Rationale and design of feeding America's bravest: Mediterranean diet-based intervention to change firefighters' eating habits and improve cardiovascular risk profiles

The dietary inflammatory index and cardiometabolic parameters in US firefighters

Introduction

Dietary choices play a crucial role in influencing systemic inflammation and the eventual development of cardiovascular diseases (CVD). The Dietary Inflammatory Index (DII®) is a novel tool designed to assess the inflammatory potential of one's diet. Firefighting, which is characterized by high-stress environments and elevated CVD risk, represents an interesting context for exploring the dietary inflammatory-CVD connection.

Aim

This study aims to investigate the associations between Energy-adjusted Dietary Inflammatory Index (E-DII™) scores and cardiometabolic risk parameters among US firefighters.

Methods

The study analyzed 413 participants from the Indianapolis Fire Department who took part in a Federal Emergency Management Agency (FEMA)-sponsored Mediterranean diet intervention trial. Thorough medical evaluations, encompassing physical examinations, standard laboratory tests, resting electrocardiograms, and submaximal treadmill exercise testing, were carried out. Participants also completed a detailed food frequency questionnaire to evaluate dietary patterns, and E-DII scores were subsequently computed based on the gathered information.

Results

Participants had a mean body mass index (BMI) of 30.0 ± 4.5 kg/m2 and an average body fat percentage of 28.1 ± 6.6%. Regression analyses, adjusted for sex, BMI, maximal oxygen consumption (VO2 max), max metabolic equivalents (METS), age, and body fat percentage, revealed significant associations between high vs. low E-DII scores and total cholesterol (β = 10.37, p = 0.04). When comparing low Vs median E-DII scores there is an increase in glucose (β = 0.91, p = 0.72) and total cholesterol (β = 5.51, p = 0.26).

Conclusion

Our findings support an association between higher E-DII scores and increasing adiposity, as well as worse lipid profiles.

Mediterranean diet intervention among World Trade Center responders with post-traumatic stress disorder: Feasibility and outcomes of a pilot randomized controlled trial

Objective

Responders of the World Trade Center (WTC) disaster suffer from co-morbidities. A Mediterranean Diet (MedDiet) nutrition intervention with physical activity was implemented among WTC responders with overweight/obesity and post-traumatic stress disorder (PTSD).

Methods

WTC Health Program members (N = 62), 45-65 years, males 87%, body mass index (BMI) 27-45 kg/m2 randomized to MedDiet (n = 31) or usual nutrition counseling (n = 31). The 10-week intervention included online nutrition education, text messages, and group experiential cooking; both groups had three in-person individual nutrition counseling. Anthropometrics, serum biomarkers, psychosocial factors, MedDiet score, and PTSD symptoms were assessed at baseline, post-intervention, and 3-months (follow-up). The primary outcome was intervention feasibility and secondary outcomes were within- and between-group changes of all measures at post-intervention and follow-up. Nonparametric Wilcoxon rank sum tests for between-group comparisons and Wilcoxon signed rank tests for pre-post within-group comparisons.

Results

A total of 58(94%) and 46(74%) participants completed the post-intervention and follow-up measurements, respectively. Both groups experienced significant improvements in anthropometrics, MedDiet score, oxidized low-density lipoprotein, and PTSD symptoms. Baseline median (range) were weight 100.42 (73.66-135.17) kg, BMI 33.20 (27.50-41.75) kg/m2, and Waist circumference (WC) 109.22 (90.17-150.62) cm. Median % weight loss at post-intervention was MedDiet: -3% (-11%-7%), p = 0.0002; Control: -1% (-13%-4%), p = 0.008 and at follow-up MedDiet: -2% (-14%-12%), p = 0.07; Control: -2% (-20%-3%), p = 0.006. The overall BMI was reduced by -0.68 kg/m2 (-4.61-2.09) kg/m2 p < 0.0001 at post-intervention and by -0.60 kg/m2 (-6.91-3.39) kg/m2, p < 0.0009 at follow-up. Overall, median WC was reduced (p < 0.0001); post-intervention -3.81 cm (-33.00-3.30)cm and follow-up -4.45(-38.10-4.57)cm. There were group differences in HbA1c (p = 0.019) and serum ω6/ω3 (p = 0.029) at post-intervention.

