A Large Randomized Individual and Group Intervention Conducted by Registered Dietitians Increased Adherence to Mediterranean-Type Diets: The PREDIMED Study

Avoiding weight gain in cardiometabolic disease: a systematic review

Patients with cardiometabolic disease are at higher risk for obesity-related adverse effects. Even without weight loss, weight maintenance may be beneficial. We performed a systematic review to identify the effect of nonweight loss-focused lifestyle interventions in adults with cardiometabolic disease. We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify comparative studies of lifestyle interventions (self-management, diet, exercise, or their combination) without a weight loss focus in adults with or at risk for diabetes and cardiovascular disease. Weight, BMI, and waist circumference at ≥12 months were the primary outcomes. Of 24,870 citations, we included 12 trials (self-management, n = 2; diet, n = 2; exercise, n = 2; combination, n = 6) studying 4,206 participants. Self-management plus physical activity ± diet versus minimal/no intervention avoided meaningful weight (-0.65 to -1.3 kg) and BMI (-0.4 to -0.7 kg/m(2)) increases. Self-management and/or physical activity prevented meaningful waist circumference increases versus control (-2 to -4 cm). In patients with cardiometabolic disease, self-management plus exercise may prevent weight and BMI increases and self-management and/or exercise may prevent waist circumference increases versus minimal/no intervention. Future studies should confirm these findings and evaluate additional risk factors and clinical outcomes.

Mediterranean diet improves cognition: the PREDIMED-NAVARRA randomised trial

OBJECTIVE

Previous observational studies reported beneficial effects of the Mediterranean diet (MedDiet) on cognitive function, but results were inconsistent. We assessed the effect on cognition of a nutritional intervention using MedDiets in comparison with a low-fat control diet.

METHODS

We assessed 522 participants at high vascular risk (44.6% men, age 74.6 ± 5.7 years at cognitive evaluation) enrolled in a multicentre, randomised, primary prevention trial (PREDIMED), after a nutritional intervention comparing two MedDiets (supplemented with either extra-virgin olive oil (EVOO) or mixed nuts) versus a low-fat control diet. Global cognitive performance was examined by Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) after 6.5 years of nutritional intervention. Researchers who assessed the outcome were blinded to group assignment. We used general linear models to control for potential confounding.

RESULTS

After adjustment for sex, age, education, Apolipoprotein E genotype, family history of cognitive impairment/dementia, smoking, physical activity, body mass index, hypertension, dyslipidaemia, diabetes, alcohol and total energy intake, participants allocated to the MedDiet+EVOO showed higher mean MMSE and CDT scores with significant differences versus control (adjusted differences: +0.62 95% CI +0.18 to +1.05, p=0.005 for MMSE, and +0.51 95% CI +0.20 to +0.82, p=0.001 for CDT). The adjusted means of MMSE and CDT scores were also higher for participants allocated to the MedDiet+Nuts versus control (adjusted differences: +0.57 (95% CI +0.11 to +1.03), p=0.015 for MMSE and +0.33 (95% CI +0.003 to +0.67), p=0.048 for CDT). These results did not differ after controlling for incident depression.

CONCLUSIONS

An intervention with MedDiets enhanced with either EVOO or nuts appears to improve cognition compared with a low-fat diet. ISRCTN:35739639.

A parallel randomized trial on the effect of a healthful diet on inflammageing and its consequences in European elderly people: design of the NU-AGE dietary intervention study

BACKGROUND

The proportion of European elderly is expected to increase to 30% in 2060. Combining dietary components may modulate many processes involved in ageing. So, it is likely that a healthful diet approach might have greater favourable impact on age-related decline than individual dietary components. This paper describes the design of a healthful diet intervention on inflammageing and its consequences in the elderly.

METHODS

The NU-AGE study is a parallel randomized one-year trial in 1250 apparently healthy, independently living European participants aged 65-80 years. Participants are randomised into either the diet group or control group. Participants in the diet group received dietary advice aimed at meeting the nutritional requirements of the ageing population. Special attention was paid to nutrients that may be inadequate or limiting in diets of elderly, such as vitamin D, vitamin B12, and calcium. C-reactive protein is measured as primary outcome.

DISCUSSION

The NU-AGE study is the first dietary intervention investigating the effect of a healthful diet providing targeted nutritional recommendations for optimal health and quality of life in apparently healthy European elderly. Results of this intervention will provide evidence on the effect of a healthful diet on the prevention of age related decline.

Factors associated with adherence to the Mediterranean diet in the adult population

Our aim was to analyze the variables associated with adherence to the Mediterranean diet in the adult population. We conducted a cross-sectional study in an established cohort of 1,553 healthy study participants (mean age=55 ± 14 years; 60.3% women). Mediterranean diet adherence was evaluated based on a 14-item questionnaire and the Mediterranean diet adherence screener, which defines adequate adherence as a score of ≥ 9. Physical activity was evaluated using the 7-day physical activity record. Sociodemographic, biological, and anthropometric variables were also evaluated. The differences between Mediterranean diet compliers and noncompliers are defined by the consumption of fruit, red meats, carbonated beverages, wine, fish/shellfish, legumes, pasta, and rice (P<0.01). Adherence was lower among individuals younger than 49 years of age. In the first age tertile, adherence was greater in women and in nonobese individuals, and the triglyceride levels were lower among compliers. In the second age tertile, the compliers exercised more and had a lower body fat percentage. In the third age tertile, the compliers also possessed less body fat. The logistic regression analysis revealed the following factors associated with improved Mediterranean diet adherence: more physical exercise (odds ratio=1.588), older age (odds ratio=2.162), and moderate alcohol consumption (odds ratio=1.342). The factors associated with improved Mediterranean diet adherence included female sex, age older than 62 years, moderate alcohol consumption, and more than 17 metabolic equivalents (METs)/h/wk of physical exercise. Poorer adherence was associated with males and obesity.

Mediterranean dietary pattern and depression: the PREDIMED randomized trial

BACKGROUND

A few observational studies have found an inverse association between adherence to a Mediterranean diet and the risk of depression. Randomized trials with an intervention based on this dietary pattern could provide the most definitive answer to the findings reported by observational studies. The aim of this study was to compare in a randomized trial the effects of two Mediterranean diets versus a low-fat diet on depression risk after at least 3 years of intervention.

