To update the European Association for the Study of Diabetes clinical practice guidelines for nutrition therapy, we conducted an umbrella review and updated systematic review and meta-analysis (SRMA) of prospective cohort studies of the association between dietary pulses with or without other legumes and cardiometabolic disease outcomes. We searched the PubMed, MEDLINE, EMBASE, and Cochrane databases through March 2019. We included the most recent SRMAs of prospective cohort studies and new prospective cohort studies published after the census dates of the included SRMAs assessing the relation between dietary pulses with or without other legumes and incidence and mortality of cardiovascular diseases (CVDs) [including coronary heart disease (CHD), myocardial infarction (MI), and stroke], diabetes, hypertension, and/or obesity. Two independent reviewers extracted data and assessed risk of bias. Risk estimates were pooled using the generic inverse variance method and expressed as risk ratios (RRs) with 95% CIs. The overall certainty of the evidence was assessed using the GRADE approach. Six SRMAs were identified and updated to include 28 unique prospective cohort studies with the following number of cases for each outcome: CVD incidence, 10,261; CVD mortality, 16,168; CHD incidence, 7786; CHD mortality, 3331; MI incidence, 2585; stroke incidence, 8570; stroke mortality, 2384; diabetes incidence, 10,457; hypertension incidence, 83,284; obesity incidence, 8125. Comparing the highest with the lowest level of intake, dietary pulses with or without other legumes were associated with significant decreases in CVD (RR: 0.92; 95% CI: 0.85, 0.99), CHD (RR: 0.90; 95% CI: 0.83, 0.99), hypertension (RR: 0.91; 95% CI: 0.86, 0.97), and obesity (RR: 0.87; 95% CI: 0.81, 0.94) incidence. There was no association with MI, stroke, and diabetes incidence or CVD, CHD, and stroke mortality. The overall certainty of the evidence was graded as "low" for CVD incidence and "very low" for all other outcomes. Current evidence shows that dietary pulses with or without other legumes are associated with reduced CVD incidence with low certainty and reduced CHD, hypertension, and obesity incidence with very low certainty. More research is needed to improve our estimates. This trial was registered at clinicaltrials.gov as NCT03555734.

CIBER Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos 3 Madrid Spain Human Nutrition Department IISPV Universitat Rovira i Virgili Reus Spain

Department of Endocrinology Diabetes and Clinical Pharmacology Dubrava University Hospital School of Medicine University of Zagreb Zagreb Croatia

Department of Epidemiology and Prevention IRCCS Neuromed Pozzilli Italy

Department of Epidemiology and Prevention IRCCS Neuromed Pozzilli Italy Research Center in Epidemiology and Preventive Medicine Department of Medicine and Surgery University of Insubria Varese Italy

Physicians Committee for Responsible Medicine Washington DC USA Institute for Clinical and Experimental Medicine Prague Czech Republic

Toronto 3D Knowledge Synthesis and Clinical Trials Unit St Michael's Hospital Toronto Ontario Canada Department of Nutritional Sciences University of Toronto Toronto Ontario Canada Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto Ontario Canada

Toronto 3D Knowledge Synthesis and Clinical Trials Unit St Michael's Hospital Toronto Ontario Canada Department of Nutritional Sciences University of Toronto Toronto Ontario Canada Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto Ontario Canada College of Pharmacy and Nutrition University of Saskatchewan Saskatoon Saskatchewan Canada

Toronto 3D Knowledge Synthesis and Clinical Trials Unit St Michael's Hospital Toronto Ontario Canada Department of Nutritional Sciences University of Toronto Toronto Ontario Canada Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto Ontario Canada Department of Medicine University of Toronto Toronto Ontario Canada Division of Endocrinology and Metabolism St Michael's Hospital Toronto Ontario Canada Li Ka Shing Knowledge Institute St Michael's Hospital Toronto Ontario Canada

Toronto 3D Knowledge Synthesis and Clinical Trials Unit St Michael's Hospital Toronto Ontario Canada Department of Nutritional Sciences University of Toronto Toronto Ontario Canada Clinical Nutrition and Risk Factor Modification Centre St Michael's Hospital Toronto Ontario Canada Division of Endocrinology and Metabolism St Michael's Hospital Toronto Ontario Canada Li Ka Shing Knowledge Institute St Michael's Hospital Toronto Ontario Canada

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