Conclusion

Online intervention with personal counseling was feasible in this population. Improvements in anthropometrics, MedDiet score, selected serum biomarkers and PTSD symptoms were found in both groups; group differences in HbA1c and serum ω6/ω3. A larger study with a delayed control is needed to better assess intervention effects.

Effect of a Nutrition Intervention on Mediterranean Diet Adherence Among Firefighters: A Cluster Randomized Clinical Trial

Importance

US firefighters are a working population at risk of chronic diseases, including obesity, cardiovascular disease, and cancer. This risk may be mitigated by a healthy diet.

Objective

To evaluate the effect of a Mediterranean nutrition intervention using a behavioral/environmental approach (firefighter/fire station/home) at the individual participant level.

Design, Setting, and Participants

This 12-month cluster randomized clinical trial included US career firefighters from fire stations and homes within 2 Indiana fire departments. Participants were randomized by fire station to either Mediterranean diet or control (usual care). The study was conducted from October 2016 to December 2019, and data were analyzed in November 2022.

Intervention

For the first 12 months of the study, firefighters located at fire stations randomized to the intervention group were provided with access to supermarket discounts and free samples of Mediterranean diet foods, online nutrition education platforms, email announcements and reminders, family and peer education and support, and chef demonstrations. Firefighters in fire stations allocated to the control group received no intervention and were instructed to follow their usual diet.

Main Outcomes and Measures

Change in dietary habits at 12 months as measured by a modified Mediterranean diet score (range, 0 to 51 points) at baseline and 6-month and 12-month follow-up. Cardiometabolic parameters were secondary outcomes.

Results

Of 485 included firefighters, 458 (94.4%) were male, and the mean (SD) age was 47 (7.5) years. A total of 241 firefighters (27 fire stations) were randomized to the Mediterranean nutrition intervention, and 244 (25 fire stations) were randomized to usual diet. Outcomes were analyzed using generalized linear mixed models for modified Mediterranean diet score at 6 months (n = 336) and 12 months (n = 260), adjusting for baseline age, sex, race and ethnicity, fire department, physical activity, and waist circumference. In the intervention group compared with the control group, the modified Mediterranean diet score significantly increased by 2.01 points (95% CI, 0.62-3.40; P = .005) at 6 months and by 2.67 points (95% CI, 1.14-4.20; P = .001) at 12 months. Among secondary outcomes, changes in cardiometabolic risk factors were not statistically significant at 1 year. Results from analyses with multilevel multiple imputation for missingness were similar.

Conclusions and Relevance

In this Mediterranean nutrition intervention of multicomponent behavioral/environmental changes, career firefighters had increased adherence to a Mediterranean diet.

Trial Registration

ClinicalTrials.gov Identifier: NCT02941757.

Mid- and long-term changes in satiety-related hormones, lipid and glucose metabolism, and inflammation after a Mediterranean diet intervention with the goal of losing weight: A randomized, clinical trial

Background

Obesity is produced by the enlargement of the adipose tissue. Functioning as an endocrine organ, it releases and receives information through a complex network of cytokines, hormones, and substrates contributing to a low-chronic inflammation environment. Diet and healthy habits play key roles in the prevention of obesity and its related pathologies. In this regard, there is a need to switch to healthier and more appetizing diets, such as the Mediterranean one.

Objective

To compare the mid-and long-term effects of two Mediterranean diet (MedDiet) interventions, one energy-reduced plus physical activity promotion versus a non-restrictive diet, on peripheral satiety-related hormones, weight loss, glucose/lipid metabolism, and pro-inflammatory markers in subjects with obesity/overweight and metabolic syndrome.

