Risk of peripheral artery disease according to a healthy lifestyle score: The PREDIMED study

Association between Mediterranean diet adherence and peripheral artery disease in type 2 diabetes mellitus: An observational study

INTRODUCTION

To evaluate the relationship between adherence to the Mediterranean diet (MD) and periphereal artery disease (PAD) in patients with type 2 diabetes mellitus (T2DM).

METHODS

An observational sectional study was conducted with 174 patients diagnosed with T2DM, of which 78 patients had PAD. A patient was considered to have PAD if they obtained an ankle-brachial index (ABI) < 0.9 and/or absence of both distal pulses in one of the two feet. Data on sociodemographic and anthropometric variables, physical activity, smoking habits, biochemical blood parameters, and comorbidities were recorded. Good adherence to the MD was considered with a score ≥ 9 in MEDAS-14. Vascular factors independently associated with adherence to the MD in patients with T2DM were identified through multivariate logistic regression analysis.

RESULTS

ABI, DFU, intermittent claudication and pedal pulse absence correlated with MD adherence. DFU, intermittent claudication and posterior tibial pulse absence were associated with the final score obtained in the MEDAS-14. Nut consumption, white meat preference and sautéed dish intake were associated with PAD presence. Multivariate analysis linked MD adherence to sex (OR = 0.044, 95 % CI 0.003-0619), age (OR = 0.139, 95 % CI 0.029-0.666), duration of T2DM (OR = 7.383, 95 % CI 1.523-35.779) and age at diagnosis of T2DM (OR = 6082, 95 % IC 1.415-26.136), as well as the presence of DFU (OR = 0.000, 95 % IC 0.000-0.370) and intermittent claudication (OR = 0.004, 95 % IC 0.000-0.534).

CONCLUSIONS

Adherence to the MD is associated with a reduction in vascular complications in T2DM, highlighting its potential as a dietary intervention strategy.

Association between essential metals, adherence to healthy lifestyle behavior, and ankle-brachial index

BACKGROUND

Ankle-brachial index (ABI) is a noninvasive diagnostic method for peripheral arterial disease (PAD) and a predictor of cardiovascular events.

OBJECTIVE

The present study aimed to evaluate the association between individual or combined essential metals and ABI, as well as assess the collective impact of essential metals when coupled with healthy lifestyle on ABI.

METHODS

A total of 2865 participants were recruited in Wuhan Tongji Hospital between August 2018 and March 2019. Concentrations of essential metals in urine were measured by inductively coupled plasma mass spectrometer.

RESULTS

The results of general linear regression models demonstrated that after adjusting for confounding factors, there was a positive association between ABI increase and per unit increase of log 10-transformed, creatinine-corrected urinary Cr (β (95 % CI): 0.010 (0.004, 0.016), PFDR = 0.007), Fe (β (95 % CI): 0.010 (0.003, 0.017), PFDR = 0.018), and Co (β (95 % CI): 0.013 (0.005, 0.021), PFDR = 0.007). The WQS regression revealed a positive relationship between the mixture of essential metals and ABI (β (95 % CI): 0.006 (0.003, 0.010), P < 0.001), with Cr and Co contributing most to the relationship (weighted 45.48 % and 40.14 %, respectively). Compared to individuals with unfavorable lifestyle and the lowest quartile of Cr, Fe and Co, those with favorable lifestyle and the highest quartile of Cr, Fe and Co exhibited the most increase in ABI (β (95 % CI): 0.030 (0.017, 0.044) for Cr, β (95 % CI): 0.027 (0.013, 0.040) for Fe, and β (95 % CI): 0.030 (0.016, 0.044) for Co).

CONCLUSION

In summary, our study indicates that adequate essential metal intake together with healthy lifestyle behaviors perform crucial roles in PAD protection.

Nutritional habits in patients with peripheral arterial disease: Adherence to the mediterranean diet

INTRODUCTION

Adherence to the Mediterranean diet (Dietmed) exerts protective effects on cardiovascular disease (CVD). In the Lower Extremity Peripheral Arterial Disease (PAD) there are fewer studies that analyze these data.

OBJECTIVE

To determine adherence to Dietmed and dietary habits in patients with PAD, according to a history of CVD (coronary and/or cerebral ischaemic pathology) and according to the ankle-brachial index (ABI ≥ or <0,5).