METHODS

This was a multicenter, randomized, primary prevention field trial of cardiovascular disease (Prevención con Dieta Mediterránea (PREDIMED Study)) based on community-dwelling men aged 55 to 80 years and women aged 60 to 80 years at high risk of cardiovascular disease (51% of them had type 2 diabetes; DM2) attending primary care centers affiliated with 11 Spanish teaching hospitals. Primary analyses were performed on an intention-to-treat basis. Cox regression models were used to assess the relationship between the nutritional intervention groups and the incidence of depression.

RESULTS

We identified 224 new cases of depression during follow-up. There was an inverse association with depression for participants assigned to a Mediterranean diet supplemented with nuts (multivariate hazard ratio (HR) 0.78; 95% confidence interval (CI) 0.55 to 1.10) compared with participants assigned to the control group, although this was not significant. However, when the analysis was restricted to participants with DM2, the magnitude of the effect of the intervention with the Mediterranean diet supplemented with nuts did reach statistical significance (multivariate HR = 0.59; 95% CI 0.36 to 0.98).

CONCLUSIONS

The result suggest that a Mediterranean diet supplemented with nuts could exert a beneficial effect on the risk of depression in patients with DM2.

TRIAL REGISTRATION

This trial has been registered in the Current Controlled Trials with the number ISRCTN 35739639.

Primary prevention of cardiovascular disease with a Mediterranean diet

BACKGROUND

Observational cohort studies and a secondary prevention trial have shown an inverse association between adherence to the Mediterranean diet and cardiovascular risk. We conducted a randomized trial of this diet pattern for the primary prevention of cardiovascular events.

METHODS

In a multicenter trial in Spain, we randomly assigned participants who were at high cardiovascular risk, but with no cardiovascular disease at enrollment, to one of three diets: a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with mixed nuts, or a control diet (advice to reduce dietary fat). Participants received quarterly individual and group educational sessions and, depending on group assignment, free provision of extra-virgin olive oil, mixed nuts, or small nonfood gifts. The primary end point was the rate of major cardiovascular events (myocardial infarction, stroke, or death from cardiovascular causes). On the basis of the results of an interim analysis, the trial was stopped after a median follow-up of 4.8 years.

RESULTS

A total of 7447 persons were enrolled (age range, 55 to 80 years); 57% were women. The two Mediterranean-diet groups had good adherence to the intervention, according to self-reported intake and biomarker analyses. A primary end-point event occurred in 288 participants. The multivariable-adjusted hazard ratios were 0.70 (95% confidence interval [CI], 0.54 to 0.92) and 0.72 (95% CI, 0.54 to 0.96) for the group assigned to a Mediterranean diet with extra-virgin olive oil (96 events) and the group assigned to a Mediterranean diet with nuts (83 events), respectively, versus the control group (109 events). No diet-related adverse effects were reported.

CONCLUSIONS

Among persons at high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events. (Funded by the Spanish government's Instituto de Salud Carlos III and others; Controlled-Trials.com number, ISRCTN35739639.).

Virgin olive oil supplementation and long-term cognition: the PREDIMED-NAVARRA randomized, trial

OBJECTIVE

To assess the effect on cognition of a controlled intervention testing Mediterranean diets (MedDiet).

DESIGN

Randomized trial after 6.5 years of nutritional intervention.

SETTING

Eight primary care centers affiliated to the University of Navarra.

PARTICIPANTS

A random subsample of 285 participants (95 randomly allocated to each of 3 groups) of the PREDIMED-NAVARRA trial. All of them were at high vascular risk (44.8% men, 74.1±5.7 years at cognitive evaluation).

INTERVENTIONS

Nutritional intervention comparing two MedDiets (supplemented with extra-virgin olive oil [EVOO] or mixed nuts) versus a low-fat control diet. Participants received intensive education to increase adherence to the intended intervention. Participants allocated to the MedDiet groups received EVOO (1 l/week) or 30 g/day of mixed nuts. Dietary habits were evaluated using a validated 137-item food frequency questionnaire (FFQ). Additionally, adherence to MedDiet was appraised using a 14-item questionnaire both at baseline and yearly thereafter.

MEASUREMENTS

Cognitive performance as a main outcome and cognitive status (normal, mild cognitive impairment [MCI] or dementia) as a secondary outcome were evaluated by two neurologists blinded to group assignment after 6.5 years of nutritional intervention.

RESULTS

Better post-trial cognitive performance versus control in all cognitive domains and significantly better performance across fluency and memory tasks were observed for participants allocated to the MedDiet+EVOO group. After adjustment for sex, age, education, apolipoprotein E genotype, family history of cognitive impairment/dementia, smoking, physical activity, body mass index, hypertension, dyslipidaemia, diabetes, alcohol and total energy intake, this group also showed lower MCI (OR=0.34 95% CI: 0.12-0.97) compared with control group. Participants assigned to MedDiet+Nuts group did not differ from controls.

CONCLUSION

A long-term intervention with an EVOO-rich MedDiet resulted in a better cognitive function in comparison with a control diet. However, non-significant differences were found for most cognitive domains. Participants allocated to an EVOO-rich MedDiet had less MCI than controls.

A Mediterranean diet enriched with olive oil is associated with higher serum total osteocalcin levels in elderly men at high cardiovascular risk

BACKGROUND

The intake of olive oil has been related to the prevention of osteoporosis in experimental and in in vitro models. Very few prospective studies have evaluated the effects of olive oil intake on circulating osteocalcin (OC) in humans.

OBJECTIVE

The objective of the study was to examine the longitudinal effects of a low-fat control diet (n=34), a Mediterranean diet enriched with nuts (MedDiet+nuts, n=51), or a Mediterranean diet enriched with virgin olive oil (MedDiet+VOO, n=42) on circulating forms of OC and bone formation markers in elderly men at high cardiovascular risk.

DESIGN

Longitudinal associations between baseline and follow-up (2 yr) measurements of total OC, undercarboxylated osteocalcin, C-telopeptide of type I collagen, and procollagen I N-terminal propeptide (P1NP) concentrations were examined in 127 elderly men randomized to three healthy dietary interventions.