Materials and methods

A randomized, lifestyle intervention was conducted in 23 Spanish centers, with a large cohort of patients presenting metabolic syndrome. Our study is a subproject set in IMIM (Hospital del Mar Research Institute). Participants were men and women, aged 55–75 and 60–75, respectively, who at baseline met at least three metabolic syndrome components. Subjects were assigned to two intervention groups: (1) an intensive lifestyle intervention with an energy-reduced MedDiet and physical activity promotion (intervention group) with the aim of weight loss; and (2) a normocaloric MedDiet (control). We quantified in a subsample of 300 volunteers from Hospital del Mar Research Institute (Barcelona), following analytes at baseline, 6 months, and 1 year: glucose, HbA1c, triglycerides, total cholesterol, high-density lipoprotein cholesterol, LDL cholesterol, C-peptide, ghrelin, GLP-1, glucagon, insulin, leptin, PAI-1, resistin, and visfatin. Anthropometric and classical cardiovascular risk factors were also determined. A multivariate statistical model was employed to compare the two groups. Linear mixed-effect models were performed to compare changes in risk factors and biomarkers between intervention groups and over time.

Results

Compared to participants in the control group, those in intervention one showed greater improvements in weight, waist circumference, insulin (P &lt; 0.001), glucose metabolism-related compounds (P &lt; 0.05), triglyceride-related lipid profile (P &lt; 0.05), leptin, blood pressure, and pro-inflammatory markers such as PAI-1 (P &lt; 0.001) at mid-and/or long-term. High-sensitivity C-reactive protein, resistin, and vifastin also decreased in both groups.

Conclusion

A weight loss intervention employing a hypocaloric MedDiet and physical activity promotion has beneficial effects on adiposity, glucose metabolism, lipid profile, leptin, and pro-inflammatory markers, such as PAI-1 in both mid-and long-term.

Dietary Behavior and Diet Interventions among Structural Firefighters: A Narrative Review

Structural firefighters (SFFs) are exposed to multiple occupational hazards that affect dietary behavior and can contribute to increased risks of cancer and cardiovascular disease compared to the United States’ general population. Dietary behavior is a feasible modification for positive health outcomes. The objectives of this narrative review are to summarize the diet behavior of SFFs, review findings of diet interventions that positively modify diet behavior, identify research gaps, and suggest recommendations for addressing those gaps. PubMed, MEDLINE, Scopus, and CABI Web of Science were searched between February 2020 and June 2022 for peer-reviewed articles. The inclusion criteria were as follows: (1) study population must include SFFs; (2) investigate diet or diet intervention among SFFs; (3) report results specific to SFFs; and (4) be published in the English language. Thirty-four studies were included. Results indicate that SFFs recognize the importance of a healthy dietary pattern, but do not follow one, and that food choices are often influenced by colleagues. Diet interventions, such as the Mediterranean diet, were observed to have positive health improvements, such as improved lipid levels and lower CVD risk. Team counseling was found to be more effective for adopting healthier diets compared to one-on-one counseling; and general counseling was more effective than no counseling. A gap identified by this review is the lack of information concerning differences in dietary intake, diet quality, and dietary behaviors while on- and off-shift, and throughout the career. Diet is an important risk factor for occupational disease development; therefore, effective, consistent dietary interventions are necessary.

Eating Habits among US Firefighters and Association with Cardiometabolic Outcomes

Cardiovascular disease is the leading cause of on-duty mortality among firefighters, with obesity as an important risk factor. However, little is known regarding the dietary patterns which are characteristic in this population and how these patterns relate to cardiometabolic outcomes. The aim of this study was to identify the dietary patterns of US firefighters and examine their association with cardiometabolic outcomes. The participants (n = 413) were from the Indianapolis Fire Department, and were recruited for a Federal Emergency Management Agency (FEMA)-sponsored Mediterranean diet intervention study. All of the participants underwent physical and medical examinations, routine laboratory tests, resting electrocardiograms, and maximal treadmill exercise testing. A comprehensive food frequency questionnaire was administered, and dietary patterns were derived using principal component analysis. The mean body mass index (BMI) was 30.0 ± 4.5 kg/m2 and the percentage of body fat was 28.1 ± 6.6%. Using principal component analysis, two dietary patterns were identified, namely a Mediterranean diet and a Standard American diet. Following the adjustment for gender, BMI, maximal oxygen consumption (VO2 max), max metabolic equivalents (METS), age, and body fat percent, the Mediterranean diet was positively associated with high-density lipoprotein (HDL) cholesterol (β = 1.20, p = 0.036) in linear regression models. The Standard American diet was associated with an increase in low-density lipoprotein (LDL) cholesterol (β = −3.76, p = 0.022). In conclusion, the Mediterranean diet was associated with more favorable cardiometabolic profiles, whereas the Standard American diet had an inverse association. These findings could help in providing adequate nutrition recommendations for US firefighters to improve their health.

