Efficacy of tailored recommendations to promote healthy lifestyles: a post hoc analysis of a randomized controlled trial

Prevention is the key to stopping the ravages of cardiovascular diseases, the main cause of death worldwide. The objective was to analyze the efficacy of tailored recommendations to promote healthy lifestyles. Parallel-arm randomized controlled trial with 1 year follow-up. Individuals aged 35-74 years from Girona (Spain) randomly selected from a population with no cardiovascular diseases at baseline were included. Participants in the intervention group received a brochure with tailored healthy choices according to the individual risk profile and a trained nurse explained all recommendations in detail in a 30 min consultation. One year changes in smoking, Mediterranean diet adherence, physical activity, and weight were analyzed with McNemar, Student's t, Wilcoxon, and Fisher exact tests according to an intention-to-treat strategy. Of 955 individuals (52.3% women; mean age 50 [±10] years) randomly allocated to the intervention or control group, one participant in each group presented a cardiovascular event and 768 (81%) were reexamined at 1 year follow-up. The prevalence of nonsmokers increased in both the intervention and control groups (78.1%-82.5%, p = <.001, and 76.7% to 78.8%, p = .015, respectively); however, significance persisted only in the intervention group when stratified by sex, age group, and educational level. Adherence to a Mediterranean diet increased in the intervention group (22.3%-26.5%, p = .048). In conclusion, a brief personalized intervention with science-based recommendations according to individual risk profiles appears to improve healthy lifestyles, particularly nonsmoking and adherence to a Mediterranean diet. This promising intervention system offers evidence-based recommendations to develop healthy lifestyles.

Variety in fruits and vegetables, diet quality and lifestyle in an older adult mediterranean population

BACKGROUND AND AIMS

Previous studies, mainly focused on quantity rather than variety, have shown beneficial associations between the amount of fruit and vegetable consumed, diet quality and healthy lifestyle. The aim is to evaluate the association between fruit and vegetable consumption, diet quality and lifestyle in an elderly Mediterranean population, considering both variety and the combination of quantity and variety (QV).

METHODS

A cross-sectional analysis of 6647 participants (51.6% of males) was conducted in the framework of the PREDIMED-Plus study. A variety score was created as the sum of vegetables and/or fruits consumed at least once per month using food frequency questionnaires. Dietary Reference Intakes (EAR and IA values) were used to estimate the prevalence of inadequate intake of dietary fiber and micronutrients. Logistic regression models were performed to examine the association between fruit and vegetable consumption and not meeting the DRIs, by tertiles of fruit and vegetable variety and QV categories.

RESULTS

Participants with higher fruit and vegetable variety score reported a significant higher intake of fiber, vitamins, minerals and flavonoids and were significantly more likely to be physically active and non-smoker. Besides, higher variety in fruit and vegetable consumption was associated with lower prevalence of having an inadequate intake of fiber [(0.13 (0.11-0.16)], two or more [(0.17 (0.14-0.21)], three or more [(0.15 (0.13-0.18)] and four or more [(0.11 (0.10-0.14)] micronutrients in our participants. Higher quantity and variety in fruit and vegetable consumption was associated with lower prevalence of having an inadequate intake of fiber [(0.05 (0.04-0.06)], two or more [(0.08 (0.06-0.10)], three or more [(0.08 (0.06-0.09)] and four or more [(0.06 (0.05-0.07)] micronutrients.

CONCLUSION

Greater variety in fruit and vegetable intake was associated with better nutrient adequacy, diet quality and healthier lifestyle in an elderly Mediterranean population.

DHA intake relates to better cerebrovascular and neurodegeneration neuroimaging phenotypes in middle-aged adults at increased genetic risk of Alzheimer disease

BACKGROUND

The number of APOE-ε4 alleles is a major nonmodifiable risk factor for sporadic Alzheimer disease (AD). There is increasing evidence on the benefits of dietary DHA (22:6n-3) before the onset of AD symptoms, particularly in APOE-ε4 carriers. Brain alterations in the preclinical stage can be detected by structural MRI.

OBJECTIVES

We aimed, in middle-aged cognitively unimpaired individuals at increased risk of AD, to cross-sectionally investigate whether dietary DHA intake relates to cognitive performance and to MRI-based markers of cerebral small vessel disease and AD-related neurodegeneration, exploring the effect modification by APOE-ε4 status.

