], with insulin sensitivity believed to play a role in endothelial dysfunction and
hypertension [43]. Another major contributor to endothelial function is nitric oxide, which may
be increased by increased fibre intake. Consuming foods high in dietary fibre may provide
additional antioxidants [44], reducing the role of oxidative stress in the pathogenesis of
atherosclerosis [45].

Other potential mechanisms for the beneficial effects observed with higher fibre intakes may
relate to concomitant intakes of inorganic nitrate, or reduced body weight. High fibre foods
such as vegetables also contain other beneficial nutrients that are metabolised into compounds
such as nitric oxide, which may improve blood pressure through greater bioavailability for use
in vasodilation [46, 47]. The current work found some support for reductions in body weight
with higher fibre intakes, as shown in evidence synthesis of the general population [3] and
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those with diabetes [4], with weight loss beneficial in the treatment and prevention of
hypertension [48]. Recent work has shown that the intake of whole grains, a considerable
source of dietary fibre, when compared with refined grains leads to great measures of satiety
[49], providing some rationale for why higher fibre diets may reduce energy intake through
increased satiety.

The present study has many strengths, primarily the parallel consideration of the effects of
increasing fibre intake from controlled trials and higher fibre intakes in prospective cohort
studies enabled us to consider mechanisms supporting hard outcomes [50]. We followed
recognised procedures for conducting systemic review and meta-analysis [7, 8] as well as an
assessment of the certainty of evidence to support clinical and dietary guidelines [19]. To our
knowledge this is the first meta-analysis to consider fibre for CVD and hypertension
management, adding novelty to our work. The primary limitation of this work was the lack of
relevant data available. Although only four cohort studies were identified, and it is never
possible to fully exclude confounding from observational studies, follow-up duration was
reasonable (weighted mean 8.6 years) and the cohorts were conducted in three distinct
populations. Trials were generally of a limited number of participants, with the majority of
studies of 12 weeks duration. Such limitations in the data increase the chance of observing
spurious effects, although we considered that uncertainty when assessing the evidence. Further
trials and cohorts of those with CVD or hypertension are needed, with some currently
underway [51]. We varied from the protocol of this review by considering only trials of at least
six weeks intervention duration rather than the stated two weeks. This decision was made
before searches were conducted to better consider meaningful change in a broader range of
cardiometabolic risk factors beyond blood lipids and blood pressure. A wider variety of
interventions considering multiple food sources of fibre would increase confidence in the
presented findings and may provide further evidence on the place of high dietary fibre intakes
as an adjunct therapy in CVD and hypertension management.

The findings from this meta-analysis support the incorporation of high fibre foods in CVD and
hypertension management, with improvement in cardiometabolic risk factors supporting the
observed reduction in premature mortality. However, further trials and cohort analyses in this
area would increase confidence in these results.

Supplementary Information

Additional file 1. Search strategy. (15.4KB, docx)

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12916_2022_2328_MOESM2_ESM.docx (17.1KB, docx)

Additional file 2: Table 1. Description of identified prospective studies.

12916_2022_2328_MOESM3_ESM.docx (17.5KB, docx)

Additional file 3: Table 1. Description of identified CVD trials.

12916_2022_2328_MOESM4_ESM.docx (21.5KB, docx)

Additional file 4: Table 1. Description of identified hypertension trials.

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12916_2022_2328_MOESM5_ESM.docx (1.5MB, docx)

Additional file 5: Analyses shown in full. Figure 1. Fibre and all-cause mortality meta
analysis. Figure 2. Cereal fibre and all-cause mortality meta analysis. Figure 3. Fibre
and CVD mortality meta analysis. Figure 4. Cereal fibre and CVD mortality meta analysis.
Figure 5. Fibre and total cholesterol in hypertension meta analysis. Figure 6. Fibre and
total cholesterol in hypertension dose controlled meta analysis. Figure 7. Fibre and HDL
cholesterol in hypertension meta analysis. Figure 8. Fibre and HDL cholesterol in
hypertension dose controlled meta analysis. Figure 9. Fibre and triglycerides in
hypertension meta analysis. Figure 10. Fibre and triglycerides in hypertension dose
controlled meta analysis. Figure 11. Fibre and fasting plasma glucose in hypertension
meta analysis. Figure 12. Fibre and fasting plasma glucose in hypertension dose
controlled meta analysis. Figure 13. Fibre and fasting plasma insulin in hypertension
meta analysis. Figure 14. Fibre and fasting plasma insulin in hypertension dose
controlled meta analysis. Figure 15. Fibre and systolic blood pressure in hypertension
meta analysis. Figure 16. Fibre and systolic blood pressure in hypertension dose
controlled meta analysis. Figure 17. Fibre and diastolic blood pressure in hypertension
meta analysis. Figure 18. Fibre and diastolic blood pressure in hypertension dose
controlled meta analysis.