Perspective: Novel Approaches to Evaluate Dietary Quality: Combining Methods to Enhance Measurement for Dietary Surveillance and Interventions

Refining existing dietary assessment methods to reduce measurement error and facilitate the routine evaluation of dietary quality is essential to inform health policy. Notable advancements in technology in the past decade have enhanced the precision and transformation of dietary assessment methods with applications toward both population health and precision nutrition. Within population health, innovative applications of big data including use of automatically collected food purchasing data, quantitative measurement of food environments, and novel, yet simplified dietary quality metrics provide important complementary data to traditional self-report methods. Precision nutrition is similarly advancing with greater use of validated biomarkers for assessing dietary patterns and understanding individual variability in metabolism. Concurrently enhancing our understanding of diet-disease relations at the population health and precision nutrition levels provides tremendous potential to generate evidence needed to advance public health nutrition policy. This commentary highlights the importance of these advances toward progressing the field of dietary assessment and discusses the application of food purchasing data, data analytics, alternative dietary quality metrics, and -omics technology in population and clinical medicine.

Mediterranean Diet Social Network Impact along 11 Years in the Major US Media Outlets: Thematic and Quantitative Analysis Using Twitter

Background: Media outlets influence social attitudes toward health. Thus, it is important that they share contents which promote healthy habits. The Mediterranean diet (MedDiet) is associated with lower cardiovascular disease risk. Analysis of tweets has become a tool for understanding perceptions on health issues. Methods: We investigated tweets posted between January 2009 and December 2019 by 25 major US media outlets about MedDiet and its components as well as the retweets and likes generated. In addition, we measured the sentiment analysis of these tweets and their dissemination. Results: In total, 1608 tweets, 123,363 likes and 48,946 retweets about MedDiet or its components were analyzed. Dairy (inversely weighted in MedDiet scores) accounted for 45.0% of the tweets (723/1608), followed by nuts 19.7% (317/1608). MedDiet, as an overall dietary pattern, generated only 9.8% (157/1608) of the total tweets, while olive oil generated the least number of tweets. Twitter users’ response was quantitatively related to the number of tweets posted by these US media outlets, except for tweets on olive oil and MedDiet. None of the MedDiet components analyzed was more likely to be liked or retweeted than the MedDiet itself. Conclusions: The US media outlets analyzed showed reduced interest in MedDiet as a whole, while Twitter users showed greater interest in the overall dietary pattern than in its particular components.

Impact of the Mediterranean Dietary pattern on n-3 fatty acid tissue levels-A systematic review

INTRODUCTION

The Mediterranean Diet (MedDiet) is described as a plant-based dietary pattern with adherence associated with reductions in chronic disease risk and longevity. Although the nutrient profile is diverse and complex, the MedDiet is often described as a rich source of n-3 polyunsaturated fatty acids (PUFA) derived from fish, seafood and nuts. However, whether MedDiet adherence results in appreciable increases in tissue levels of n-3 PUFAs is yet to be systematically investigated. This systematic review synthesized the literature to determine the impact of the MedDiet on n-3 PUFA tissue levels.

MATERIALS AND METHODS

Medline, Embase, Amed, and CINAHL databases were searched for studies reporting on adherence to a MedDiet and tissue levels of n-3 PUFAs. PROSPERO registration number is CRD 42020162114.

RESULTS

Twenty-two studies were included. Seven were observational studies and 15 were randomised controlled trials (RCTs). All observational studies reported a positive relationship between adherence and higher tissue n-3 PUFA levels. Two-thirds (10/15) of RCTs reported significant increases in n-3 PUFA concentrations.

DISCUSSION

MedDiet adherence is associated with higher tissue levels of n-3 PUFA. However, we report heterogeneity in the description across all MedDiet interventions.