RESULTS

Baseline characteristics (age, body mass index, waist circumference, lipid profile, fasting insulin levels, and bone formation and resorption markers) were similar in all intervention groups. The total osteocalcin concentration increased robustly in the MedDiet+VOO group (P=0.007) in parallel to increased P1NP levels (P=0.01) and homeostasis model assessment-β-cell function (P=0.01) but not in subjects on the MedDiet+nuts (P=0.32) or after the control diet (P=0.74). Interestingly, the consumption of olives was associated positively with both baseline total osteocalcin (r=0.23, P=0.02) and the 2-yr osteocalcin concentrations (r=0.21, P=0.04) in the total cohort.

CONCLUSIONS

Consumption of a Mediterranean diet enriched with virgin olive oil for 2 years is associated with increased serum osteocalcin and P1NP concentrations, suggesting protective effects on bone.

Adherence to the Mediterranean dietary pattern and personality in patients attending a primary health center

Personality influences lifestyle behaviors, and particularly dietary behavior. The possible association of personality with adherence to the Mediterranean diet pattern (MDP) has not been reported. The objective of this study was to analyze the possible association of personality traits with adherence to the MDP, controlling for sociodemographic variables, presence of chronic illnesses, minor psychiatric morbidity, body mass index (BMI), daily smoking, and physical activity. This cross-sectional study included 206 patients, age 18 to 65 years, recruited at a primary health service in Granada, Spain, during 2007 to 2008. The participants answered a questionnaire, including sociodemographic characteristics, data on personality, and MDP. Personality was measured by the Temperament and Character Inventory (TCI-125). Adherence to MDP was measured using the validated 14-point Mediterranean Diet Adherence Screener (MEDAS). MEDAS score was directly associated with the character dimension of self-directedness, age, and minor psychiatric morbidity score; and inversely with marital status (widowed, separated, or divorced) and BMI. Because highly self-directed individuals may respond better to diet advice, consideration of personality may prove helpful in the design of interventions to enhance the adherence to MDP. To improve the adherence to MDP in interventions with patients with low self-directedness, more intensive professional support and counseling with tailored messages about the health benefits of MDP may be indicated.

A 14-item Mediterranean diet assessment tool and obesity indexes among high-risk subjects: the PREDIMED trial

OBJECTIVE

Independently of total caloric intake, a better quality of the diet (for example, conformity to the Mediterranean diet) is associated with lower obesity risk. It is unclear whether a brief dietary assessment tool, instead of full-length comprehensive methods, can also capture this association. In addition to reduced costs, a brief tool has the interesting advantage of allowing immediate feedback to participants in interventional studies. Another relevant question is which individual items of such a brief tool are responsible for this association. We examined these associations using a 14-item tool of adherence to the Mediterranean diet as exposure and body mass index, waist circumference and waist-to-height ratio (WHtR) as outcomes.

DESIGN

Cross-sectional assessment of all participants in the "PREvención con DIeta MEDiterránea" (PREDIMED) trial.

SUBJECTS

7,447 participants (55-80 years, 57% women) free of cardiovascular disease, but with either type 2 diabetes or ≥ 3 cardiovascular risk factors. Trained dietitians used both a validated 14-item questionnaire and a full-length validated 137-item food frequency questionnaire to assess dietary habits. Trained nurses measured weight, height and waist circumference.

RESULTS

Strong inverse linear associations between the 14-item tool and all adiposity indexes were found. For a two-point increment in the 14-item score, the multivariable-adjusted differences in WHtR were -0.0066 (95% confidence interval, -0.0088 to -0.0049) for women and -0.0059 (-0.0079 to -0.0038) for men. The multivariable-adjusted odds ratio for a WHtR>0.6 in participants scoring ≥ 10 points versus ≤ 7 points was 0.68 (0.57 to 0.80) for women and 0.66 (0.54 to 0.80) for men. High consumption of nuts and low consumption of sweetened/carbonated beverages presented the strongest inverse associations with abdominal obesity.

CONCLUSIONS

A brief 14-item tool was able to capture a strong monotonic inverse association between adherence to a good quality dietary pattern (Mediterranean diet) and obesity indexes in a population of adults at high cardiovascular risk.

The Mediterranean diet pattern and its main components are associated with lower plasma concentrations of tumor necrosis factor receptor 60 in patients at high risk for cardiovascular disease

Adherence to a Mediterranean diet (MD) is associated with a reduced risk of coronary heart disease. However, the molecular mechanisms involved are not fully understood. The aim of this study was to compare the effects of 2 MD with those of a low-fat-diet (LFD) on circulating inflammatory biomarkers related to atherogenesis. A total of 516 participants included in the Prevention with Mediterranean Diet Study were randomized into 3 intervention groups [MD supplemented with virgin olive oil (MD-VOO); MD supplemented with mixed nuts (MD-Nuts); and LFD]. At baseline and after 1 y, participants completed FFQ and adherence to MD questionnaires, and plasma concentrations of inflammatory markers including intercellular adhesion molecule-1(ICAM-1), IL-6, and 2 TNF receptors (TNFR60 and TNFR80) were measured by ELISA. At 1 y, the MD groups had lower plasma concentrations of IL-6, TNFR60, and TNFR80 (P < 0.05), whereas ICAM-1, TNFR60, and TNFR80 concentrations increased in the LFD group (P < 0.002). Due to between-group differences, participants in the 2 MD groups had lower plasma concentrations of ICAM-1, IL-6, TNFR60, and TNFR80 compared to those in the LFD group (P ≤ 0.028). When participants were categorized in tertiles of 1-y changes in the consumption of selected foods, those in the highest tertile of virgin olive oil (VOO) and vegetable consumption had a lower plasma TNFR60 concentration compared with those in tertile 1 (P < 0.02). Moreover, the only changes in consumption that were associated with 1-y changes in the geometric mean TNFR60 concentrations were those of VOO and vegetables (P = 0.01). This study suggests that a MD reduces TNFR concentrations in patients at high cardiovascular risk.

Reduced or modified dietary fat for preventing cardiovascular disease

BACKGROUND

Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear.

OBJECTIVES

To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration.

SEARCH METHODS

For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, were searched through to June 2010. References of Included studies and reviews were also checked.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed.