METHODS

In 340 participants of the ALFA (ALzheimer and FAmilies) study, which is enriched for APOE-ε4 carriership (n = 122, noncarriers; n = 157, 1 allele; n = 61, 2 alleles), we assessed self-reported DHA intake through an FFQ. We measured cognitive performance by administering episodic memory and executive function tests. We performed high-resolution structural MRI to assess cerebral small vessel disease [white matter hyperintensities (WMHs) and cerebral microbleeds (CMBs)] and AD-related brain atrophy (cortical thickness in an AD signature). We constructed regression models adjusted for potential confounders, exploring the interaction DHA × APOE-ε4.

RESULTS

We observed no significant associations between DHA and cognitive performance or WMH burden. We observed a nonsignificant inverse association between DHA and prevalence of lobar CMBs (OR: 0.446; 95% CI: 0.195, 1.018; P = 0.055). DHA was found to be significantly related to greater cortical thickness in the AD signature in homozygotes but not in nonhomozygotes (P-interaction = 0.045). The association strengthened when analyzing homozygotes and nonhomozygotes matched for risk factors.

CONCLUSIONS

In cognitively unimpaired APOE-ε4 homozygotes, dietary DHA intake related to structural patterns that may result in greater resilience to AD pathology. This is consistent with the current hypothesis that those subjects at highest risk would obtain the largest benefits from DHA supplementation in the preclinical stage.This trial was registered at clinicaltrials.gov as NCT01835717.

Longitudinal changes in adherence to the portfolio and DASH dietary patterns and cardiometabolic risk factors in the PREDIMED-Plus study

BACKGROUND & AIMS

The Portfolio and Dietary Approaches to Stop Hypertension (DASH) diets have been shown to lower cardiometabolic risk factors in randomized controlled trials (RCTs). However, the Portfolio diet has only been assessed in RCTs of hyperlipidemic patients. Therefore, to assess the Portfolio diet in a population with metabolic syndrome (MetS), we conducted a longitudinal analysis of one-year data of changes in the Portfolio and DASH diet scores and their association with cardiometabolic risk factors in Prevención con Dieta Mediterránea (PREDIMED)-Plus trial.

METHODS

PREDIMED-Plus is an ongoing clinical trial (Trial registration: ISRCTN89898) conducted in Spain that includes 6874 older participants (mean age 65 y, 48% women) with overweight/obesity fulfilling at least three criteria for MetS. Data for this analysis were collected at baseline, six months and one year. Adherence to the Portfolio and DASH diet scores were derived from a validated 143-item food frequency questionnaire. We used linear mixed models to examine the associations of 1-SD increase and quartile changes in the diet scores with concomitant changes in cardiometabolic risk factors.

RESULTS

After adjusting for several potential confounders, a 1-SD increase in the Portfolio diet score was significantly associated with lower HbA1c (β [95% CI]: -0.02% [-0.02, -0.01], P < 0.001), fasting glucose (-0.47 mg/dL [-0.83, -0.11], P = 0.01), triglycerides (-1.29 mg/dL [-2.31, -0.28], P = 0.01), waist circumference (WC) (-0.51 cm [-0.59, -0.43], P < 0.001), and body mass index (BMI) (-0.17 kg/m² [-0.19, -0.15], P < 0.001). A 1-SD increase in the DASH diet score was significantly associated with lower HbA1c (-0.03% [-0.04, -0.02], P < 0.001), glucose (-0.84 mg/dL [-1.18, -0.51], P < 0.001), triglycerides (-3.38 mg/dL [-4.37, -2.38], P < 0.001), non-HDL-cholesterol (-0.47 mg/dL [-0.91, -0.04], P = 0.03), WC (-0.69 cm [-0.76, -0.60 cm], P < 0.001), BMI (-0.25 kg/m² [-0.28, -0.26 kg/m²], P < 0.001), systolic blood pressure (-0.57 mmHg [-0.81, -0.32 mmHg], P < 0.001), diastolic blood pressure (-0.15 mmHg [-0.29, -0.01 mmHg], P = 0.03), and with higher HDL-cholesterol (0.21 mg/dL [0.09, 0.34 mg/dL, P = 0.001]). Similar associations were seen when both diet scores were assessed as quartiles, comparing extreme categories of adherence.

