Ultra-processed food consumption and its correlates among Italian children, adolescents and adults from the Italian Nutrition & Health Survey (INHES) cohort study

OBJECTIVE

To assess ultra-processed food (UPF) consumption and its socio-demographic, psychosocial and behavioural correlates in a general population of Italian children, adolescents and adults.

DESIGN

Cross-sectional telephone-based survey.

SETTING

Italy, 2010-2013.

PARTICIPANTS

In total, 9078 participants (5-97 years) from the Italian Nutrition & Health Survey. Dietary intakes were collected by a 1-d 24-h dietary recall. UPF was defined by the NOVA classification and expressed as percentage of total energies.

RESULTS

Average energy intake from UPF (95 % CI) was 17·3 % (17·1 %, 17·6 %) among adults and 25·9 % (24·8 %, 27·0 %) in children/adolescents. Top sources of UPF were processed meats (32·5 %) and bread substitutes (16·7 %). Among adults, age (β = -3·10; 95 % CI (-4·40, -1·80) for >65 years v. 20-40 years; βs are dimensionless) and residing in Southern Italy (β = -0·73; 95 % CI (-1·32, -0·14) v. Northern) inversely associated with UPF. Screen view during meals was directly linked to UPF, as well as poor self-rated health (β = 5·32; 95 % CI (2·66, 7·99)), adverse life events (β = 2·33; 95 % CI (1·48, 3·18)) and low sleep quality (β = 2·34; 95 % CI (1·45, 3·23)). Boys consumed two-point percent more UPF of the total energy than girls (β = 2·01; 95 % CI (0·20, 3·82)). For all ages, a Mediterranean diet was inversely associated with UPF (β = -4·86; 95 % CI (-5·53, -4·20) for good v. poor adherence in adults and (β = -5·08; 95 % CI (-8·38, -1·77) for kids).

CONCLUSIONS

UPF contributes a modest proportion of energy to the diets of Italian adults while being one-quarter of the total energies in children/adolescents. UPF was associated with several psychosocial factors and eating behaviours. Increased adherence to Mediterranean diet would possibly result in lower UPF consumption.

Psychological distress resulting from the COVID-19 confinement is associated with unhealthy dietary changes in two Italian population-based cohorts

Purpose

To examine the relationship between psychological distress resulting from the COVID-19 lockdown and dietary changes.

Methods

Cross-sectional analysis from 2 retrospective Italian cohorts recruited from May to September 2020: (1) The Moli-LOCK cohort consists of 1401 participants from the Moli-sani Study (n = 24,325) who were administered a telephone-based questionnaire to assess lifestyles and psychological factors during confinement; (2) the ALT RISCOVID-19 is a web-based survey of 1340 individuals distributed throughout Italy who self-responded to the same questionnaire using Google® forms.

Psychological distress was measured by assessments of depression (PHQ-9 and depressive items from the Screening Questionnaire for Disaster Mental Health- SQD-D), anxiety (GAD-7), stress (PSS-4), and post-traumatic stress disorder (SQD-P). Diet quality was assessed either as changes in consumption of ultra-processed foods (UPF) or adherence to Mediterranean diet (MD).

Results

In ALT RISCOVID-19, increased UPF intake was directly associated with depression (both PHQ-9 and SQD-D; p < 0.0001), anxiety (p < 0.0001), stress (p = 0.001) and SQD-P (p = 0.001); similar results were obtained in the Moli-LOCK cohort except for perceived stress. When psychometric scales were analysed simultaneously, only depression (SQD-D) remained associated with UPF (both cohorts). In both cohorts, psychological distress poorly influenced changes toward an MD, except for depression (SQD-D) that resulted inversely associated in the ALT RISCOVID-19 participants (β = − 0.16; 95% CI − 0.26, − 0.06).

Conclusions

Psychological distress from the COVID-19 confinement is directly associated with unhealthy dietary modifications in two Italian cohorts. In view of possible future restrictive measures to contain pandemic, public health actions are warranted to mitigate the impact of psychological distress on diet quality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-021-02752-4.

Ultra-processed food intake and all-cause and cause-specific mortality in individuals with cardiovascular disease: the Moli-sani Study

AIMS 

To evaluate the association of ultra-processed food (UPF) intake and mortality among individuals with history of cardiovascular disease (CVD) and analyse some biological pathways possibly relating UPF intake to death.

METHODS AND RESULTS 

Longitudinal analysis on 1171 men and women (mean age: 67 ± 10 years) with history of CVD, recruited in the Moli-sani Study (2005-10, Italy) and followed for 10.6 years (median). Food intake was assessed using a food frequency questionnaire. UPF was defined using the NOVA classification according to degree of processing and categorized as quartiles of the ratio (%) between UPF (g/day) and total food consumed (g/day). The mediating effects of 18 inflammatory, metabolic, cardiovascular, and renal biomarkers were evaluated using a logistic regression model within a counterfactual framework. In multivariable-adjusted Cox analyses, higher intake of UPF (Q4, ≥11.3% of total food), as opposed to the lowest (Q1, UPF <4.7%), was associated with higher hazards of all-cause (hazard ratio [HR]: 1.38; 95% confidence interval (CI): 1.00-1.91) and CVD mortality (HR: 1.65; 95% CI: 1.07-2.55). A linear dose-response relationship of 1% increment in UPF intake with all-cause and CVD mortality was also observed. Altered levels of cystatin C explained 18.3% and 16.6% of the relation between UPF (1% increment in the diet) with all-cause and CVD mortality, respectively.

CONCLUSION 

A diet rich in UPF is associated with increased hazards of all-cause and CVD mortality among individuals with prior cardiovascular events, possibly through an altered renal function. Elevated UPF intake represents a major public health concern in secondary CVD prevention.