MAIN RESULTS

This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I(2) 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis.Few studies compared reduced with modified fat diets, so direct comparison was not possible.

AUTHORS' CONCLUSIONS

The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.

Virgin olive oil and nuts as key foods of the Mediterranean diet effects on inflammatory biomakers related to atherosclerosis

Previous epidemiological and feeding studies have observed that adherence to Mediterranean diet (Med-Diet) is associated with reduced cardiovascular risk. However, the molecular mechanisms involved are not fully understood. Since atherosclerosis is nowadays considered a low-grade inflammatory disease, recent studies have explored the anti-inflammatory effects of a Med-Diet intervention on serum and cellular biomarkers related to atherosclerosis. In two sub-studies of the PREDIMED (PREvencion con DIeta MEDiterranea) trial, we analyzed the effects at 3 months of two Med-Diet interventions supplemented with either virgin olive oil (VOO) or nuts compared with a control low-fat diet (LFD). Both Med-Diets showed an anti-inflammatory effect reducing serum C-reactive protein, interleukin-6 (IL6) and endothelial and monocytary adhesion molecules and chemokines (P<0.05; all), whereas these parameters increased after the LFD intervention (P<0.05; all). In another substudy, we evaluated the long-term (1 year) effects of these interventions on vascular risk factors in 516 high-risk subjects, as well as the effect of different Med-Diet components in the reduction of these biomarkers. At 1 year, the Med-Diet groups had significant decreases in the plasma concentrations of IL6, tumor necrosis factor receptor (TNFR) 60 and TNFR80 (P<0.05), while intercellular adhesion molecule 1 (ICAM-1), TNFR60 and TNFR80 concentrations increased in the LFD group (P<0.002). In addition, those allocated in the highest tertile of VOO and vegetables consumption had a significant diminution of plasma TNFR60 concentration compared with those in tertile 1 (P<0.02). In conclusion, Med-Diet exerts an anti-inflammatory effect on cardiovascular system since it down-regulates cellular and circulating inflammatory biomarkers related to atherogenesis in subjects at high cardiovascular risk.

Implementing Heart Healthy Dietary Guidelines

Over recent decades, abundant scientific evidence has led to authoritative dietary guidelines and recommendations for heart healthy eating and lifestyle behaviors. But most children and adults do not regularly achieve these goals. Consequently, our focus must now be on helping individual patients and our communities implement these guidelines in everyday life. This article reviews current evidence for insights and practical techniques that can help individuals move from ideal goals to real practice of heart healthy nutrition and lifestyle behaviors.

Adherence to Mediterranean diet and close dietetic supervision increase total dietary antioxidant intake and plasma antioxidant capacity in subjects with abdominal obesity

PURPOSE

To determine the effect of Mediterranean-type diet and close dietetic supervision on dietary antioxidant intake and plasma total antioxidant capacity (TAC) in patients with abdominal obesity.

METHODS

Ninety subjects with abdominal obesity, 46 in intervention group, 44 in control group, participated in a 2-month, randomized, parallel dietary intervention. All participants were counseled on Greek Mediterranean diet. The intervention group was under close dietetic supervision, followed a specific relevant daily and weekly food plan consuming antioxidant-rich foods and food products. Total dietary antioxidant intake was calculated from the volunteers' food diaries, and plasma TAC using plasma ORAC assay and plasma ferric-reducing antioxidant power (FRAP) assay, both at baseline and at 2 months.

RESULTS

Following the 2-month period, total dietary antioxidant intake was increased in the intervention group compared to the control group (P = 0.000). In addition, increased intake of total fat, due to higher consumption of monounsaturated fatty acids, as well as increased intakes of dietary fiber, vitamin C and alcohol was also observed in the intervention group compared to the control group (P < 0.05). Plasma TAC was increased in the intervention group compared to the control group (P = 0.039) using the ORAC assay, while there was a trend toward a TAC increase (P = 0.077) using the FRAP assay.

CONCLUSION

Adherence to a Mediterranean-type diet, with emphasis on an increase in foods rich in antioxidants and close dietetic supervision, can increase total dietary antioxidant intake and plasma TAC in patients with abdominal obesity.

The Mediterranean diet: effects on proteins that mediate fatty acid metabolism in the colon

A Mediterranean diet appears to have health benefits in many domains of human health, mediated perhaps by its anti-inflammatory effects. Metabolism of fatty acids and subsequent eicosanoid production is a key mechanism by which a Mediterranean diet can exert anti-inflammatory effects. Both dietary fatty acids and fatty acid metabolism determine fatty acid availability for cyclooxygenase- and lipoxygenase-dependent production of eicosanoids, namely prostaglandins and leukotrienes. In dietary intervention studies and in observational studies of the Mediterranean diet, blood levels of fatty acids do reflect dietary intakes but are attenuated. Small differences in fatty acid levels, however, appear to be important, especially when exposures occur over long periods of time. This review summarizes how fat intakes from a Greek-style Mediterranean diet can be expected to affect fatty acid metabolizing proteins, with an emphasis on the metabolic pathways that lead to the formation of proinflammatory eicosanoids. The proteins involved in these pathways are ripe for investigation using proteomic approaches and may be targets for colon cancer prevention.

Effect of Mediterranean diet on lipid peroxidation marker TBARS in obese patients with OSAHS under CPAP treatment: a randomised trial

PURPOSE

The aim of our study was to examine the possible effect of the Mediterranean diet on thiobarbituric acid reacting substances (TBARS) in obese patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS) who are under continuous positive airway pressure treatment.

METHODS

Nine hundred patients were evaluated during a 1-year period (November 2008-October 2009), and 21 obese patients who met the inclusion criteria, with moderate to severe OSAHS based on overnight attended polysomnography, were included in the study. After randomisation, 11 followed the Mediterranean diet and 10 a prudent diet for a 6-month period. TBARS were measured in serum.

RESULTS

TBARS levels decreased notably in both groups (p < 0.05), but no difference was observed between them (p > 0.05). There were significant differences in other characteristics. The Mediterranean diet group showed a greater reduction in weight (-10.8 ± 3.8), body mass index (-3.9 ± 1.6), waist circumference (-9.9 ± 3.0) and percentage of body fat (-4.7 ± 2.3) compared with the other group (-6.9 ± 3.1, -2.5 ± 1.0, -5.3 ± 2.6 and -2.2 ± 1.5, respectively; p < 0.05).