MATERIAL AND METHODS

Cross-sectional analytical study carried out in a tertiary hospital. The sample was collected consecutively. Sociodemographic and clinical history, ankle-brachial index (ABI) and a 14-point Dietmed adherence dietary questionnaire were included. The analysis of categorical variables was carried out using the Pearson's Chi-Square test, the T-Student's statistic test for independent samples was used for parametric variables and the U. Mann-Whitney test for non-parametric variables.

RESULTS

Of the 97 patients, 87,6% had low adherence to Dietmed, with no differences according to the severity of PAD. However, when we analysed the data according to whether or not they had a history of CVD, we observed a high adherence to some items included in Dietmed, specifically, in the CVD group, the consumption of lean meat (95,5% vs 64%; P=.004). In addition, we observed a significant difference in the consumption in the group without a history of CVD (32% vs 9,1%; P=.033).

CONCLUSION

In our population, patients with PAD, regardless of the stage of the disease and whether they had associated coronary or cerebral ischaemic pathology, had low adherence to Dietmed. Therefore, it is important to implement nutritional education programmes in patients with PAD in all stages, as well as in those patients who have already suffered a vascular event, so that they maintain adherence to healthy dietary habits in the long term.

Medical Therapy for Peripheral Artery Disease

PURPOSE OF REVIEW

Patients with lower extremity peripheral artery disease (PAD) are at high risk for major adverse cardiovascular events (MACE) and major adverse limb events (MALE). This manuscript will review the current evidence for medical therapy in patients with PAD according to different clinical features and the overall cardiovascular (CV) risk.

RECENT FINDINGS

The management of PAD encompasses non-pharmacologic strategies, including lifestyle modification such as smoking cessation, supervised exercise, Mediterranean diet and weight loss as well as pharmacologic interventions, particularly for high risk patients. Benefits for reduction of CV and limb outcomes have been demonstrated for new therapies, including antithrombotic therapy (i.e., low-dose rivaroxaban plus aspirin), lipid lowering therapy (i.e., proprotein convertase subtilisin/kexin type 9 inhibitors), and glucose lowering therapy (i.e., sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists). However, the adoption of these therapies in PAD remains suboptimal in practice. Implementation science studies have recently shown promising results in PAD patients. Comprehensive medical and non-medical management of PAD patients is crucial to improving patient outcomes, mitigating symptoms, and reducing the risk of MACE and MALE. A personalized approach, considering the patient's overall risk profile and preference, is essential for optimizing medical management of PAD.

Healthy Lifestyle Score and Glycemic Control in Type 2 Diabetes Mellitus Patients: A City-Wide Survey in China

BACKGROUND

Few studies have investigated the combined impact of healthy lifestyle factors on glycemic control. Our study aimed to examine the associations of a healthy lifestyle score (HLS) with glycemic control and to explore the interactive effects of lifestyle factors among patients with type 2 diabetes mellitus (T2DM) in China.

METHODS

This cross-sectional study was conducted among T2DM patients based on the health management of residents from Guangzhou, China. Good glycemic control was defined as fasting plasma glucose < 7.0 mmol/L. HbA1c < 7.0% was also defined as good glycemic control in sensitivity analysis. The HLS was defined as including physical activity, waist circumference, body mass index, dietary habit, smoking, and alcohol consumption. Logistic regression models were used to examine the associations and interactions between the lifestyle factors and glycemic control.

RESULTS

Compared with participants with an HLS ≤ 2, the odds ratios (95% confidence intervals) for an HLS of 3, 4, 5, and 6 were 0.82 (0.77-0.87), 0.74 (0.70-0.79), 0.61 (0.57-0.65), and 0.56 (0.53-0.60), respectively. Significant interactions of healthy lifestyle factors in relation to glycemic control were shown (P_interaction < 0.05).

CONCLUSIONS

A healthier lifestyle was significantly associated with good glycemic control in patients with T2DM, and combined healthy lifestyle factors had a better effect than considering them individually.