Free-Living Dietary Intake in Tactical Personnel and Implications for Nutrition Practice: A Systematic Review

Tactical personnel (including military, law enforcement, and fire and rescue) are responsible for ensuring national and public safety. Dietary intake is an important consideration to support optimal health and performance. The aims of this systematic review were to: (1) describe the reported free-living dietary intake (energy and macronutrients) of tactical personnel, and (2) describe the practical implications of reported dietary intakes to support the physical and dietary requirements of tactical personnel. A systematic search of databases (MEDLINE, EMBASE, CINAHL and Web of Science) was conducted following the PRISMA guidelines. English and full text research articles were identified and screened against inclusion and exclusion criteria. Demographic and dietary intake data were extracted, tabulated, and synthesized narratively. The quality of the studies was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Twenty-two studies (15 military, 4 law enforcement, and 2 fire and rescue) were eligible to inform this review. The volume of evidence suggested that tactical personnel met dietary protein and exceeded dietary fat recommendations but failed to meet energy and carbohydrate recommendations. Therefore, practical approaches to support optimized energy, fat and carbohydrate intake in tactical personnel is important.

Time Restricted Feeding Reduces Inflammation and Cortisol Response to a Firegrounds Test in Professional Firefighters

OBJECTIVE

Firefighters are at a heightened risk for developing cardiovascular disease. The purpose of this study was to determine if time restricted feeding (TRF) can improve the stress/inflammatory response to a simulated firegrounds test (FGT) in professional firefighters.

METHODS

Thirteen firefighters participated in an 8-week TRF intervention (14:10 [fasting:feeding]) protocol and completed a FGT before and after the intervention. Blood lactate, heart rate, salivary C-reactive protein (CRP), interleukin-6 (IL-6), interleukin 1-β (IL-1β), and cortisol were measured pre and post FGT.

RESULTS

Following TRF, the salivary cortisol response to the FGT was significantly (P < 0.05) reduced. Salivary IL-6 and IL-1β were also significantly lower, and CRP was higher following the intervention.

CONCLUSIONS

These findings demonstrate lower inflammation and reduced stress response to FGT following TRF and may suggest implications in terms of cardiometabolic benefits for firefighters.

Mediterranean diet scoring systems: understanding the evolution and applications for Mediterranean and non-Mediterranean countries

The Mediterranean diet (MedD) is a flexible dietary pattern which has such variability that has led to inconsistencies in definitions and assessment. The purpose of this narrative review is to evaluate scoring systems in a cultural and geographic context, from Mediterranean and non-Mediterranean countries, for comparison and application. The early MedD scoring systems (i.e. Trichopoulou's MedD Scale (T-MDS) and alternative MedD Scale (aMed)) are widely applied throughout the world but use population-specific median cut-offs which limit interpretation and cross-study comparisons. The T-MDS and aMed also do not account for non-traditional MedD foods which are consumed in greater quantities than when the scoring systems were developed. Scoring systems developed after the MedD pyramid publication in 2011 have generally used these recommendations as a basis for food group intake cut-offs, incorporating more foods/food groups as negative components, and some have included dietary and lifestyle behaviours. The different approaches to MedD assessment have created much variability in the foods/food group components included in scoring systems. Assessments that include dietary and lifestyle behaviours may reflect the nutrition transition occurring in Mediterranean countries and better guide clinical intervention approaches. While the new scoring systems are theorised to better capture MedD adherence and behaviours, comparisons are sparse in the literature and none exists outside of Europe. Consensus on food and dietary behaviours to include as well as the methodology for assigning points in MedD scoring systems is needed to advance our understanding of MedD and health relationships to promote public health messaging and clinical application.