CONCLUSIONS

Our results showed that the Mediterranean diet did not reduce the TBARS more than the prudent diet.

Can the Mediterranean diet lower HbA1c in type 2 diabetes? Results from a randomized cross-over study

BACKGROUND AND AIMS

To investigate the impact of a diet modeled on the traditional Cretan Mediterranean diet on metabolic control and vascular risk in type 2 diabetes.

METHODS AND RESULTS

Twenty-seven subjects (47-77 yrs) with type 2 diabetes were randomly assigned to consume either the intervention diet ad libitum or their usual diet for 12 weeks and then cross over to the alternate diet. Most of the meals and staple foods for the intervention diet were provided. Lipids, glycemic variables, blood pressure, homocysteine, C-reactive protein, plasma carotenoids and body composition (anthropometry and dual energy X-ray absorptiometry) were assessed at baseline, and at the end of both diet periods. Dietary adherence was monitored using plasma carotenoid and fatty acid (FA) analysis, complemented by diet diaries. Compared with usual diet, on the ad libitum Mediterranean intervention diet glycosylated haemoglobin fell from 7.1% (95% CI: 6.5-7.7) to 6.8% (95% CI: 6.3-7.3) (p=0.012) and diet quality improved significantly [plant:animal (g/day) food ratio increased from 1.3 (95% CI: 1.1-1.5) to 5.4 (95% CI: 4.3-6.6) (p<0.001)], plasma lycopene and lutein/zeaxanthin increased (36% and 25%, respectively), plasma saturated and trans FAs decreased, and monounsaturated FAs increased.

CONCLUSION

A traditional moderate-fat Mediterranean diet improves glycemic control and diet quality in men and women with well-controlled type 2 diabetes, without adverse effects on weight.

Reduced or modified dietary fat for preventing cardiovascular disease

BACKGROUND

Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear.

OBJECTIVES

To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration.

SEARCH STRATEGY

For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, were searched through to June 2010. References of Included studies and reviews were also checked.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed.

MAIN RESULTS

This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I(2) 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis.Few studies compared reduced with modified fat diets, so direct comparison was not possible.

AUTHORS' CONCLUSIONS

The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.

Nut consumption, weight gain and obesity: Epidemiological evidence

BACKGROUND AND AIMS

Short-term trials support that adding tree nuts or peanuts to usual diets does not induce weight gain. We reviewed the available epidemiological evidence on long-term nut consumption and body weight changes. We also report new results from the SUN ("Seguimiento Universidad de Navarra") cohort.

METHODS AND RESULTS

Published epidemiologic studies with ≥1-yr follow-up were located. Two published reports from large cohorts (SUN and Nurses Health Study-2) showed inverse associations between frequency of nut consumption and long-term weight changes. A beneficial effect of a Mediterranean diet supplemented with tree nuts on waist circumference was reported after 1-yr follow-up in the first 1224 high-risk participants in the PREDIMED ("PREvencion DIeta MEDiterranea") trial. After assessing 11,895 participants of the SUN cohort, a borderline significant (p value for trend = 0.09) inverse association between baseline nut consumption and average yearly weight gain (multivariate-adjusted means = 0.32 kg/yr (95% confidence interval: 0.22-0.42) and 0.24 (0.11-0.37) kg/yr for participants with no consumption and >4 servings/week, respectively) was found after a 6-yr follow-up.

CONCLUSIONS

Consumption of nuts was not associated with a higher risk of weight gain in long-term epidemiologic studies and clinical trials.

A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women

Ensuring the accuracy of dietary assessment instruments is paramount for interpreting diet-disease relationships. The present study assessed the relative and construct validity of the 14-point Mediterranean Diet Adherence Screener (MEDAS) used in the Prevención con Dieta Mediterránea (PREDIMED) study, a primary prevention nutrition-intervention trial. A validated FFQ and the MEDAS were administered to 7146 participants of the PREDIMED study. The MEDAS-derived PREDIMED score correlated significantly with the corresponding FFQ PREDIMED score (r = 0.52; intraclass correlation coefficient = 0.51) and in the anticipated directions with the dietary intakes reported on the FFQ. Using Bland Altman's analysis, the average MEDAS Mediterranean diet score estimate was 105% of the FFQ PREDIMED score estimate. Limits of agreement ranged between 57 and 153%. Multiple linear regression analyses revealed that a higher PREDIMED score related directly (P < 0.001) to HDL-cholesterol (HDL-C) and inversely (P < 0.038) to BMI, waist circumference, TG, the TG:HDL-C ratio, fasting glucose, and the cholesterol:HDL-C ratio. The 10-y estimated coronary artery disease risk decreased as the PREDIMED score increased (P < 0.001). The MEDAS is a valid instrument for rapid estimation of adherence to the Mediterranean diet and may be useful in clinical practice.

Total polyphenol excretion and blood pressure in subjects at high cardiovascular risk

BACKGROUND AND AIMS

Dietary factors are critical for the prevention and treatment of hypertension, but data on the effects of specific nutrients on blood pressure (BP) are scarce. The aim of this study was to assess the relationship between total polyphenol excretion (TPE) in urine, as an objective measurement of total polyphenol intake and BP in an elderly population at high cardiovascular risk.

METHODS AND RESULTS

Cross-sectional substudy of 589 high-risk participants entering in the PREDIMED trial. BP was measured and TPE was determined in urine by Folin-Ciocalteu assay. A significant positive association was observed between TPE in urine and daily intake of fruit and vegetables (F&V), coffee or wine after adjusting for potential confounders. The intake of 100 g of F&V (Beta=0.150;P<0.001) had a greater contribution to TPE than 100 mL of coffee (Beta=0.141;P=0.001), and the latter two foods contributed more than the consumption of 100 mL of wine (Beta=0.120;P=0.019). An inverse association was observed between urinary TPE and the prevalence of hypertension. Participants in the highest quartile of urinary TPE had a reduced prevalence of hypertension compared to those in the lowest quartile (Odds Ratio=0.64; 95% confidence interval 0.45 to 0.92; P=0.015). Systolic and diastolic BP were inversely associated with urinary TPE after adjustment for potential confounders (P=0.024 and P=0.003, respectively).