Fine-grained investigation of the relationship between human nutrition and global DNA methylation patterns

PURPOSE

Nutrition is an important, modifiable, environmental factor affecting human health by modulating epigenetic processes, including DNA methylation (5mC). Numerous studies investigated the association of nutrition with global and gene-specific DNA methylation and evidences on animal models highlighted a role in DNA hydroxymethylation (5hmC) regulation. However, a more comprehensive analysis of different layers of nutrition in association with global levels of 5mC and 5hmC is lacking. We investigated the association between global levels of 5mC and 5hmC and human nutrition, through the stratification and analysis of dietary patterns into different nutritional layers: adherence to Mediterranean diet (MD), main food groups, macronutrients and micronutrients intake.

METHODS

ELISA technique was used to measure global 5mC and 5hmC levels in 1080 subjects from the Moli-sani cohort. Food intake during the 12 months before enrolment was assessed using the semi-quantitative EPIC food frequency questionnaire. Complementary approaches involving both classical statistics and supervised machine learning analyses were used to investigate the associations between global 5mC and 5hmC levels and adherence to Mediterranean diet, main food groups, macronutrients and micronutrients intake.

RESULTS

We found that global DNA methylation, but not hydroxymethylation, was associated with daily intake of zinc and vitamin B3. Random Forests algorithms predicting 5mC and 5hmC through intakes of food groups, macronutrients and micronutrients revealed a significant contribution of zinc, while vitamin B3 was reported among the most influential features.

CONCLUSION

We found that nutrition may affect global DNA methylation, suggesting a contribution of micronutrients previously implicated as cofactors in methylation pathways.

Impaired metabolic health over-time and high abdominal fat are prospectively associated with high-sensitivity C-reactive protein in children: The IDEFICS study

BACKGROUND

Metabolic risk and inflammatory state have an early life onset and are associated with future diseases.

OBJECTIVES

To assess the association between metabolic syndrome (MetS) and metabolic health with high-sensitive C-reactive protein (hsCRP), cross-sectionally and longitudinally, in children.

METHODS

2913 European children (2-10 years) from eight countries from the IDEFICS study were investigated. Data were collected at baseline and 2 years later (follow-up). A MetS z-score was computed with waist circumference (WC), insulin resistance index, blood pressure, high-density lipoprotein cholesterol and triglycerides. Metabolically unhealthy (MU) status was assessed. Multi-level linear and logistic regressions were performed.

RESULTS

Among the MetS markers, WC was more consistently associated with hsCRP cross-sectional and prospectively. Baseline MetS score was significantly associated with greater risk of high hsCRP at follow-up and with prevalence and incidence of hsCRP. Those children who became MU overtime were significantly (P < .05) associated with future higher levels of hsCRP, independently of weight status at baseline.

CONCLUSIONS

Transition over time to a MU state was associated with higher levels of hsCRP at follow-up, independent of weight status at baseline. Screening of metabolic factors and routine measurement of WC are needed to prevent inflammatory status and related chronic diseases in children.

Natriuretic Peptides and Risk of Type 2 Diabetes: Results From the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) Consortium

OBJECTIVE

Natriuretic peptide (NP) concentrations are increased in cardiovascular diseases (CVDs) but are associated with a lower diabetes risk. We investigated associations of N-terminal pro-B-type NP (NT-proBNP) and midregional proatrial NP (MR-proANP) with incident type 2 diabetes stratified by the presence of CVD.

RESEARCH DESIGN AND METHODS

Based on the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) Consortium, we included 45,477 participants with NT-proBNP measurements (1,707 developed type 2 diabetes over 6.5 years of median follow-up; among these, 209 had CVD at baseline) and 11,537 participants with MR-proANP measurements (857 developed type 2 diabetes over 13.8 years of median follow-up; among these, 106 had CVD at baseline). The associations were estimated using multivariable Cox regression models.

RESULTS

Both NPs were inversely associated with incident type 2 diabetes (hazard ratios [95% CI] per 1-SD increase of log NP: 0.84 [0.79; 0.89] for NT-proBNP and 0.77 [0.71; 0.83] for MR-proANP). The inverse association between NT-proBNP and type 2 diabetes was significant in individuals without CVD but not in individuals with CVD (0.81 [0.76; 0.86] vs. 1.04 [0.90; 1.19]; P multiplicative interaction = 0.001). There was no significant difference in the association of MR-proANP with type 2 diabetes between individuals without and with CVD (0.75 [0.69; 0.82] vs. 0.81 [0.66; 0.99]; P multiplicative interaction = 0.236).

CONCLUSIONS

NT-proBNP and MR-proANP are inversely associated with incident type 2 diabetes. However, the inverse association of NT-proBNP seems to be modified by the presence of CVD. Further investigations are warranted to confirm our findings and to investigate the underlying mechanisms.

Association between body mass index, waist circumference, and relative fat mass with the risk of first unprovoked venous thromboembolism

BACKGROUND AND AIMS

Obesity defined by body mass index (BMI) is independently associated with venous thromboembolism (VTE). Abdominal obesity, defined by waist circumference, is a predictor of cardiovascular events. Recently, relative fat mass (RFM) was proposed as a marker of cardiovascular risk. We assessed the role of three different measures of obesity to predict unprovoked VTE in a longitudinal study.