CONCLUSIONS

Among older adults at high cardiovascular risk with MetS, greater adherence to the Portfolio and DASH diets showed significant favourable prospective associations with several clinically relevant cardiometabolic risk factors. Both diets are likely beneficial for cardiometabolic risk reduction.

High Fruit and Vegetable Consumption and Moderate Fat Intake Are Associated with Higher Carotenoid Concentration in Human Plasma

Carotenoids are pigments contained mainly in fruit and vegetables (F&V) that have beneficial effects on cardiometabolic health. Due to their lipophilic nature, co-ingestion of fat appears to increase their bioavailability via facilitating transfer to the aqueous micellar phase during digestion. However, the extent to which high fat intake may contribute to increased carotenoid plasma concentrations is still unclear. The objective was to examine the degree to which the consumption of different amounts of both carotenoid-rich foods and fats is associated with plasma carotenoid concentrations within a Mediterranean lifestyle context (subsample from the PREDIMED-Plus study baseline) where consumption of F&V and fat is high. The study population was categorized into four groups according to their self-reported consumption of F&V and fat. Carotenoids were extracted from plasma samples and analyzed by HPLC-UV-VIS-QqQ-MS/MS. Carotenoid systemic concentrations were greater in high consumers of F&V than in low consumers of these foods (+3.04 μmol/L (95% CI: 0.90, 5.17), p-value = 0.005), but circulating concentrations seemed to decrease when total fat intake was very high (−2.69 μmol/L (−5.54; 0.16), p-value = 0.064). High consumption of F&V is associated with greater systemic levels of total carotenoids, in particular when fat intake is low-to-moderate rather than very high.

Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions.

Anthropometric variables as mediators of the association of changes in diet and physical activity with inflammatory profile

BACKGROUND

Mechanisms underlying the associations of high levels of physical activity (PA) and adherence to the Mediterranean Diet (MedDiet) with a better inflammatory profile remain unclear. Our objective was to assess the mediating role of changes in body mass index (BMI) and waist circumference (WC), as markers of body fat in the association of changes in PA and adherence to the MedDiet, with changes in the inflammatory profile.

METHODS

This study included 489 adults, aged 55 to 75 years, from the PREDIMED-Plus multi-centre lifestyle intervention trial. An inflammatory score was calculated, based on 8 blood biomarkers: high-sensitivity C-reactive protein, interleukin 6, interleukin 8, interleukin 18, monocyte chemo-attractant protein-1, C-peptide, leptin, and regulated on activation, normal T-cell expressed and secreted chemokine (RANTES). Biomarkers, levels of PA, score of MedDiet adherence, BMI and WC were measured at baseline and at one-year follow-up. Linear regression models were fitted according to the Baron and Kenny framework for mediation analysis.

RESULTS

Changes in BMI and WC mediated the association of both changes in PA and changes in the MedDiet adherence with the inflammatory score. BMI mediated 26% of the association of changes in total PA with the inflammatory profile, and 27% of the association of changes in the MedDiet, while WC mediated 13% and 12% of these associations, respectively.

CONCLUSION

In older adults at high cardiovascular risk, increasing PA levels and adherence to a MedDiet during 1 year were associated with a lower inflammatory score, which was partly mediated by a reduction in body fat.

Zapico A, Gusi N, Aznar S, Alcaraz PE, González-Valeiro M, Serra-Majem L, Terrados N, Tur JA, Segú M, Lassale C, Homs C, Oses M, González-Gross M, Sánchez-Gómez J, Jiménez-Zazo F, Marín-Cascales E, Sevilla-Sánchez M, Herrera-Ramos E, Pulgar S, Bibiloni MDM, Sancho-Moron O, Schröder H, Barón-López FJ. Screen Time and Parents' Education Level Are Associated with Poor Adherence to the Mediterranean Diet in Spanish Children and Adolescents: The PASOS Study

The aim of this study is to evaluate if screen time and parents' education levels are associated with adherence to a Mediterranean dietary pattern. This cross-sectional study analyzed a representative sample of 3333 children and adolescents (8 to 16 years) included in the Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS) study in Spain (which ran from March 2019 to February 2020). Data on screen time (television, computer, video games, and mobile phone) per day, Mediterranean diet adherence, daily moderate or vigorous physical activity, and parents' education levels were gathered using questionnaires. A descriptive study of the variables according to sex and parents' education level was performed. Logistic regression models (adjusted by sex and weight status) were fitted to evaluate the independent association between screen time and Kids' level of adherence to the Mediterranean diet (KIDMED) index, as well as some of its items. A greater amount of screen time was associated with worse adherence to the Mediterranean diet; a lower consumption of fruit, vegetables, fish, legumes, and nuts; and a greater consumption of fast food, sweets, and candies. A lower parents' education level was associated with worse adherence to the Mediterranean diet. It is necessary to promote the responsible, limited use of screen time, especially in children with parents with a lower education level.