CONCLUSIONS

Polyphenol intake, assessed via TPE in urine, was negatively associated with BP levels and prevalence of hypertension in an elderly Mediterranean population at high cardiovascular risk. Participants with the highest intake of polyphenol-rich foods showed the lowest BP measurements.

Olive oil in the primary prevention of cardiovascular disease

Ischemic heart disease is the leading cause of mortality worldwide. Many mechanistic reasons support that a high consumption of olive oil may provide a protection against myocardial infarction, the hallmark of ischemic heart disease. International comparisons are also consistent with this hypothesis. Surprisingly, there is not much evidence coming from analytical epidemiological studies about this issue. A case-control study conducted at the University of Navarra (Spain) found a strong inverse association between olive oil consumption and the risk of a first non-fatal myocardial infarction. Subsequently a large cohort in Italy and another case-control study conducted in Greece also found inverse associations. However, no complete consistency exists and further prospective studies and trials are being implemented in order to obtain more complete evidence.

A Mediterranean diet rich in virgin olive oil may reverse the effects of the -174G/C IL6 gene variant on 3-year body weight change

Only a few studies have analyzed the effects of the potential interaction between the -174G/C polymorphism of IL6 gene and the adherence to the Mediterranean diet (MD) on adiposity indexes. Our aim was to investigate the interplay between the -174G/C polymorphism of the IL6 gene and a Mediterranean-style diet on body weight changes after 3 years of nutritional intervention in a high cardiovascular risk population. A total of 737 participants, aged 55-80 years were assigned to a low-fat diet or to a Mediterranean-style diet group with high intake of virgin olive oil (VOO) or nuts. Anthropometric measurements were taken at baseline and after 3-year follow-up. The -174G/C polymorphism of the IL6 gene was genotyped. Minor allele frequency (C) was 0.39. At baseline, the CC genotype was associated with higher measures of adiposity. After 3 years, a significant interaction (p=0.028) was found between the polymorphism (GG+GC versus CC) and the nutritional intervention: CC subjects following the MD+VOO had the lowest body weight gain. In conclusion, at baseline, CC subjects for the -174G/C polymorphism of IL6 had the highest body weight and BMI. However, after 3 years of nutritional intervention with MD+VOO, these subjects were predicted to have the greatest reduction in body weight.

Herbals used for diabetes, obesity, and metabolic syndrome

Diabetes mellitus and particularly noninsulin-dependent diabetes (type 2 diabetes) is an increasingly prevalent condition worldwide with serious consequences of multiorgan involvement and in particular cardiovascular and renal disease. Obesity is a significant risk factor for type 2 diabetes, and its incidence has doubled in the past 2 decades among younger adults, adolescents, and children globally. Inflammation and insulin resistance are the underlying mechanisms for metabolic syndrome (MetS) and its increased risk of cardiovascular, renal, and pulmonary morbidity and mortality. MetS is affecting younger populations with adverse consequences seen in later years. Dietary supplements and herbals are often marketed for these conditions. This article review common herbals and supplements marketed or used by patients with diabetes, obesity, and MetS.

Eating competence of elderly Spanish adults is associated with a healthy diet and a favorable cardiovascular disease risk profile

Eating competence (EC), a bio-psychosocial model for intrapersonal approaches to eating and food-related behaviors, is associated with less weight dissatisfaction, lower BMI, and increased HDL-cholesterol in small U.S. studies, but its relationship to nutrient quality and overall cardiovascular risk have not been examined. Prevención con Dieta Mediterránea (PREDIMED) is a 5-y controlled clinical trial evaluating Mediterranean diet efficacy on the primary prevention of cardiovascular diseases (CVD) in Spain. In a cross-sectional study, 638 PREDIMED participants (62% women, mean age 67 y) well phenotyped for cardiovascular risk factors were assessed for food intake and EC using validated questionnaires. Overall, 45.6% were eating-competent. EC was associated with being male and energy intake (P < 0.01). After gender and energy adjustment, participants with EC compared with those without showed higher fruit intake and greater adherence to the Mediterranean diet (P < 0.05) and tended to consume more fish (P = 0.076) and fewer dairy products (P = 0.054). EC participants tended to have a lower BMI (P = 0.057) and had a lower fasting blood glucose concentration and serum LDL-:HDL-cholesterol ratio (P < 0.05) and a higher HDL-cholesterol concentration (P = 0.025) after gender adjustment. EC participants had lower odds ratios (OR) of having a blood glucose concentration >5.6 mmol/L (0.71; 95% CI 0.51-0.98) and HDL-cholesterol <1.0 mmol/L (0.70; 95% CI 0.68-1.00). The OR of actively smoking, being obese, or having a serum LDL-cholesterol concentration > or =3.4 mmol/L were <1.0, but the 95% CI included the 1.0 (P > 0.1). Our findings support further examination of EC as a strategy for enhancing diet quality and CVD prevention.

The cumulative effect of small dietary changes may significantly improve nutritional intakes in free-living children and adults

BACKGROUND/OBJECTIVES

The ELPAS (Etude Longitudinale Prospective Alimentation et Santé) study was an 8-month randomized controlled dietary modification trial designed to test the hypothesis that family dietary coaching would improve nutritional intakes and weight control in 2026 free-living children and parents. It resulted in significant nutritional changes, with beneficial effects on body mass index in adults. In these ancillary analyses, we investigated dietary changes throughout the intervention.

SUBJECTS/METHODS

Before the study, modeling analyses were carried out on the French Association Sucre Produits Sucrés Consommation et Communication (ASPCC) food-consumption database to identify the most efficient dietary intervention strategy. During the study, all participants performed monthly three nonconsecutive 24-h dietary recalls: this allowed for measuring changes in the number of servings per day and serving size for each targeted food category throughout the intervention.

RESULTS

Modeling analyses showed that targeting only the 10 main foods contributing to fat and carbohydrate intakes did not allow for reaching the ELPAS nutritional goals. As a result, it was decided to target more foods and to propose several types of dietary advice (such as change in serving size, change in cooking method, food substitution). This strategy led to many appropriate dietary changes during the intervention, but only a few of them reached significance. The mean number of servings per day was indeed significantly modified for only 7% of the targeted food categories in children and 17% in parents. The mean serving size was modified for only 12% of targeted food categories in children and 9% in parents.