METHODS AND RESULTS

Moli-sani is a prospective cohort study carried out in the general population of the Molise region, Italy. A total of 23,538 individuals (48% men, age 55.4 years) enrolled between 2005 and 2010 were eligible. Patients on anticoagulant treatment were excluded. BMI ≥30 kg/m² defined obesity, waist circumference >102 cm for men or 88 cm for women defined abdominal obesity, tertiles of RFM were compared. The long-term incidence of first unprovoked VTE during follow-up was assessed. Overall, 29.6% individuals were obese and 44.2% had abdominal obesity. A total of 66 first unprovoked VTE events were diagnosed during a median follow-up of 8.2 years. After multivariable Cox regression analysis, the risk of unprovoked VTE was significantly higher in obese participants (HR 1.89, 95% CI 1.16-3.07) than in participants with BMI <30; in subjects with abdominal obesity than with normal waist circumference (HR 2.19, 1.26-3.81); and in subjects with third vs first RFM tertile index (HR 2.46, 1.15-5.28). The areas under the curves for the models including the three obesity indexes were comparable.

CONCLUSIONS

Three indexes of obesity based on BMI, waist circumference or RFM similarly predict first occurrence of unprovoked VTE.

Adherence to the Mediterranean Diet during COVID-19 national lockdowns: a systematic review

Background

The Mediterranean Diet (MD) is one of the healthy eating plans recommended to promote health and prevent chronic diseases. During the COVID-19 pandemic, many countries adopted restrictive measures to mitigate infection spread, which might have influenced people's lifestyle and dietary habits. We conducted a systematic review to evaluate the impact of stay-at home orders' implementation on adherence to MD.

Methods

Studies were identified searching Medline, Embase, and Web Of Science, the search strategy was developed using a combination of free text and mesh terms referring to COVID-19 pandemic, lockdown, and MD. Studies published until March 31st, 2021 were included. We only considered studies reporting original data from quantitative analysis and assessing modifications of adherence to the MD through validated dietary scores or any change in consumption of food categories that are typically ascribed to the MD. Data extraction, pooling and quality appraisal of the included studies, were conducted applying PRISMA guidelines.

Results

42 studies were retrieved. After duplicates removal, and in-blind two-step screening, 10 studies met our a priori defined inclusion criteria and were included in the review. 71.4% of the studies reporting a rate of change in adherence, measured through validated questionnaire both before and during lockdown, reported an increase, while 28.6% reported no significative changes. All included studies reporting the percentage of participants having a high adherence to the MD, based on their results on MEDAS questionnaire, before and during the lockdown, found an increase in this percentage.

Conclusions

Adherence to the MD could have raised in people undergoing lockdowns due to COVID-19.

Key messages

The impact of restrictive measures on determinants of health must be monitored.

Despite the literature suggests adherence to MD has declined in the last years, this trend may have reversed or, at least, slowed during the initial phases of the current pandemic.

Moderate partially skimmed milk consumption is associated with reduced mortality risk

Background

Data on milk and other dairy products intake with health outcomes are inconsistent. We investigated the association of milk and total dairy consumption with the risk of all-cause and cause-specific mortality in a Mediterranean population.

Methods

We performed a longitudinal analysis on 22,889 men and women (mean age 55.4±11.7 y; 52.3% women), from the Moli-sani Study cohort (enrollment 2005-2010) followed-up for a median of 11 years. Dietary data were collected through a 188-item food frequency questionnaire. Total dairy consumption (g/d) was calculated as the sum of milk (whole and partially-skimmed, g/d), yogurt (whole and partially skimmed, g/d) and cheese (fresh and hard, g/d). Hazard ratio (HRs) with 95% confidence interval (CI) were calculated by multivariable Cox regression, modelled by spline curves.

Results

In multivariable-adjusted analysis controlled for sociodemographic, clinical and dietary factors, cheese, yogurt or whole milk intake were not associated with either all-cause or cause-specific mortality (p for overall association &gt;0.38), as well as was total diary intake (p &gt; 0.18). On the contrary, non-linear J-shaped curves were observed for the association of partially skimmed milk intake with all-cause and cancer mortality (p value for total and non-linear association=0.0072 and 0.035, and 0.097 and 0.049, respectively; magnitude of the relative reduction =16% and 18% at nadir of 128 and 114 g/d, respectively). A linear association between partially skimmed milk intake and CVD mortality was observed (p for association =0.047; p for non-linearity= 0.41), with HR = 0.82 (95%CI: 0.68-0.98) at 125 g/d and a window of statistically significant protection ranging from 100 to 250 g/d.

Conclusions

In a large Mediterranean population of adults, consumption of 1 standard cup of partially skimmed milk was associated with lower all-cause, cancer and CVD mortality. Other dairy sources were not associated with mortality.

Key messages

In a large Mediterranean population, total dairy intake did not predict mortality. Daily consumption of 1 standard cup of partially skimmed milk lowers the risk of all-cause, cardiovascular and cancer mortality.

Psychological distress from the COVID-19 confinement is associated with unhealthy dietary changes

Background

The confinement due to COVID-19 pandemic had adverse effects on mental health, but the relation between psychological distress resulting from lockdown measures and dietary habits needs to be elucidated.

Methods

We analysed 2,741 subjects (mean age 58.1±15.3 y) pooled from 2 retrospective Italian cohorts recruited from May to September 2020: 1) The Moli-LOCK cohort consists of 1,401 adults, a portion of the larger Moli-sani Study (n = 24,325) who were administered a telephone-based questionnaire to assess lifestyles and psychological factors during confinement; 2) the ALT RISCOVID-19 is a web-based survey of 1,340 individuals distributed throughout Italy who self-responded to the same questionnaire by using Google® forms. Psychological distress was measured by assessments of depression (PHQ-9), anxiety (GAD-7), stress (PSS-4), and post-traumatic stress disorder (PTSD). Diet quality was assessed either as changes in consumption of ultra-processed foods (UPF) or adherence to Mediterranean diet (MD).