Focus on Prevention: Peripheral Arterial Disease and the Central Role of the Cardiologist

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerotic disease. PAD patients have a poor prognosis with an increased risk of cardiovascular (CV) events, including myocardial infarction (MI), stroke, limb ischemia and CV death; therefore, it is important to detect and treat PAD early. PAD and coronary artery disease (CAD) share a common pathogenesis and risk factors for development; therefore, cardiologists are in a unique position to screen, diagnosis and treat PAD. Moreover, PAD and CAD also share some treatment goals, including an aggressive modification of risk factors to reduce the risk of CV events. However, PAD remains an underdiagnosed and undertreated disease with medico-legal implications. As the role of cardiologists is expanding, the purpose of this review was to awaken the clinicians to the significance of PAD.

Management of Peripheral Arterial Disease: Lifestyle Modifications and Medical Therapies

Peripheral artery disease (PAD) commonly refers to atherosclerotic narrowing of noncoronary arteries, primarily those supplying the lower extremities. The risk factors for PAD include smoking, hyperlipidemia, hypertension, and diabetes mellitus. Patients with PAD are at a heightened risk of major adverse cardiovascular events (including myocardial infarction, stroke, and cardiovascular death) and major adverse limb events (including progressive symptoms or limb ischemia requiring peripheral revascularization, amputation, and acute limb ischemia), highlighting the need for guideline-directed therapies. Lifestyle modifications and medical therapies are utilized to improve function and outcomes in this patient population. Adherence to a healthy diet and smoking cessation are both associated with better outcomes in patients with PAD. Medical therapies targeting axes of risk, including lipid-modifying therapies, antithrombotic therapies, and targeted diabetes therapies, are available to reduce this risk in patients with PAD; however, significant residual risk remains. Unfortunately, despite guideline recommendations and efforts at education, even available medical therapies remain underutilized in patients with PAD. Continued development of novel therapies and efforts to improve the provision of care in patients with PAD are needed.

Social Marketing in Promoting Sustainable Healthy Lifestyle among Student Population

Although there are some differences in healthy lifestyle measurement, physical activity is an indispensable factor within that construct. By increasing the level of physical activity of the population, the contribution to social sustainability is provided. Social marketing can be considered as a manner to promote behavior change (including increase in physical activity level). It uses commercial marketing tools in delivering social goods. In that context can be explained previous uses of the theory of planned behavior (TPB) in social marketing researches aiming at increasing the level of physical activity of the population. In this paper, the modified TPB model, extended with self-identity and motivation variable, is implemented within the student population of the University of Novi Sad, Serbia, in 2019. The results show that intention to do regular physical activity in the week after the research was directly influenced by behavioral and normative beliefs and self-identity. It was influenced indirectly by students’ motivation. The motivation, however, directly affects students’ behavioral, normative and control beliefs. Nevertheless, the results differ among genders; although positive at both genders, the effects of normative beliefs and motivation on intention were significant only in female students (0.123 and 0.243, respectively). The authors also provide social marketing implications, i.e., potential activities within social marketing that could be performed in order to encourage students to be more physically active. In addition to belonging to relatively scarce similar researches in domestic context, the wider contribution of this paper can be identified from a methodological aspect, treating the behavioral, normative and control beliefs as formative constructs.

Body Fat Distribution, Cardiometabolic Traits, and Risk of Major Lower-Extremity Arterial Disease in Postmenopausal Women

OBJECTIVE

To assess the relationship between body fat distribution and incident lower-extremity arterial disease (LEAD).

RESEARCH DESIGN AND METHODS

We included 155,925 postmenopausal women with anthropometric measures from the Women's Health Initiative who had no known LEAD at recruitment. A subset of 10,894 participants had body composition data quantified by DXA. Incident cases of symptomatic LEAD were ascertained and adjudicated through medical record review.

RESULTS

We identified 1,152 incident cases of LEAD during a median 18.8 years follow-up. After multivariable adjustment and mutual adjustment, waist and hip circumferences were positively and inversely associated with risk of LEAD, respectively (both P-trend < 0.0001). In a subset (n = 22,561) where various cardiometabolic biomarkers were quantified, a similar positive association of waist circumference with risk of LEAD was eliminated after adjustment for diabetes and HOMA of insulin resistance (P-trend = 0.89), whereas hip circumference remained inversely associated with the risk after adjustment for major cardiometabolic traits (P-trend = 0.0031). In the DXA subset, higher trunk fat (P-trend = 0.0081) and higher leg fat (P-trend < 0.0001) were associated with higher and lower risk of LEAD, respectively. Further adjustment for diabetes, dyslipidemia, and blood pressure diminished the association for trunk fat (P-trend = 0.49), yet the inverse association for leg fat persisted (P-trend = 0.0082).