Contribution of ultra-processed foods in visceral fat deposition and other adiposity indicators: Prospective analysis nested in the PREDIMED-Plus trial

BACKGROUND & AIMS

Ultra-processed food and drink products (UPF) consumption has been associated with obesity and its-related comorbidities. Excess of visceral fat, which appears with increasing age, has been considered as the culprit contributing to adiposity-associated adverse health outcomes. However, none of previous studies elucidated the link between UPF and directly quantified adiposity and its distribution. We aimed to prospectively investigate the association between concurrent changes in UPF consumption and objectively assessed adiposity distribution.

METHODS

A subsample of 1485 PREDIMED-Plus participants (Spanish men and women aged 55-75 years with overweight/obesity and metabolic syndrome) underwent body composition measurements. Consumption of UPF at baseline, 6 and 12 months was evaluated using a validated 143-item semi-quantitative Food Frequency Questionnaire. Food items (g/day) were categorized according to their degree of processing using NOVA system. Regional adiposity (visceral fat (in g) and android-to-gynoid fat ratio) and total fat mass (in g) at three time points were measured with dual-energy X-ray absorptiometry (DXA) and were normalized using sex-specific z-scores. The association of changes in UPF consumption, expressed as the percentage of total daily intake (daily g of UPF/total daily g of food and beverage intake∗100), with adiposity changes was evaluated using linear mixed-effects models.

RESULTS

On average, the consumption of UPF accounted for 8.11% (SD 7.41%) of total daily intake (in grams) at baseline. In multivariable-adjusted model, 10% daily increment in consumption of UPF was associated with significantly (all p-values <0.05) greater accumulation of visceral fat (β 0.09 z-scores, 95% CI 0.05; 0.13), android-to-gynoid fat ratio (0.05, 0.00; 0.09) and total fat (0.09, 0.06; 0.13).

CONCLUSION

A higher consumption of UPF was associated with greater age-related visceral and overall adiposity accumulation. Further studies are warranted to confirm these results in other populations and settings.

TRIAL REGISTRATION

The trial was registered at the International Standard Randomized Controlled Trial (ISRCTN: http://www.isrctn.com/ISRCTN89898870) with number 89898870 and registration date of 24 July 2014, retrospectively registered.

Milk and Dairy Products Intake Is Related to Cognitive Impairment at Baseline in Predimed Plus Trial

SCOPE

To examine the association between milk and dairy products intake and the prevalence of cognitive decline among Spanish individuals at high cardiovascular risk.

METHODS AND RESULTS

Cross-sectional analyses are performed on baseline data from 6744 adults (aged 55-75 years old). Intake of milk and dairy products is estimated using a food frequency questionnaire grouped into quartiles. The risk of developing cognitive impairment is based on the Mini-Mental State Examination (MMSE). A higher prevalence of cognitive decline was found in subjects who consumed more grams. Patients with worse MMSE score (10-24) consumed a mean of 395.14 ± 12.21 g, while patients with better MMSE score (27-30) consumed a mean of 341.23 ± 2.73 g (p < 0.05). Those subjects with the lower milk consumption (<220 g/day) had a higher MMSE score (28.35 ± 0.045). Higher intake of fermented dairy products was observed in participants with a lower MMSE score (OR 1.340, p = 0.003). A positive correlation was found between the consumption of whole milk and the MMSE score (r = 0.066, p < 0.001).

CONCLUSIONS

These findings suggest that greater consumption of milk and dairy products could be associated with greater cognitive decline according to MMSE. Conversely, consumption of whole-fat milk could be linked with less cognitive impairment in the cross-sectional study.

Reference ranges of glycated hemoglobin (HbA1c) in capillary blood in the Spanish population

Cross-sectional analysis describing HbA1c reference values by sex and age in a randomly selected Mediterranean general population sample. Using two methods, Point-of-Care systems and centralized laboratory, results show that HbA1c values increase with age. Almost half of the sample aged 65 years or older had median values >5.7% (prediabetes cut-off point).