Results

In a multivariable regression analysis controlled for major sociodemographic factors, depression (β=-0.06, 95%CI -0.10, -0.01), anxiety (β=-0.05, -0.09, -0.004) and PTSD (β=-0.04, -0.08, -0.002) were inversely associated with MD and directly with UPF (β = 0.13, 0.09, 0.18; β = 0.12, 0.08, 0.16 and β = 0.10, 0.06, 0.13, respectively); stress was associated with UPF (β = 0.06, 0.02, 0.10) but not with MD (β=-0.03, -0.08, 0.01).

Conclusions

Psychological distress resulting from confinement due to the COVID-19 pandemic is directly associated with unhealthy dietary modifications in a sample of the Italian population. In view of possible future restrictive measures, particular attention should be paid to public health actions promoting psychological support to more vulnerable groups.

Key messages

Psychological distress resulting from confinement due to the COVID-19 pandemic is directly associated with unhealthy dietary modifications.

Particular attention should be paid to public health actions promoting psychological support to more vulnerable groups also in view of future restrictive measures to contain the pandemic spread.

Economic hardship from the great recession and long-term changes in depression and quality of life

Background

Economic downturns may have detrimental effects on mental health. We investigated whether economic hardship resulting from the late 2000s great recession is associated with long-term changes in mental health over 12.8 years of follow up.

Methods

We analysed data on 2,001 participants from the CASSIOPEA Study, a sub-cohort of the larger Moli-sani study (2005-2010, Italy), who were re-examined between 2017-2020 (mean age at baseline 53±9 y; 55% women). Economic hardship possibly experienced since participants' first visit was assessed retrospectively by a questionnaire scoring the following domains: 1) change in employment status; 2) financial hardship and 3) financial hardship for health expenditures. An Economic Hardship Score (EHS) was computed (range 0-14), with highest values indicating higher economic hardship. Mental health was reflected by measurements of depression (Patients' Health Questionnaire; PHQ-2; higher values indicating more depressive symptoms) and mental quality of life assessed by the 36-Item Short Form Health Survey (increased values indicating improved quality of life). In this analysis, the exposure was economic hardship and the outcomes were changes in depression and mental quality of life measured after a 12.8-y period. Multivariable linear regression analysis (95%CI) was used.

Results

Mean PHQ-2 and SF36 changes over 12.8 years were -0.08 (±1.28) and 0.47 (±9.90), respectively.

In a multivariable-adjusted analysis including duration of follow-up, relevant sociodemographic factors, lifestyles, clinical factors and related life course changes, 1-point increment in EHS was associated with increased depression (β = 0.041; 95%CI 0.022, 0.060) and lower mental quality of life (β=-0.037; 95%CI -0.052, -0.021).

Conclusions

Economic hardship resulting from the great recession in late 2000s was associated with a deterioration of mental health, as reflected by increased depression levels and reduced mental quality of life.

Key messages

Economic hardship resulting from the recession in late 2000s is associated with a deterioration of mental health. These findings support the notion that economic downturns may have detrimental effects on mental health and support the need for adequate strategies for more vulnerable groups.

Ultra-processed food consumption modifies the association of Nutri-Score with all-cause mortality

Background

The Nutri-Score front-of-pack label rates foods according to their nutritional quality while the NOVA classification is focused on degree of processing; both systems separately predicted mortality in epidemiological contexts. We evaluated whether ultra-processed food (UPF) modifies the association of the Nutri-Score with mortality.

Methods

Longitudinal analysis on 22,549 Italian men and women (mean age 54±12 y) from the Moli-sani Study (2005-2010) followed for 11.2 y. Food intake was assessed by a food frequency questionnaire. The Food Standards Agency nutrient profiling system (FSAm-NPS) score, used to derive the Nutri-Score, was calculated for each food based on its amount of energy, saturated fat, sugar, sodium, fibre, protein, fruits, vegetables, legumes and nuts per 100 g of product. The FSAm-NPS dietary index was calculated for each participant as an energy weighted mean of the FSAm-NPS score of all foods consumed, and increased values indicate lower nutritional quality. UPF intake was the proportion (%) of UPF in the total weight of food consumed (g/d) and categorized as low/high (below/above the population median, respectively).

Results

In a multivariable analysis, 1-SD increase in the FSAm-NPS index led to increased risk of all-cause (HR = 1.07; 95%CI 1.02-1.13) and CVD mortality (HR = 1.08; 1.00-1.18). UPF intake was an effect modifier since the association of FSAm-NPS index with mortality was confined to individuals with high UPF intake (HR = 1.14; 1.05-1.25) but not in those with low UPF (HR = 1.00; 0.93-1.07; p for interaction=0.034). Similar findings were reported for CVD mortality (HR = 1.14;0.99-1.31 and HR = 1.01;0.90-1.13 for high and low UPF consumers, respectively; p for interaction=0.18).

Conclusions

Higher mortality risk associated with a NutriScore revealing nutrient-poor food intake is limited to individuals also reporting high UPF intake. Food labelling systems should account for food processing in addition to nutritional content.

Key messages

Ultra-processed food modifies the association between the 5-color Nutri-Score front-of-pack label with all-cause mortality in an Italian general population. Food labelling systems, that are conceived to help consumers make healthier food choices, should also account for food processing in addition to nutritional content.