CONCLUSIONS

Among U.S. postmenopausal women, a positive association of upper-body fat with risk of LEAD appeared to be attributable to traditional risk factors, especially insulin resistance. Lower-body fat was inversely associated with risk of LEAD beyond known risk factors.

Midlife Cardiorespiratory Fitness and the Development of Peripheral Artery Disease in Later Life

Background Data are sparse on the prospective associations between physical activity and incidence of lower extremity peripheral artery disease (PAD). Methods and Results Linking participant data from the CCLS (Cooper Center Longitudinal Study) to Medicare claims files, we studied 19 023 participants with objectively measured midlife cardiorespiratory fitness through maximal effort on the Balke protocol who survived to receive Medicare coverage between 1999 and 2009. The study aimed to determine the association between midlife cardiorespiratory fitness and incident PAD with proportional hazards intensity models, adjusted for age, sex, body mass index, and other covariates, to PAD failure time data. During 121 288 person-years of Medicare follow-up, we observed 805 PAD-related hospitalizations/procedures among 19 023 participants (21% women, median age 50 years). Lower midlife fitness was associated with a higher rate of incident PAD in patients aged 65 years and older (low fit [quintile 1]: 11.4, moderate fit [quintile 2 to 3]: 7.8, and high fit [quintile 4 to 5]: 5.7 per 1000 person years). After multivariable adjustment for common predictors of incident PAD such as age, body mass index, hypertension, and diabetes, these findings persisted. Lower risk for PAD per greater metabolic equivalent task of fitness was observed (hazard ratio [HR], 0.93 [95% CI, 0.90-0.97]; P<0.001). Among a subset of patients with an additional fitness assessment, each 1 metabolic equivalent task increase from baseline fitness was associated with decreased risk of incident PAD (HR, 0.90 [95% CI, 0.82-0.99]; P=0.03). Conclusions Cardiorespiratory fitness in healthy, middle-aged adults is associated with lower risk of incident PAD in later life, independent of other predictors of incident PAD.

A lifestyle pattern during adolescence is associated with cardiovascular risk markers in young adults: results from the DONALD cohort study

Lifestyle score approaches combining individual lifestyle factors, e.g. favourable diet, physical activity or normal body weight, showed inverse associations with cardiovascular disease (CVD) risk. However, research mainly focussed on adult behaviour and is scarce for vulnerable time windows for adult health like adolescence. We investigated associations between an adolescent lifestyle score and CVD risk markers in young adulthood. Overall, we analysed 270 participants of the open DONALD cohort study with 1–6 complete measurements of five lifestyle factors (healthy diet, moderate-to-vigorous physical activity, sedentary behaviour, sleep duration and BMI standard deviation score) during adolescence (females: 8⋅5–15⋅5 years and males: 9⋅5–16⋅5 years). Multivariable linear regression models were used to investigate the prospective association between the adolescent lifestyle score (0–5 points) and CVD risk markers in young adulthood (18–30 years). On average, participants obtained a mean adolescent lifestyle score of 2⋅9 (0–5) points. Inverse associations between the adolescent lifestyle score and waist circumference, waist-to-height ratio and percentage of body fat were observed (4⋅1, 4⋅1 and 9⋅2 % decrease per 1 point increase in adolescent lifestyle score, respectively, P < 0⋅05). For the remaining CVD risk markers (glucose, blood lipids, blood pressure and a proinflammatory score), no associations were observed. A healthy adolescent lifestyle is particularly associated with CVD risk-related favourable anthropometric markers in adulthood. A more comprehensive understanding of lifestyle patterns in the life course might enable earlier, targeted preventive measures to assist vulnerable groups in prevention of chronic diseases.

[Relationship between physical activity during leisure time and progression of ankle-brachial index]

OBJECTIVE

To study the relationship between physical activity during leisure time and progression of ankle-brachial index (ABI) in the Spanish general population.

METHOD

Prospective, multicentre cohort study with 1941 subjects over 49 years of age, free of peripheral arterial disease at the time of recruitment of the cohort, were studied. Physical activity during leisure time variable was obtained using the VREM questionnaire. Peripheral arterial disease was considered to be an ankle-brachial index (ABI) <0.9. A multivariate logistic regression analysis was performed to evaluate the independent association between physical activity during leisure time and ABI.