Control of cardiovascular risk factors with tailored recommendations: A randomized controlled trial

This study analyzed the efficacy of tailored recommendations to control cardiovascular risk factors at 1-year follow-up in a population-based randomized controlled trial in individuals aged 35-74 years with no history of cardiovascular disease at baseline. Total, low-density lipoprotein (LDL), and high-density lipoprotein cholesterol and systolic and diastolic blood pressure (BP) were measured at baseline and at 1-year follow-up. The primary outcome was the quantitative change in total cholesterol. To estimate the differences within and between groups, McNemar and Student t-tests were applied according to an intention-to-treat strategy. We enrolled 955 individuals [52.3% women; mean age, 50 years (standard deviation 10)]. Finally, 1 participant in each group presented a cardiovascular event and 768 were reexamined at 1-year follow-up. Intervention and control groups showed significant increases in total cholesterol [5.49 (standard deviation 1.02) to 5.56 (1.06) mmol/L and 5.34 (0.94) to 5.43 (0.93) mmol/L, respectively]. Men in the intervention group showed significant decreases in systolic and diastolic BP [117.2 (14.6) to 115.6 mmHg (14.1) and 77.9 (9.7) to 76.5 mmHg (9.7), respectively]; no changes were found in the rates of total cholesterol <5.2 mmol/L and LDL cholesterol <3.0 mmol/L. In the control group, both values were significantly decreased (43.5 to 36.4% and 26.4 to 20.8%, respectively) in men. In the stratified analysis, women showed no differences in any of the outcomes. In conclusion, an intervention with tailored recommendations increased mean total cholesterol values. The intervention effect was higher in men who maintained blood lipids at optimal levels and had decreased BP values.

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

BACKGROUND

Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents.

METHODS

For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5-19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence.

FINDINGS

We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9-10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes-gaining too little height, too much weight for their height compared with children in other countries, or both-occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls.

INTERPRETATION

The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks.

FUNDING

Wellcome Trust, AstraZeneca Young Health Programme, EU.

Hospitalization for Acute Respiratory Tract Infection in a Low-Antibiotic-Prescribing Setting: Cross-Sectional Data from General Practice

Background: Acute respiratory tract infections (ARTI) are the main cause of inappropriate antibiotic prescribing. To date, there is limited evidence concerning whether low levels of antibiotic prescribing may impact patient safety. We investigate whether antibiotic prescribing for patients seeking primary care for ARTI correlates with the odds for hospitalization. Methods: Analysis of patient baseline data (n = 3669) within a cluster-randomized controlled trial. Adult patients suffering from ARTI in German primary care are included. The main outcome measure is acute hospitalization for respiratory infection and for any acute disease from 0 to 42 days after initial consultation. Results: Neither the antibiotic status of individual patients (OR 0.91; 95% CI: 0.49 to 1.69; p-value = 0.769) nor the physician-specific antibiotic prescription rates for ARTI (OR 1.22; 95% CI: 1.00 to 1.49; p-value = 0.054) had a significant effect on hospitalization. The following factors increased the odds for hospitalization: patient’s age, the ARTI being defined as lower respiratory tract infections (such as bronchitis) by the physician, the physician’s perception of disease severity, and being cared for within group practices (versus treated in single-handed practices). Conclusions: In a low-antibiotic-prescribing primary care setting such as Germany, lack of treatment with antibiotics for ARTI did not result in higher odds for hospitalization in an adult population.

Study protocol of a population-based cohort investigating Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth: the PASOS study

INTRODUCTION

Physical activity (PA) is essential to healthy mental and physical development in early life. However, the prevalence of physical inactivity, which is considered a key modifiable driver of childhood obesity, has reached alarming levels among European youth. There is a need to update the data for Spain, in order to establish if current measures are effective or new approaches are needed.