How genetics and epigenetics can improve cardiovascular risk prediction: examples from the Moli-sani and Moli-family studies

One of the goals of personalized medicine (PM) is to use the ever-growing understanding of biology to provide a higher level of precision in disease prevention and patient care. The simultaneous study of the risk markers and epigenetic factors may have the desired discriminatory accuracy to distinguish between high-risk and low-risk subjects. The presentation will illustrate how genetics and epigenetics can improve cardiovascular risk (CVD) prediction in Italian adults from the general population. A subcohort of 1160 subjects (55.3±11.7 years; men 47.7%) was randomly selected from the Moli-sani cohort study (N = 24,325, yrs:2005-2010) and compared in a nested case-cohort design with incident CVD events (N = 592 validated myocardial infarctions or strokes), identified in a median follow-up of 9.2 years. DNA samples were used to genotype 14 tag SNPs in the genes NMU (encoding for Neuromedin U, a hypothalamic peptide), NMUR1 and NMUR2 (receptors) and NMS (Neuromedin S) and to quantify methylation levels at 17 CpG sites of two NMU regions through pyrosequencing. ELISA tests on circulating NMU levels are on-going. The associations between variants and incident CVD events using classical CVD risk factors as covariates and prediction metrics using standard risk alogrithms as reference were calculated. Four SNPs in NMU and NMUR1 genes and 6 NMU CpG sites showed a statistically significant association with events (p from 0.037 to &lt; 0.0001), independently from classical CVD risk factors. Combined epigenetic and genetic variants in genes from the NMU pathway are associated with increased CVD risk and could have a potential clinical utility when added to current CVD risk algorithms for CVD prediction.

Adherence to the Mediterranean Diet during the COVID-19 national lockdowns: a systematic review of observational studies

Background and aim of the work:

During the COVID-19 pandemic, many countries adopted restrictive measures to mitigate infection spread, which might have influenced people’s lifestyle and dietary habits. We conducted a systematic review to evaluate the impact of national lockdowns on adherence to the Mediterranean Diet (MD).

Methods:

Studies were identified searching Medline, Embase, Web of Science, and the Cochrane Library. Studies published until 4^th May 2021 were included. We only considered studies reporting original data from quantitative analysis and assessing changes in adherence to the MD, using validated dietary scores, or in consumption of MD food items. Data extraction, pooling, and quality appraisal of included studies were conducted following the PRISMA guidelines.

Results:

Forty-two studies were retrieved. After screening, 12 studies met inclusion criteria and were included in the review, of which 4 (33%) were longitudinal studies. Six (85.7%) of the seven studies that measured changes in MD adherence before-during lockdown reported an increase (rate of change of high-adherence to MD ranged between +3.3% and +21.9%). Evidence indicates that consumption of MD food items increased during lockdown but is heterogeneous in study design, quality, and findings.

Conclusions:

Our results suggest adherence to the MD during lockdown might have increased in some settings, while the determinants of such a trend are to be further explored. We raise awareness of the need to research further the impacts and long-term consequences of COVID-19 containment measures on dietary and lifestyle habits. (www.actabiomedica.it)

Platelet Distribution Width Is Associated with P-Selectin Dependent Platelet Function: Results from the Moli-Family Cohort Study

Defined as an index of platelet size heterogeneity, the platelet distribution width (PDW) is still a poorly characterized marker of platelet function in (sub)clinical disease. We presently validated PDW as a marker of P-selectin dependent platelet activation in the Moli-family cohort. Platelet-bound P-selectin and platelet/leukocyte mixed aggregates were measured by flow cytometry in freshly collected venous blood, both before and after in vitro platelet activation, and coagulation time was assessed in unstimulated and LPS- or TNFα-stimulated whole blood. Closure Times (CT) were measured in a Platelet Function Analyzer (PFA)-100. Multivariable linear mixed effect regression models (with age, sex and platelet count as fixed and family structure as random effect) revealed PDW to be negatively associated with platelet P-selectin, platelet/leukocyte aggregates and von Willebrand factor (VWF), and positively with PFA-100 CT, and LPS- and TNF-α-stimulated coagulation times. With the exception of VWF, all relationships were sex-independent. In contrast, no association was found between mean platelet volume (MPV) and these variables. PDW seems a simple, useful marker of ex vivo and in vitro P-selectin dependent platelet activation. Investigations of larger cohorts will define the usefulness of PDW as a risk predictor of thrombo-inflammatory conditions where activated platelets play a contributing role.

Risk factors, subsequent disease onset and prognostic impact of myocardial infarction and atrial fibrillation

Background

Myocardial infarction (MI) is a known risk factor for incident atrial fibrillation (AF), while AF frequently complicates acute MI. Although both diseases share common cardiovascular risk factors, the direction and strength of the association of the risk factors with disease onset, subsequent disease incidence and mortality are not completely understood.

Purpose

Our goal was to define the temporal relationship of MI and AF and the association of cardiovascular risk factors with disease incidence in order to determine whether common clinical risk factors show different associations with incident MI or AF. We further aimed to investigate predictors of subsequent disease onset and the impact of subsequent disease diagnosis on mortality.

Methods

In pooled multivariable Cox regression analyses we examined temporal relations of disease onset and identified predictors of MI, AF and subsequent all-cause mortality in 108,363 individuals (median age 46.0 years, 48.2% men) free of MI and AF at baseline from six European population-based cohorts.

Results

Over a maximum follow-up of 10.0 years 3558 (3.3%) individuals were diagnosed exclusively with MI, 1922 (1.8%) with AF but no MI, and 491 (0.5%) individuals developed both MI and AF. Association of male sex, systolic blood pressure, antihypertensive treatment and diabetes mellitus appeared to be stronger with incident MI than with AF, whereas increasing age and body mass index showed a higher risk for incident AF. Total cholesterol and daily smoking were significantly related to incident MI but not AF. The combined population attributable fraction of the cardiovascular risk factors was over 70% for incident MI, whereas it was only about one quarter for incident AF. Subsequent MI after incident AF (hazard ratio1.68, 95% CI 1.03–2.74) and subsequent AF after MI (hazard ratio 1.75, 95% CI 1.31–2.34) both significantly increased overall mortality risk.