Mediterranean diet - promotion and dissemination of healthy eating: proceedings of an exploratory seminar at the Radcliffe institute for advanced study

The traditional Mediterranean diet is considered the world's most evidence-based eating pattern for promoting health and longevity. However, institutional food environments and their busy consumers often sacrifice health benefits for the convenience of faster and cheaper foods that generally are of lower quality and are more processed, and thus, contribute to the current epidemics of obesity and diabetes. Expert consensus has even identified the Mediterranean diet as the easiest to follow among healthy eating patterns. Nonetheless, fewer American families cook at home and many food services have been slow to implement healthier food options compatible with the Mediterranean diet. In September 2019, we convened a group of thought leaders at an exploratory seminar entitled: "Mediterranean Diet: Promotion and Dissemination of Healthy Eating", hosted by the Radcliffe Institute for Advanced Studies at Harvard University. The multidisciplinary faculty discussed best practices for translating traditional Mediterranean lifestyle principles to modern society.

Introducing Plant-Based Mediterranean Diet as a Lifestyle Medicine Approach in Latin America: Opportunities Within the Chilean Context

Latin America is experiencing a significant epidemiological and nutritional transition, with a trend toward higher incidence of food-related chronic diseases. In this context, Lifestyle Medicine (LM) is a growing field focused on assisting individuals in adopting healthy behaviors for the prevention and treatment of these chronic diseases, including, among other pillars, a great emphasis on healthy eating. There is also a growing interest worldwide in environmental sustainability of dietary patterns, with increasing concern about their effects on planetary health. In this context, whole-food, plant-based diets -such as the Mediterranean diet (MD)- have emerged as a solution for both healthier eating and lowering environmental impact. Yet in order to be effective at these goals and achieve a high adherence to any nutritional prescription, the sociocultural reality of the community or population where we aim to practice must also be taken into account. In this review, we specifically highlight the plant-based MD as a LM-contextualized dietary pattern that is adaptable, applicable, and sustainable within the Chilean context and has the potential to address the current trend of chronic diseases in our country.

The Effects of Fire Academy Training and Probationary Firefighter Status on Select Basic Health and Fitness Measurements

PURPOSE

This study aimed to investigate changes in firefighter recruits' select health and fitness measurements, from academy training to the early probationary firefighter period.

METHODS

Firefighter recruits from two New England fire academies were followed up prospectively from enrollment at the academy to graduation after 15- to 16-wk training programs, and then for an average of 8 months as probationary firefighters. The participants' demographic, lifestyle, and mental health information was collected using a questionnaire. Body mass index, percent body fat, blood pressure, and push-ups were also measured at each time point. Furthermore, the academies tested the recruits on selected fitness measures (push-ups, pull-ups, and 1.5-mile running time) at academy entry, midtraining, and at graduation.

RESULTS

Ninety-two recruits consented and were included in the analyses. The recruits' percent body fat significantly decreased (median, 21.0%-18.2%) from baseline to graduation, and push-up capacity significantly improved (median, 34-53 per minute) in the same period, along with pull-ups and 1.5-mile running time. However, the recruits' blood pressure, both systolic and diastolic, increased significantly by an average of 3 mm Hg during the training. Those completing probationary follow-up (45/92 recruits) showed that most health/fitness improvements declined after graduation. From academy graduation to probationary follow-up, recruits' physical activity decreased and TV screen time increased significantly, leading to a lower healthy lifestyle score (median, 4-3). After multivariate adjustments, the recruits' diastolic blood pressure increased by 2 mm Hg per measuring time throughout the study period.

CONCLUSIONS

Fire academy training improved recruits' select health and fitness measurements, but the benefits dissipated as probationary firefighters, and blood pressures increased throughout the study period. Further interventions regarding blood pressure and to maintain training benefits after joining fire departments are warranted.

The Mediterranean lifestyle (MEDLIFE) index and metabolic syndrome in a non-Mediterranean working population

BACKGROUND & AIMS

The Mediterranean lifestyle (MEDLIFE), as an overall lifestyle pattern, may be associated with a lower prevalence of metabolic syndrome. We assessed the association of a validated MEDLIFE index with metabolic syndrome and its components in a non-Mediterranean working population.

METHODS

A cross-sectional analysis was conducted at baseline among 249 US career firefighters in Feeding America's Bravest 2016-2018. The MEDLIFE index consisted of 26 items on food consumption, dietary habits, physical activity, rest, and social interactions that scored 0 or 1 point. Thus, total scores could range from 0 to 26 points. Multivariable logistic regression models were used to determine the associations across tertiles of MEDLIFE adherence with metabolic syndrome and each of its individual components. Multivariable linear models further assessed each component as a continuous outcome.