METHODS AND ANALYSIS

We present the protocol for Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS). This observational, nationally representative, multicentre study aims to determine the PA levels, sedentary behaviours and prevalence of physical inactivity (defined as <60 min of moderate to vigorous PA per day) in a representative sample of Spanish children and adolescents. The PASOS study has recruited a representative random sample of children and adolescents aged 8-16 years from 242 educational centres in the 17 'autonomous regions' into which Spain is divided. The aim is to include a total of 4508 youth participants and their families. Weight, height and waist circumference will be measured by standardised procedures. Adherence to the Mediterranean diet, quality of life, sleep duration, PA and sedentary behaviour are being measured by validated questionnaires. PA is measured by the Physical Activity Unit 7-item Screener. A representative subsample (10% of participants) was randomly selected to wear accelerometers for 9 days to obtain objective data on PA. Parents are asked about their educational level, time spent doing PA, diet quality, self-perceived stress, smoking habit, weight, height, their child's birth weight and if the child was breast fed.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Fundació Sant Joan de Déu, Barcelona, Spain. Main findings of the study will be disseminated to the scientific community and to general public by media conferences, social media and a website.

TRIAL REGISTRATION NUMBER

ISRCTN34251612.

[Appropriate allocation of resources for interhospital transfer in emergency medical service-is a physician in the dispatch center helpful?]

BACKGROUND

The number of interhospital transfers is constantly increasing because of specialization of medical facilities, capacity balancing between intensive care units as well as earlier rehabilitation procedures. This leads to an increase in requests for emergency physicians to accompany patient transfers. This study investigated whether clarification of interhospital transport by an emergency physician at the dispatch center can optimize the use of emergency services resources.

METHOD

All transport clarifications performed by a tele-emergency physician between 1 January 2018 and 31 December 2019 were retrospectively analyzed as well as the transport request forms. Furthermore, all data on the number and alarmed rescue resources for interhospital transfers in the city of Aachen from 2013 onwards were exported from the dispatch center databank and included in the evaluation.

RESULTS

In total 2333 requests for interhospital patient transfers from 2018 and 2019 were analyzed as well as 10,923 transports recorded from 2013 to 2019. The number of patient transfers accompanied by an emergency physician from 2013 to 2019 was significantly reduced from 786 (68.2%) to 495 (30.5%, p > 0.001). The correct resources of rescue vehicles and staff was requested in 1816 cases (77.8%). The urgency of emergency patient transfers was correctly evaluated in 567 (89.2%) cases. In total 526 assignments were carried out without an emergency physician and 315 of these patients were accompanied by a tele-emergency physician during transfer.

CONCLUSION

The immediate clarification of interhospital transport requests by an emergency physician at the dispatch center leads to a significant reduction in unnecessary medical accompaniment of patient transfers. The choice of an appropriate transfer vehicle and staff should not be left to the requesting hospital physician alone.

Leisure time physical activity is associated with improved HDL functionality in high cardiovascular risk individuals: a cohort study

AIMS

Physical activity has consistently been shown to improve cardiovascular health and high-density lipoprotein-cholesterol levels. However, only small and heterogeneous studies have investigated the effect of exercise on high-density lipoprotein functions. Our aim is to evaluate, in the largest observational study to date, the association between leisure time physical activity and a range of high-density lipoprotein functional traits.

METHODS

The study sample consisted of 296 Spanish adults at high cardiovascular risk. Usual leisure time physical activity and eight measures of high-density lipoprotein functionality were averaged over two measurements, one year apart. Multivariable linear regression models were used to explore the association between leisure time physical activity (exposure) and each high-density lipoprotein functional trait (outcome), adjusted for cardiovascular risk factors.

RESULTS

Higher levels of leisure time physical activity were positively and linearly associated with average levels over one year of plasma high-density lipoprotein-cholesterol and apolipoprotein A-I, paraoxonase-1 antioxidant activity, high-density lipoprotein capacity to esterify cholesterol and cholesterol efflux capacity in individuals free of type 2 diabetes only. The increased cholesterol esterification index with increasing leisure time physical activity reached a plateau at around 300 metabolic equivalents.min/day. In individuals with diabetes, the relationship with cholesteryl ester transfer protein followed a U-shape, with a decreased cholesteryl ester transfer protein activity from 0 to 300 metabolic equivalents.min/day, but increasing from there onwards. Increasing levels of leisure time physical activity were associated with poorer high-density lipoprotein vasodilatory capacity.

CONCLUSIONS

In a high cardiovascular risk population, leisure time physical activity was associated not only with greater circulating levels of high-density lipoprotein-cholesterol, but also with better markers of high-density lipoprotein functionality, namely cholesterol efflux capacity, the capacity of high-density lipoprotein to esterify cholesterol and paraoxonase-1 antioxidant activity in individuals free of diabetes and lower cholesteryl ester transfer protein activity in individuals with type 2 diabetes.