Conclusions

Subsequent diagnosis of MI and AF was associated with a significant increase in mortality, irrespective of the first event. We found different associations of common cardiovascular risk factors with incident MI and AF indicating distinct pathophysiological pathways in disease development.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation programme (grant agreement No 847770, AFFECT-EU) European Union's Horizon 2020 research and innovation programme (grant agreement No 648131)

Risk prediction of atrial fibrillation and its complications in the community using high-sensitivity cardiac troponin I: results from the BiomarCaRE Consortium

Aims

Atrial fibrillation (AF) is becoming increasingly common and is associated with serious complications. Traditional cardiovascular risk factors (CVRF) do not explain all AF cases. Blood-based biomarkers reflecting cardiac injury may help close this gap. High-sensitivity troponin I (hsTnI) has emerged as a potential predictor.

Methods

We investigated the predictive ability of hsTnI for incident AF in 29,227 participants (median age 52.6 years, 51.2% men) across four different European community cohorts of the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) consortium in comparison to CVRF and established biomarkers (high-sensitive C-reactive protein (hsCRP), N-terminal pro B-type natriuretic peptide (NT-proBNP)).

Results

During a median follow-up of 13.8 (lower and upper quartiles 4.5, 21.3) years, 1,509 (5.2%) participants developed AF. Those in the highest fourth of hsTnI values at baseline (≥5.1 ng/L) had a 2.71-fold (95% confidence interval (CI) 2.31, 3.17; P&lt;0.01) risk for developing AF compared to those in the lowest fourth (≤2.1 ng/L). In multivariable-adjusted Cox proportional hazard models no statistically significant association was seen between hsTnI and AF, whereas NT-proBNP (hazard ratio (HR) per two-fold increase in NT-proBNP 1.64; 95% CI 1.56, 1.72; P&lt;0.001) as well as hsCRP (HR ratio per two-fold increase in hsCRP 1.05; 95% CI 1.01, 1.10; P=0.01) were statistically significantly related to incident AF. Inclusion of hsTnI did not improve model discrimination over CVRFs (C-index CVRF 0.7914 vs. C-index CVRF, hsTnI 0.7927; 95% CI −0.0004, 0.0031; P=0.130). Higher hsTnI concentrations were associated with AF complications such as stroke (HR 1.25; 95% CI 1.03, 1.51; P=0.02), heart failure (HR 1.27; 95% CI 1.12, 1.44; P&lt;0.001) and cardiovascular events (HR 1.24; 95% CI 1.08, 1.42; P&lt;0.001) as well as overall mortality (HR 1.15; 95% CI 1.05, 1.25; P&lt;0.001) in those who were diagnosed with AF.

Conclusion

hsTnI as a biomarker of myocardial injury does not improve prediction of AF incidence beyond classical CVRFs. However, it is associated with AF complications and mortality after AF onset probably reflecting underlying subclinical cardiovascular impairment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union Seventh Framework Programme (FP7/2007-2013

Chronic kidney disease and risk of atrial fibrillation and heart failure in general population-based cohorts – the BiomarCaRE project

Background

Chronic kidney disease (CKD) has a complicated relationship with the heart, leading to many adverse outcomes.

Purpose

The aim of the study was to evaluate the relationship between CKD and the incidence of atrial fibrillation (AF) and heart failure (HF) along with mortality as a competing risk in general population cohorts.

Methods

This study was conducted as part of the BiomarCaRE project using harmonised data from 12 population-based cohorts (n=40,212) from Europe. Cox proportional hazards models were used to determine hazard ratios (HRs) for the incidence of AF and HF in CKD and with competing mortality risk after adjusting for covariates.

Results

Mean age at baseline was 51.1 (standard deviation 11.9) years, and 49.3% were men. Overall, 3.5% had CKD at baseline. The rate for incident AF was 3.9 per 1000 person-years during follow-up. The HR for AF for those with CKD compared with those without was 1.23 (95% CI 1.00–1.52, p=0.0465) after adjustment for covariates. The rate for incident HF was 3.9 per 1000 person-years and the associated risk in the presence of CKD was HR 1.67 (95% CI 1.39–2.01). In subjects with CKD, N-terminal pro-B-type natriuretic peptide (NT-proBNP) showed an association with AF, while NT-proBNP and C-reactive protein (CRP) showed an association with HF.

Conclusion

CKD is an independent risk factor for subsequent AF and even more so for HF. In patients with CKD, NT-proBNP was clearly associated with subsequent risk of AF. In addition to this marker, hs-CRP was also associated with risk of subsequent HF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 7th framework programme collaborative project, grant agreement no. HEALTH-F2-2011_278913. Atrial Fibrillation and HF in CKD

Circulating Inflammation Markers Partly Explain the Link Between the Dietary Inflammatory Index and Depressive Symptoms

Background

Depression is a mood disorder characterized by a high rate of resistance to pharmacological treatments, which has often been linked to chronic inflammation. This can be influenced by different environmental factors, in particular pro-inflammatory diets. However, a mediating role of circulating inflammation has never been observed.

Aim

To test the association between a dietary inflammatory index (DII^®) and continuous depressive symptoms (adapted version of PHQ9) in an Italian population cohort (N=13,301), along with potential explanatory effect of a composite index (INFLA-score) based on four circulating inflammatory biomarkers: C-reactive protein, granulocyte-to-lymphocyte ratio, platelet and white blood cell counts.