12916_2022_2328_MOESM6_ESM.docx (31.2KB, docx)

Additional file 6. GRADE tables of certainty of evidence. Table 1. GRADE table of fibre
and mortality. Table 2. GRADE table of fibre in CVD management. Table 3. GRADE table
of fibre in hypertension management.

Acknowledgements

Many thanks to Dr Francesco Sofi for providing additional data from an identified publication,
and to our article translators.

Abbreviations

CVD

https://pmc.ncbi.nlm.nih.gov/articles/PMC9027105/ 18/28
5/22/25, 1:22 AM Dietary fibre in hypertension and cardiovascular disease management: systematic review and meta-analyses - PMC

Cardiovascular disease
GRADE
Grading of Recommendations Assessment, Development and Evaluation
HDL
High-density lipoprotein
LDL
Low-density lipoprotein
MD
Mean difference
PRISMA
Preferred reporting items for systematic reviews and meta-analyses

Authors’ contributions

ANR was responsible for the systematic review and meta-analyses, wrote the manuscript, had
full access to all the data, and had final responsibility for the decision to submit for publication.
AA was involved with research design, screening, data extraction, and critically reviewed the
draft manuscript. SK was involved with screening and data extraction and critically reviewed
the draft manuscript. HTDP was involved with screening and data extraction and critically
reviewed the draft manuscript. SC was involved with the interpretation of results and critically
reviewed the draft manuscript. JM was involved with the interpretation of results and their
context to inform clinical guidelines, as well as critically reviewing the draft manuscript. The
authors read and approved the final manuscript.

Funding

This research received no external funding. ANR is supported by a Heart Foundation of New
Zealand Research Fellowship. SK was supported by a Department of Health Sciences summer
scholarship administered by the Otago Medical Research Foundation. JM is supported by the
Healthier Lives National Science Challenge.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its
supplementary information files. Effect size estimates and study details were extracted from
the original papers, which are available in the public domain.

Declarations

https://pmc.ncbi.nlm.nih.gov/articles/PMC9027105/ 19/28
5/22/25, 1:22 AM Dietary fibre in hypertension and cardiovascular disease management: systematic review and meta-analyses - PMC

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and
institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in
this article.

Supplementary Materials
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Additional file 1. Search strategy. (15.4KB, docx)

12916_2022_2328_MOESM2_ESM.docx (17.1KB, docx)

Additional file 2: Table 1. Description of identified prospective studies.

12916_2022_2328_MOESM3_ESM.docx (17.5KB, docx)

Additional file 3: Table 1. Description of identified CVD trials.

12916_2022_2328_MOESM4_ESM.docx (21.5KB, docx)

Additional file 4: Table 1. Description of identified hypertension trials.

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12916_2022_2328_MOESM5_ESM.docx (1.5MB, docx)

Additional file 5: Analyses shown in full. Figure 1. Fibre and all-cause mortality meta
analysis. Figure 2. Cereal fibre and all-cause mortality meta analysis. Figure 3. Fibre
and CVD mortality meta analysis. Figure 4. Cereal fibre and CVD mortality meta analysis.
Figure 5. Fibre and total cholesterol in hypertension meta analysis. Figure 6. Fibre and
total cholesterol in hypertension dose controlled meta analysis. Figure 7. Fibre and HDL
cholesterol in hypertension meta analysis. Figure 8. Fibre and HDL cholesterol in
hypertension dose controlled meta analysis. Figure 9. Fibre and triglycerides in
hypertension meta analysis. Figure 10. Fibre and triglycerides in hypertension dose
controlled meta analysis. Figure 11. Fibre and fasting plasma glucose in hypertension
meta analysis. Figure 12. Fibre and fasting plasma glucose in hypertension dose
controlled meta analysis. Figure 13. Fibre and fasting plasma insulin in hypertension
meta analysis. Figure 14. Fibre and fasting plasma insulin in hypertension dose
controlled meta analysis. Figure 15. Fibre and systolic blood pressure in hypertension
meta analysis. Figure 16. Fibre and systolic blood pressure in hypertension dose
controlled meta analysis. Figure 17. Fibre and diastolic blood pressure in hypertension
meta analysis. Figure 18. Fibre and diastolic blood pressure in hypertension dose
controlled meta analysis.

12916_2022_2328_MOESM6_ESM.docx (31.2KB, docx)

Additional file 6. GRADE tables of certainty of evidence. Table 1. GRADE table of fibre
and mortality. Table 2. GRADE table of fibre in CVD management. Table 3. GRADE table
of fibre in hypertension management.

Data Availability Statement

All data generated or analysed during this study are included in this published article and its
supplementary information files. Effect size estimates and study details were extracted from
the original papers, which are available in the public domain.

Articles from BMC Medicine are provided here courtesy of BMC

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