RESULTS

The mean age was 63.4 years and 54.6% were women. In the multivariate analysis, there was a positive relationship between physical activity during leisure time and ABI in patients with an energy consumption of more than 5000 MET in 14 days (odds ratio: 0.37; 95% confidence interval: 0.18-0.80). These specific activities doing sports or dancing, going shopping on foot, and cleaning the house for more than an hour a day showed a protective effect. In the group of subjects who maintained the physical activity during leisure time during the time of the research, a protective effect was observed with overall physical activity (MET) and going shopping on foot.

CONCLUSIONS

In our research, PALT was favorably associated with ABI, in a sample of the Spanish general population that is very active and has a low-cardiovascular risk.

Risk Models and Scores in Patients with Peripheral Artery Disease and Chronic Limb-threatening Ischemia: A Comprehensive Review

Peripheral artery disease (PAD) affects more than 200 million patients worldwide and chronic limbthreatening ischemia (CLTI) is the most advanced stage of PAD with very high morbidity and mortality rates. Cardiovascular medicine is trending towards a more personalized approach where each individual patient will be managed according to specific risk factors, disease characteristics, expectations related to their disease and individualized assessment of potential outcomes. For this reason, a number of risk models and scores have been developed during the last few years. Our aim in this comprehensive review article is to provide an overview of selected risk models and scores for patients with PAD and CLTI. Given that some of the published scores were of low quality (minimal discriminatory ability), we included scores that were already externally validated or scores that had promising initial findings. Available scoring systems were grouped in the five following categories according to their utility: i) scores that can detect asymptomatic patients who should be screened for PAD, ii) scores for assessment of functional status and quality of life in patients with PAD, iii) scores assessing risk for amputation and other major adverse limb events among patients with CLTI, iv) scores for the optimal revascularization strategy in each patient and scores predicting successful procedural outcomes; v) scores predicting short or long-term cardiovascular and limb related outcomes after either revascularization or at least angiographic assessment. Limitations of available scoring systems include development and validation in specific populations, lack of external validation (for some of them) and also lack of synchrony with current era endovascular technology. However, with further optimization of current scores and the development of new scores, the field of PAD and CLI can be transitioned to a personalized medicine approach.

Contemporary Medical Management of Peripheral Artery Disease

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis. Modifiable risk factors including cigarette smoking, dyslipidemia, diabetes, poor diet quality, obesity, and physical inactivity, along with underlying genetic factors contribute to lower extremity atherosclerosis. Patients with PAD often have coexistent coronary or cerebrovascular disease, and increased likelihood of major adverse cardiovascular events, including myocardial infarction, stroke and cardiovascular death. Patients with PAD often have reduced walking capacity and are at risk of acute and chronic critical limb ischemia leading to major adverse limb events, such as peripheral revascularization or amputation. The presence of polyvascular disease identifies the highest risk patient group for major adverse cardiovascular events, and patients with prior critical limb ischemia, prior lower extremity revascularization, or amputation have a heightened risk of major adverse limb events. Medical therapies have demonstrated efficacy in reducing the risk of major adverse cardiovascular events and major adverse limb events, and improving function in patients with PAD by modulating key disease determining pathways including inflammation, vascular dysfunction, and metabolic disturbances. Treatment with guideline-recommended therapies, including smoking cessation, lipid lowering drugs, optimal glucose control, and antithrombotic medications lowers the incidence of major adverse cardiovascular events and major adverse limb events. Exercise training and cilostazol improve walking capacity. The heterogeneity of risk profile in patients with PAD supports a personalized approach, with consideration of treatment intensification in those at high risk of adverse events. This review highlights the medical therapies currently available to improve outcomes in patients with PAD.

Are cardiovascular function and habitual physical activity levels similar in patients with classic and atypical claudication symptoms? A cross-sectional study

Objective

To analyze the impact of the different types of exertional leg pain on cardiovascular function, functional capacity, and habitual physical activity levels in patients with peripheral arterial disease.