Results

Significant positive associations were observed between DII and total depressive symptoms (standardized β (SE) = 0.038 (0.005), p < 0.001), and with two factors tagging somatic (0.012 (0.003), p < 0.001) and cognitive symptoms (0.012 (0.003), p < 0.001), after adjustment for different potential confounders (socioeconomic status, chronic health conditions and lifestyles). These associations were about twice as strong in women than in men. INFLA-score explained a small but significant proportion of the association with total depressive symptoms (0.90–2.30%, p < 0.05), which was mainly driven by granulocyte-to-lymphocyte ratio (1.18–1.65%). This effect was even stronger for the somatic (2.66–4.66%) but not for the cognitive factor (0%).

Conclusion

These findings support a strong link between inflammatory diet and depression, especially with somatic symptoms and within women. Moreover, they provide novel evidence for a potential explanatory role of circulating inflammation in this association, suggesting new paths for prevention and treatment of major and atypical depression.

Hydroxychloroquine and mortality in COVID-19 patients: a systematic review and a meta-analysis of observational studies and randomized controlled trials

Background: Hydroxychloroquine (HCQ) was proposed as potential treatment for COVID-19, but its association with mortality is unclear. We reviewed published literature for evidence of an association between HCQ (with or without azithromycin (AZM)) and total mortality in COVID-19 patients.Methods: Articles were retrieved until April 29th, 2021 by searching in seven databases. Data were combined using the general-variance-based method.Results: A total of 25 cohort studies (N=41,339 patients) and 11 randomized clinical trials (RCTs; N=8,709) were found. The use of HCQ was not associated with mortality in meta-analysis of RCTs (pooled risk ratio (PRR): 1.08, 95%CI: 0.97-1.20; I2=0%), but it was associated with 20% lower mortality risk (PRR=0.80, 95%CI: 0.69-0.93; I2=80%) in pooling of cohort studies. The negative association with mortality was mainly apparent by pooling cohort studies that used lower doses of HCQ (≤400 mg/day; PRR=0.69, 95%CI: 0.57-0.87). Use of HCQ+AZM (11 studies) was associated with 25% non-statistically significant lower mortality risk (PPR=0.75; 0.51-1.10; P=0.15). Use of HCQ was not associated with severe adverse events (PRR=1.12, 95%CI: 0.88-1.44; I2=0%).Conclusions: HCQ use was not associated with mortality in COVID-19 patients in pooling results from RCTs (high level of certainty of evidence), but it was associated with 20% mortality reduction when findings from observational studies were combined (low level of certainty of evidence). The reduction of mortality was mainly apparent in observational studies where lower doses of HCQ were used. These findings might help disentangling the debate on HCQ use in COVID-19.

Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels.

METHODS

We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level.

FINDINGS

In 2019, there were 12·2 million (95% UI 11·0-13·6) incident cases of stroke, 101 million (93·2-111) prevalent cases of stroke, 143 million (133-153) DALYs due to stroke, and 6·55 million (6·00-7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8-12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1-6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0-73·0), prevalent strokes increased by 85·0% (83·0-88·0), deaths from stroke increased by 43·0% (31·0-55·0), and DALYs due to stroke increased by 32·0% (22·0-42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0-18·0), mortality decreased by 36·0% (31·0-42·0), prevalence decreased by 6·0% (5·0-7·0), and DALYs decreased by 36·0% (31·0-42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0-24·0) and incidence rates increased by 15·0% (12·0-18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5-3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5-3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57-8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97-3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01-1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7-90·8] DALYs or 55·5% [48·2-62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3-48·6] DALYs or 24·3% [15·7-33·2]), high fasting plasma glucose (28·9 million [19·8-41·5] DALYs or 20·2% [13·8-29·1]), ambient particulate matter pollution (28·7 million [23·4-33·4] DALYs or 20·1% [16·6-23·0]), and smoking (25·3 million [22·6-28·2] DALYs or 17·6% [16·4-19·0]).

INTERPRETATION

The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.

FUNDING

Bill & Melinda Gates Foundation.

Diabetes status-related differences in risk factors and mediators of heart failure in the general population: results from the MORGAM/BiomarCaRE consortium

Background

The risk of heart failure among diabetic individuals is high, even under tight glycemic control. The correlates and mediators of heart failure risk in individuals with diabetes need more elucidation in large population-based cohorts with long follow-up times and a wide panel of biologically relevant biomarkers.

Methods

In a population-based sample of 3834 diabetic and 90,177 non-diabetic individuals, proportional hazards models and mediation analysis were used to assess the relation of conventional heart failure risk factors and biomarkers with incident heart failure.

Results

Over a median follow-up of 13.8 years, a total of 652 (17.0%) and 5524 (6.1%) cases of incident heart failure were observed in participants with and without diabetes, respectively. 51.4% were women and the mean age at baseline was 48.7 (standard deviation [SD] 12.5) years. The multivariable-adjusted hazard ratio (HR) for heart failure among diabetic individuals was 2.70 (95% confidence interval, 2.49–2.93) compared to non-diabetic participants. In the multivariable-adjusted Cox models, conventional cardiovascular disease risk factors, such as smoking (diabetes: HR 2.07 [1.59–2.69]; non-diabetes: HR 1.85 [1.68–2.02]), BMI (diabetes: HR 1.30 [1.18–1.42]; non-diabetes: HR 1.40 [1.35–1.47]), baseline myocardial infarction (diabetes: HR 2.06 [1.55–2.75]; non-diabetes: HR 2.86 [2.50–3.28]), and baseline atrial fibrillation (diabetes: HR 1.51 [0.82–2.80]; non-diabetes: HR 2.97 [2.21–4.00]) had the strongest associations with incident heart failure. In addition, biomarkers for cardiac strain (represented by nT-proBNP, diabetes: HR 1.26 [1.19–1.34]; non-diabetes: HR 1.43 [1.39–1.47]), myocardial injury (hs-TnI, diabetes: HR 1.10 [1.04–1.16]; non-diabetes: HR 1.13 [1.10–1.16]), and inflammation (hs-CRP, diabetes: HR 1.13 [1.03–1.24]; non-diabetes: HR 1.29 [1.25–1.34]) were also associated with incident heart failure. In general, all these associations were equally strong in non-diabetic and diabetic individuals. However, the strongest mediators of heart failure in diabetes were the direct effect of diabetes status itself (relative effect share 43.1% [33.9–52.3] and indirect effects (effect share 56.9% [47.7-66.1]) mediated by obesity (BMI, 13.2% [10.3–16.2]), cardiac strain/volume overload (nT-proBNP, 8.4% [-0.7–17.4]), and hyperglycemia (glucose, 12.0% [4.2–19.9]).