Ecological Momentary Assessment for the Evaluation of the Adherence to the Mediterranean Diet in the Context of Clinical Trials

Objectives

The validation of tailored dietary Ecological Momentary Assessments (EMAs) to evaluate the continuous adherence to the Mediterranean Diet (MedDiet) for its use in the framework of nutritional intervention clinical studies.

Methods

We have developed a set of dietary mobile-app EMAs to evaluate the consumption of characteristics components key in the MedDiet. The EMAs will capture the frequency of consumption of the MedDiet products during a week and extract the rate of adherence to the MedDiet. A total of 100 healthy adults were enrolled on a trial to validate the use of EMAs as a novel screener of the MedDiet adherence. Participants received on their phone four randomized questions every day for 8 weeks. The questions were semi-qualitative and enquired for their intake diet on the last hours. The validity of the EMAs is compared with two validated questionnaires: Mediterranean Diet adherence screener (MEDAS) and a food frequency questionnaire (FFQ), both validated for the Spanish population. The levels of certain urinary dietetic biomarkers associated with the MedDiet was measured during the study. Tyrosol and hydroxytyrosol (two biomarkers of olive oil consumption) and alcohol biomarkers and free fatty acids were measured.

Results

A preliminary analysis of 21 subjects showed the capacity of EMAs to capture the adherence to the MedDiet, ranging in this population from 25–80% of adherence to the MedDiet recommendations. Scores obtained were correlated with the ones obtained in MEDAS, and the food frequencies captured in EMAs correlated with the frequencies reported in the FFQ at the end of the study. Individuals with higher scores in EMAs presented higher urinary levels of tyrosol and hydroxytyrosol. Participants reported a change in their dietary habits following their participation in the study, suggesting an additional beneficial effect of the EMAs.

Conclusions

The tailored EMAs are a reliable dietary assessment tool that provides an improved MedDiet adherence scoring while reducing participant's burden and capturing an accurate and continuous representation of the habitual dietary patterns. Moreover, they can be used to reinforce nutritional intervention and its sustainability.

Funding Sources

Alzheimer's Association and Instituto de Salud Carlos III of Spain.

Analysis of the dose-response relationship of leisure-time physical activity to cardiovascular disease and all-cause mortality: the REGICOR study

INTRODUCTION AND OBJECTIVES

Regular leisure-time physical activity (LTPA) has been consistently recognized as a protective factor for cardiovascular diseases (CVD) and all-cause mortality. However, the pattern of this relationship is still not clear. The aim of this study was to assess the relationship of LTPA with incident CVD and mortality in a Spanish population.

METHODS

A prospective population-based cohort of 11 158 randomly selected inhabitants from the general population. LTPA was assessed by a validated questionnaire. Mortality and CVD outcomes were registered during the follow-up (median: 7.24 years). The association between LTPA and outcomes of interest (all-cause mortality and cardiovascular disease) was explored using a generalized additive model with penalized smoothing splines and multivariate Cox proportional hazard models.

RESULTS

We observed a significant nonlinear association between LTPA and all-cause and CVD mortality, and fatal and nonfatal CVD. Moderate-vigorous intensity LTPA, but not light-intensity LTPA, were associated with beneficial effects. The smoothing splines identified a cutoff at 400 MET-min/d. Below this threshold, each increase of 100 MET-min/d in moderate-vigorous LTPA contributed with a 16% risk reduction in all-cause mortality (HR, 0.84; 95%CI, 0.77-0.91), a 27% risk reduction in CVD mortality (HR, 0.73; 95%CI, 0.61-0.87), and a 12% risk reduction in incident CVD (HR, 0.88; 95%CI, 0.79-0.99). No further benefits were observed beyond 400 MET-min/d.

CONCLUSIONS

Our results support a nonlinear inverse relationship between moderate-vigorous LTPA and CVD and mortality. Benefits of PA are already observed with low levels of activity, with a maximum benefit around 3 to 5 times the current recommendations.

High density lipoprotein functionality and cardiovascular events and mortality: A systematic review and meta-analysis

BACKGROUND AND AIMS

The aim of this systematic review and meta-analysis is to synthesize studies assessing the associations between high-density lipoprotein functionality and risk of cardiovascular disease and mortality.