CONCLUSIONS

The cumulative effect of small dietary changes may induce significant nutritional improvements, with limited burden for populations.

Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain

The aim of the present study was to assess reproducibility and relative validity of a self-administered FFQ used in the PREDIMED Study, a clinical trial for primary prevention of CVD by Mediterranean diet in a population at high cardiovascular risk. The FFQ was administered twice (FFQ1 and FFQ2) to explore reproducibility at 1 year. Four 3 d dietary records (DR) were used as reference to explore validity; participants therefore recorded their food intake over 12 d in the course of 1 year. The degree of misclassification in the FFQ was also evaluated by a contingency table of quintiles comparing the information from the FFQ2 and the DR. A total of 158 men and women (aged 55-80 years) were asked not to modify their dietary habits during the study period. Reproducibility for food groups, energy and nutrient intake, explored by the Pearson correlation coefficient (r) ranged 0.50-0.82, and the intraclass correlation coefficient (ICC) ranged from 0.63 to 0.90. The FFQ2 tended to report higher energy and nutrient intake than the DR. The validity indices of the FFQ in relation to the DR for food groups and energy and nutrient intake ranged (r) from 0.24 to 0.72, while the range of the ICC was between 0.40 and 0.84. With regard to food groups, 68-83 % of individuals were in the same or adjacent quintile in both methods, a figure which decreased to 55-75 % for energy and nutrient intake. We concluded that FFQ measurements had good reproducibility and a relative validity similar to those of FFQ used in other prospective studies.

A 3-year Mediterranean-style dietary intervention may modulate the association between adiponectin gene variants and body weight change

PURPOSE

Adiponectin gene variations have been associated with obesity. There are few interventional studies analyzing this association. The aim of this study was to analyze the effects of a nutritional intervention with Mediterranean-style diet and three (-4034A/C, +45T/G, and +276 G/T) adiponectin gene variants on 3-year body weight changes in high cardiovascular risk patients.

SUBJECTS AND METHODS

A total of 737 participants, aged 55-80 at high cardiovascular risk were assigned to a low-fat diet or to a Mediterranean-style diet (MD) groups, one with high intake of virgin olive oil (VOO) and the other with high intake of nuts. Anthropometric parameters were taken at baseline and after 3-year follow-up, and the genotyping of the -4034A/C, +45T/G, and +276 G/T polymorphisms was done.

RESULTS

GG genotype of the +45T/G polymorphism was associated with 3-year higher body weight gain (B = 1.399; B = 0.043). TT genotype of the +276G/T polymorphism was linked to the highest 3-year body weight gain in men. Both Mediterranean diets appeared to reverse this effect (p for interaction = 0.053).

CONCLUSION

Adiponectin gene variation appeared to be associated with 3-year body weight changes in a high cardiovascular risk population. This association may be modulated by a nutritional intervention with a Mediterranean-style diet.

Session 4: CVD, diabetes and cancer Evidence for the use of the Mediterranean diet in patients with CHD

Diet is associated with the development of CHD. The incidence of CHD is lower in southern European countries than in northern European countries and it has been proposed that this difference may be a result of diet. The traditional Mediterranean diet emphasises a high intake of fruits, vegetables, bread, other forms of cereals, potatoes, beans, nuts and seeds. It includes olive oil as a major fat source and dairy products, fish and poultry are consumed in low to moderate amounts. Many observational studies have shown that the Mediterranean diet is associated with reduced risk of CHD, and this result has been confirmed by meta-analysis, while a single randomised controlled trial, the Lyon Diet Heart study, has shown a reduction in CHD risk in subjects following the Mediterranean diet in the secondary prevention setting. However, it is uncertain whether the benefits of the Mediterranean diet are transferable to other non-Mediterranean populations and whether the effects of the Mediterranean diet will still be feasible in light of the changes in pharmacological therapy seen in patients with CHD since the Lyon Diet Heart study was conducted. Further randomised controlled trials are required and if the risk-reducing effect is confirmed then the best methods to effectively deliver this public health message worldwide need to be considered.

Reduction in systemic and VLDL triacylglycerol concentration after a 3-month Mediterranean-style diet in high-cardiovascular-risk subjects

The first results of the PREDIMED (PREvencion con Dieta MEDiterranea) randomized trial, after 3-month intervention, showed that the Mediterranean Diet (MD), supplemented with either virgin olive oil (VOO) or nuts, reduced systolic blood pressure, serum cholesterol and triacylglycerol (TG) concentrations and increased high-density lipoprotein (HDL)-cholesterol when compared to a control (low-fat diet) group. Serum TG levels are an independent risk factor for coronary heart disease and are strongly determined by very low-density lipoprotein (VLDL) composition, which can be specifically modified by dietary lipid source. Within the context of the PREDIMED study, we assessed the VLDL composition in 50 participants after 3 months of intake of two MD, supplemented with VOO or nuts, compared with a low-fat diet. Total and low-density lipoprotein cholesterol concentrations were reduced in subjects on the MD+nuts, whereas HDL-cholesterol increased after consumption of the MD+VOO. Serum TG concentrations were significantly lowered in both intervention groups (either the MD+nuts or MD+VOO). However, only the MD+VOO reduced the VLDL-cholesterol and VLDL-TG content and the TG/apolipoprotein B ratio in VLDL, which was used to estimate particle size. Although VLDL-TG fatty acids were very slightly modified, VLDL-TG molecular species in VLDL after consumption of the MD+nuts were characterized by a higher presence of linoleic acid (18:2, n-6), whereas after the intake of MD+VOO, they were rich in oleic acid (18:1, n-9). Therefore, we conclude that the reduction in systemic TG concentrations observed after consumption of the MD may be explained by reduction of the lipid core of VLDL and a selective modification of the molecular species composition in the particle.

A 3-year intervention with a Mediterranean diet modified the association between the rs9939609 gene variant in FTO and body weight changes

INTRODUCTION

The aim of this study was to analyze the effects of the rs9939609 (T/A) gene variant in fat mass and obesity-associated gene (FTO) on body weight changes after 3 years and its modification by a randomized nutritional intervention with a Mediterranean-style diet in a population of subjects at high cardiovascular risk.