Conclusions

The findings suggest that the main mediators of heart failure in diabetes are obesity, hyperglycemia, and cardiac strain/volume overload. Conventional cardiovascular risk factors are strongly related to incident heart failure, but these associations are not stronger in diabetic than in non-diabetic individuals. Active measurement of relevant biomarkers could potentially be used to improve prevention and prediction of heart failure in high-risk diabetic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01378-4.

Exploring domains, clinical implications and environmental associations of a deep learning marker of biological ageing

Deep Neural Networks (DNN) have been recently developed for the estimation of Biological Age (BA), the hypothetical underlying age of an organism, which can differ from its chronological age (CA). Although promising, these population-specific algorithms warrant further characterization and validation, since their biological, clinical and environmental correlates remain largely unexplored. Here, an accurate DNN was trained to compute BA based on 36 circulating biomarkers in an Italian population (N = 23,858; age ≥ 35 years; 51.7% women). This estimate was heavily influenced by markers of metabolic, heart, kidney and liver function. The resulting Δage (BA-CA) significantly predicted mortality and hospitalization risk for all and specific causes. Slowed biological aging (Δage < 0) was associated with higher physical and mental wellbeing, healthy lifestyles (e.g. adherence to Mediterranean diet) and higher socioeconomic status (educational attainment, household income and occupational status), while accelerated aging (Δage > 0) was associated with smoking and obesity. Together, lifestyles and socioeconomic variables explained ~48% of the total variance in Δage, potentially suggesting the existence of a genetic basis. These findings validate blood-based biological aging as a marker of public health in adult Italians and provide a robust body of knowledge on its biological architecture, clinical implications and potential environmental influences.

Occupational class differences in ankle-brachial index and pulse wave velocity measurements to detect subclinical vascular disease

Background:

High pulse wave velocity (PWV) and low ankle brachial index (ABI) have been proposed as surrogate end-points for cardiovascular disease (CVD).

Objectives:

In a cross-sectional setting, we aimed at assessing the distributions of PWV and ABI among occupational classes (OC) in a population-based ever-employed salaried sample.

Methods:

We enrolled 1388 salaried CVD-free workers attending a CVD population-based survey, the RoCAV study, and classified them into four OC, based on current or last job title: manager/director (MD), non-manual (NMW), skilled-manual (SMW) and (UMW) unskilled-manual workers. We derived brachial-ankle PWV and ABI from four-limb blood pressures measurements, then carotid-femoral PWV (cfPWV) was estimated. We estimated the OC gradients in cfPWV and ABI using linear and logistic regression models.

Results:

Compared to MD (reference category), UMW had higher age- and BMI-adjusted cfPWV mean values both in men (0.63 m/s; 95%CI:0.11-1.16) and women (1.60 m/s; 0.43-2.77), only marginally reduced when adjusting for CVD risk factors. Decreased ABI mean values were also detected in lower OC. The overall detection rate of abnormal cfPWV (≥12 m/s) or ABI (≤0.9) values was 28%. Compared to MD, the prevalence of abnormal cfPWV or ABI was higher in NMW (OR=1.77; 95%CI:1.12-2.79), SMW (1.71; 1.05-2.78) and UMW (2.72; 1.65-4.50). Adjustment for CVD risk factors used in risk score equations did not change the results.

Discussion:

We found a higher prevalence of abnormal values of arterial stiffness measures in lower OC, and these differences were not explained by traditional CVD risk factors. These may be presumably determined by additional work- and environmental-related risk factors.

Use of multidimensional item response theory methods for dementia prevalence prediction: an example using the Health and Retirement Survey and the Aging, Demographics, and Memory Study

BACKGROUND

Data sparsity is a major limitation to estimating national and global dementia burden. Surveys with full diagnostic evaluations of dementia prevalence are prohibitively resource-intensive in many settings. However, validation samples from nationally representative surveys allow for the development of algorithms for the prediction of dementia prevalence nationally.

METHODS

Using cognitive testing data and data on functional limitations from Wave A (2001-2003) of the ADAMS study (n = 744) and the 2000 wave of the HRS study (n = 6358) we estimated a two-dimensional item response theory model to calculate cognition and function scores for all individuals over 70. Based on diagnostic information from the formal clinical adjudication in ADAMS, we fit a logistic regression model for the classification of dementia status using cognition and function scores and applied this algorithm to the full HRS sample to calculate dementia prevalence by age and sex.

RESULTS

Our algorithm had a cross-validated predictive accuracy of 88% (86-90), and an area under the curve of 0.97 (0.97-0.98) in ADAMS. Prevalence was higher in females than males and increased over age, with a prevalence of 4% (3-4) in individuals 70-79, 11% (9-12) in individuals 80-89 years old, and 28% (22-35) in those 90 and older.

CONCLUSIONS

Our model had similar or better accuracy as compared to previously reviewed algorithms for the prediction of dementia prevalence in HRS, while utilizing more flexible methods. These methods could be more easily generalized and utilized to estimate dementia prevalence in other national surveys.