METHODS

We searched Medline and Embase for the identification of observational studies meeting the inclusion criteria. This meta-analysis was conducted following the PRISMA statement and was registered in PROSPERO (CRD42017065857). We pooled risk estimates with a random-effect model separately for cardiovascular disease (fatal and non-fatal) and all-cause mortality.

RESULTS

Out of 29 manuscripts, 20 articles investigated cholesterol efflux capacity (13 prospective and 7 cross-sectional), 10 antioxidant capacity (7 prospective and 3 cross-sectional) and two anti-inflammatory capacity of high-density lipoprotein (1 prospective and 1 cross-sectional). A greater cholesterol efflux capacity was associated with lower risk of cardiovascular disease in 8 studies (RR for 1SD increase: 0.86; 95% CI: 0.76-0.98) and of mortality in 5 studies (RR for 1SD increase: 0,77; 0.60-1.00). Better antioxidant capacity was non-significantly associated with lower cardiovascular disease risk in 2 studies (RR for 1SD increase 0.70; 0.32-1.53) and significantly with mortality in 3 studies (RR for 1SD increase 0.48; 0.28-0.81). High-density lipoprotein anti-inflammatory ability was associated with a lower cardiovascular disease risk in the only prospective study.

CONCLUSIONS

Greater high-density lipoprotein cholesterol efflux capacity and antioxidant/anti-inflammatory capacities were associated with lower risk of cardiovascular disease. However, the heterogeneity between studies and evidence of publication bias warrants caution and highlights the need for larger prospective studies with standardized assays and specific outcomes.

Impact of lifestyle behaviors in early childhood on obesity and cardiometabolic risk in children: Results from the Spanish INMA birth cohort study

BACKGROUND

Identifying modifiable lifestyle behaviors linked to childhood obesity is necessary to develop preventive strategies.

OBJECTIVE

To estimate the association of five lifestyle behaviors in children aged 4 years on obesity and cardiometabolic risk factors at age 4 years and on obesity and blood pressure at age 7 years.

METHODS

We used child lifestyle data from the INMA project at age 4 years (n = 1480). We constructed a child lifestyle score by summing five behaviors (physical activity, sleep time, television time, plant based foods and intake of ultra-processed foods) and we categorized it into tertiles. At ages 4 and 7 years, we calculated age- and sex-specific z-scores for BMI, waist circumference (WC), and blood pressure. At age 4, we also calculated age-, and sex-, specific z-scores for triglycerides and HDL. We used linear and logistic regression analyses.

RESULTS

The lifestyle score was not associated with the outcomes at 4 years, but it was negatively associated with BMI and WC z-scores at age 7 years. Children at age 4 years in the highest tertile of the score had lower risk of overweight or obesity at age 7 years (OR = 0.61; 95% CI 0.39; 0.96) and abdominal obesity (OR = 0.48; 95% CI 0.24; 0.96).

CONCLUSIONS

Higher adherence to a healthy lifestyle at age 4 years decreased risk of overweight, obesity and abdominal obesity at 7 years.

Physical fitness and physical activity association with cognitive function and quality of life: baseline cross-sectional analysis of the PREDIMED-Plus trial

Physical activity (PA) has been hypothesized to be effective to maintaining cognitive function and delay cognitive decline in the elderly, but physical fitness (PF) could be a better predictor of cognitive function. We aimed to study the association between PA and PF with cognitive function and quality of life using cross-sectional data from 6874 participants of the PREDIMED-Plus trial (64.9 ± 4.9 years, 48.5% female). PF and PA were measured with a Chair Stand Test, the REGICOR and Rapid Assessment Physical Activity questionnaires. Cognitive function was measured with Mini-mental State Examination, Control Oral Word Association Test, Trail Making Test and Digit Span tests; whereas health-related quality of life was assessed with the SF36-HRQL test. Cognitive and quality of life scores were compared among PF quartiles and PA levels (low, moderate and high) with ANCOVA and with Chair Stand repetitions and energy expenditure from total PA with multivariable linear regression adjusted for confounding factors. PF associated with higher scores in phonemic and semantic verbal fluency tests and with lower TMT A time. However, PA was not associated with the neurocognitive parameters evaluated. Both PF and PA levels were strongly associated with a better quality of life. We concluded that PF, but not PA, is associated with a better cognitive function. This trial was retrospectively registered at the International Standard Randomized Controlled Trial (ISRCTN89898870, https://www.isrctn.com/ISRCTN89898870?q=ISRCTN89898870&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search) on 07/24/2014.