DESIGN

A substudy of PREDIMED, which is a randomized trial aimed at assessing the effect of the Mediterranean diet (MD) for primary cardiovascular disease prevention. There were three nutritional intervention groups: two of them with a Mediterranean-style diet and the third was a control group advised to follow a conventional low-fat diet.

SUBJECTS

A total of 776 high cardiovascular risk subjects aged 55-80 years.

MEASUREMENTS

Anthropometric measurements were recorded at baseline and at 3 years. The participants were genotyped by RT-PCR, followed by allelic discrimination.

RESULTS

Homozygous subjects had the highest baseline body weight. The dominant model showed that subjects carrying the A allele had the lowest body weight gain (B=-0.685; P=0.022) after 3 years of nutritional intervention compared with nonmutated subjects (TT genotype) regardless of the nutritional intervention. Moreover, this effect was statistically significant in carriers of the A allele only among those allocated to the MD groups (B=-0.830; P=0.018), but it was not significant among those allocated to the control group (P for interaction=0.649).

CONCLUSION

This study confirmed the association between body weight and the FTO rs9939609 polymorphism. Interestingly, our results showed that, although at baseline the A allele was associated with higher body weight, after 3 years of nutritional intervention with a Mediterranean-style-diet, A-allele carriers had lower body weight gain than wild type subjects. No interaction between nutritional intervention and the polymorphism was found.

The Mediterranean diet protects against waist circumference enlargement in 12Ala carriers for the PPARγ gene: 2 years' follow-up of 774 subjects at high cardiovascular risk

The PPARγ gene regulates insulin sensitivity and adipogenesis. The Pro12Ala polymorphism of this gene has been related to fat accumulation. Our aim was to analyse the effects of a 2-year nutritional intervention with Mediterranean-style diets on adiposity in high-cardiovascular risk patients depending on the Pro12Ala polymorphism of the PPARγ gene. The population consisted of a substudy (774 high-risk subjects aged 55–80 years) of the Prevención con Dieta Mediterránea (PREDIMED) randomised trial aimed at assessing the effect of the Mediterranean diet for CVD prevention. There were three nutritional intervention groups: two of them of a Mediterranean-style diet and the third was a control group advised to follow a conventional low-fat diet. All the participants were genotyped by PCR-restriction fragment length polymorphism (RFLP). The results showed that carriers of the 12Ala allele allocated to the control group had a statistically significant higher change in waist circumference (adjusted difference coefficient = 2·37 cm; P = 0·014) compared with wild-type subjects after 2 years of nutritional intervention. This adverse effect was not observed among 12Ala carriers allocated to both Mediterranean diet groups. In diabetic patients a statistically significant interaction between Mediterranean diet and the 12Ala allele regarding waist circumference change was observed ( − 5·85 cm; P = 0·003). In conclusion, the Mediterranean diet seems to be able to reduce waist circumference in a high-cardiovascular risk population, reversing the negative effect that the 12Ala allele carriers of the PPARγ gene appeared to have. The beneficial effect of this dietary pattern seems to be higher among type 2 diabetic subjects.

Initiative for a new diabetes therapeutic approach in a Mediterranean country: the INDEED study

AIM

To assess the efficacy of a strategy to improve vascular risk management in patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a pilot best practice implementation enhancement programme that enrolled 578 patients with T2DM. A baseline visit was followed by a concerted effort from previously trained physicians to improve adherence to lifestyle advice and optimise drug treatment for all vascular risk factors. The patients were followed-up for 6 months. The UKPDS risk engine was used to estimate vascular risk in patients without established coronary heart disease (CHD) (n = 279).

RESULTS

There was an improvement in compliance to lifestyle measures and increased prescription of evidence-based medication. In patients without established CHD there was a 37% reduction in estimated risk for CHD, 44% for fatal CHD, 10% for stroke and 25% for fatal stroke (p < or = 0.003 for all comparisons vs. baseline). There was also a substantial increase in the proportion of patients with established CHD who achieved their vascular risk factor targets.

CONCLUSIONS

This is the first study to increase the adherence to multiple interventions in patients with T2DM in both primary care and hospital settings. Education of physicians and patients, distribution of guidelines/brochures, and the completion of a one-page form, motivated both physicians and patients to achieve multiple vascular risk factor goals.

Close adherence to a Mediterranean diet improves endothelial function in subjects with abdominal obesity

BACKGROUND

Abdominal obesity (AO) is associated with increased risk of cardiovascular disease and type 2 diabetes, whereas the Mediterranean diet exerts a cardioprotective effect.

OBJECTIVE

We examined whether a close adherence to a Mediterranean-style diet improves endothelial function in individuals with AO.

DESIGN

We recruited 90 subjects with AO without cardiovascular disease or type 2 diabetes. Participants were randomly assigned to the intervention or control group. Both groups were instructed to follow a Mediterranean-style diet for 2 mo. Subjects in the intervention group additionally had to follow a specific relevant daily and weekly food plan with close supervision by a dietitian and provision of basic foods. Flow-mediated dilatation (FMD), lipids, C-reactive protein (CRP), and insulin resistance with the homeostasis model assessment (HOMA-IR) were measured.

RESULTS

After 2 mo, subjects in the intervention group increased their intake of total fat due to higher consumption of monounsaturated fatty acids as well as intakes of dietary fiber, vitamin C, and alcohol compared with the control group (all P < 0.05). The intervention group also increased FMD ( 2.05%; 95% CI: 0.97, 3.13%), whereas no effect was found in the control group (-0.32%; 95% CI: -1.31, 0.67%). Changes in lipids and CRP concentrations did not differ between the 2 groups, whereas diastolic blood pressure decreased in the intervention group (-6.44 mm Hg; 95% CI: -8.57, -4.31 mm Hg) compared with the control group (-0.76 mm Hg; 95% CI: -2.83, 1.31 mm Hg). Finally, there was a trend for a reduction in HOMA-IR in the intervention group compared with the control group (P = 0.072).

CONCLUSION

Close adherence to a Mediterranean-style diet achieved by close dietetic supervision improves endothelial function in subjects with AO.