Methods

In this cross-sectional study, 124 patients with symptomatic peripheral arterial disease were included. Exertional leg pain was evaluated using the San Diego Claudication Questionnaire. Subsequently, patients were categorized into two groups according to their exertional leg pain: atypical leg pain (non-calf pain and atypical calf pain, n = 31) and intermittent claudication (classic intermittent claudication symptoms, n = 93). Cardiovascular function (blood pressure, heart rate, arterial stiffness, and heart rate variability), functional capacity (6-min walk distance, handgrip strength, and short physical performance battery), and habitual physical activity levels were measured.

Results

Functional capacity and physical activity levels were similar between patients with atypical leg pain and symptoms of intermittent claudication. However, patients with classic intermittent claudication symptoms presented higher central systolic blood pressure ( P = 0.028) and arterial stiffness (augmentation index and pulse pressure; P ≤ 0.001 and 0.019, respectively) compared to patients with atypical leg pain.

Conclusion

The type of exertional leg pain does not influence functional capacity and habitual physical activity levels in patients with peripheral arterial disease. However, patients with classic intermittent claudication symptoms present impaired cardiovascular function compared to patients with atypical leg pain.

Nutritional status and outcomes of superficial femoral artery stenting due to intermittent claudication

BACKGROUND

The pathogenesis of in-stent restenosis is still not clear. The aim of this study was to determine the nutritional status of patients with lower limb ischemia and the risk of target lesion revascularization (TLR) after superficial femoral artery (SFA) stenting.

METHODS

Numerous parameters of nutritional status assessment were compared between 70 patients undergoing SFA endovascular intervention with a self-expandable plane stent due to life-limiting intermittent claudication and 40 patients undergoing carotid artery stenting (CAS). All subjects were followed up for at least 1 year in relation to outcomes such as clinically driven TLR occurrence.

RESULTS

Patients undergoing SFA stenting had a lower prevalence of overweight and obesity than those who underwent CAS (51.43% vs. 72.50%; P=0.031). An increase in Ankle-Brachial Index of >0.15 after SFA stenting (early end-point) was positively associated with greater handgrip strength (HGS), fat-free mass, skeletal muscle mass and waist-to-hip ratio. Freedom from TLR (late end-point) was significantly related to a higher waist-to-height ratio (WHtR), HGS and Geriatric Nutritional Risk Index (GNRI) Score. The 1-year risk of TLR for patients with a WHtR of ≥61.39 amounted to odds ratio; 95% confidence interval: 0.21; 0.05-0.25; P=0.021.

CONCLUSIONS

Parameters of nutritional status assessment were associated with early and late outcomes of SFA stenting in patients with intermittent claudication. Abdominal fat distribution and higher HGS and GNRI scores lowered the 1-year risk of TLR. Further study is needed to determine the pathomechanism of the obesity paradox, sarcopenia and undernutrition in relation to outcomes of endovascular interventions.

Healthy diet and fiber intake are associated with decreased risk of incident symptomatic peripheral artery disease – A prospective cohort study

Peripheral artery disease (PAD) is caused by atherosclerosis and associated with an increased risk of leg amputation, cardiovascular disease, and death. A healthy diet has been shown to reduce the risk of cardiovascular events, but relationships between diet, fiber intake, and incidence of PAD are virtually unknown. The aim was to investigate the long-term impact of diet on the development of PAD among 26,010 middle-aged individuals in the prospective Malmö Diet and Cancer study (MDCS). Data on dietary intake were collected through a 7-day food diary combined with a food questionnaire and a 1-hour interview. Adherence to a recommended intake of six dietary components – saturated fat, polyunsaturated fat, fish and shellfish, fiber, fruit and vegetables, and sucrose – was scored (sum 0–6 points) to assess a diet quality index, adjusting for potential confounders. Cox regression analysis was used to estimate associations between diet variables and PAD incidence expressed in hazard ratios (HR) with 95% CI. During a median follow-up of 21.7 years, 1122 participants developed PAD. Diet score was associated with a reduced risk of PAD in multivariable analysis ( p = 0.03). When mutually adjusting for all dietary variables, only adherence to recommended levels of fiber intake was associated with a reduced risk of incident PAD (HR 0.84; 95% CI 0.72–0.99). In this prospective, population-based study including 26,010 participants with over 20 years of follow-up, a healthy diet, especially a high intake of fiber, was associated with a reduced risk of PAD. Primary prevention programs directed against PAD should therefore include a fiber recommendation.