RESULTS

The prevalence of metabolic syndrome was 17.7%. Participants with higher MEDLIFE adherence (T3: 11-17 points) had 71% lower odds of having metabolic syndrome compared to those with lower MEDLIFE adherence (T1: 2-7 points) (OR = 0.29; 95%CI: 0.10 to 0.90, p for trend = 0.04). Furthermore, significant inverse associations were found for T3 versus T1 on abdominal obesity (OR = 0.42; 95%CI: 0.18 to 0.99, p for trend = 0.07) and hypertriglyceridemia (OR = 0.24; 95%CI: 0.09 to 0.63, p for trend = 0.002). Significant inverse associations for continuous outcomes included total-cholesterol (total-c), low-density lipoprotein (LDL) cholesterol, and total-c:high-density lipoprotein (HDL) cholesterol (p for trend <0.05).

CONCLUSION

Higher adherence to traditional Mediterranean lifestyle habits, as measured by a comprehensive MEDLIFE index, was associated with a lower prevalence of metabolic syndrome and a more favorable cardiometabolic profile in a non-Mediterranean working population. Future studies employing the MEDLIFE index in other populations are warranted to support this hypothesis.

Mediterranean-Type Dietary Pattern and Physical Activity: The Winning Combination to Counteract the Rising Burden of Non-Communicable Diseases (NCDs)

Non-communicable diseases (NCDs) (mainly cardiovascular diseases, cancers, chronic respiratory diseases and type 2 diabetes) are the main causes of death worldwide. Their burden is expected to rise in the future, especially in less developed economies and among the poor spread across middle- and high-income countries. Indeed, the treatment and prevention of these pathologies constitute a crucial challenge for public health. The major non-communicable diseases share four modifiable behavioral risk factors: unhealthy diet, physical inactivity, tobacco usage and excess of alcohol consumption. Therefore, the adoption of healthy lifestyles, which include not excessive alcohol intake, no smoking, a healthy diet and regular physical activity, represents a crucial and economical strategy to counteract the global NCDs burden. This review summarizes the latest evidence demonstrating that Mediterranean-type dietary pattern and physical activity are, alone and in combination, key interventions to both prevent and control the rise of NCDs.

Sleep and Association With Cardiovascular Risk Among Midwestern US Firefighters

INTRODUCTION

Cardiovascular disease is the leading cause of on-duty fatalities among U.S. firefighters. Research has demonstrated that many modifiable risk factors are contributors to the high prevalence of cardiometabolic risk factors. The current study aimed to assess whether sleep is associated with cardiometabolic risk factors among Indianapolis firefighters. The findings could support improving sleep hygiene in this population.

MATERIAL AND METHODS

This cross-sectional study was conducted from the baseline data of eligible firefighters enrolled in "Feeding America's Bravest", a Mediterranean diet lifestyle intervention within the Indiana Fire Departments. Participants' sleep quality was categorized as "good" (≤ 8 points) or "bad" (>8 points) by a sleep quality questionnaire based on some questions from Pittsburgh Sleep Quality Index. In addition, firefighters' sleep duration was stratified based on the number of hours slept per night (≤6 as "short sleep" or >6 hours as normal). Linear and logistic regression models were used to examine the association of sleep with cardiometabolic risk factors.

RESULTS

A total of 258 firefighters were included. Bad sleepers had higher weight, greater waist circumference, higher body mass index (BMI), and increased body fat (all p<0.01) compared to good sleepers. Similarly, participants with short sleep duration were heavier (p<0.02), had greater BMI (p<0.02) and increased body fat (p<0.04) compared with participants with normal sleep duration. Both bad and short sleepers had a higher prevalence of hypertension and obesity (p <0.05).

CONCLUSIONS

Our study supports that both sleep quality and quantity are associated with cardiometabolic risk among firefighters.

Association of the Modified Mediterranean Diet Score (mMDS) with Anthropometric and Biochemical Indices in US Career Firefighters

The Mediterranean diet is associated with multiple health benefits, and the modified Mediterranean Diet Score (mMDS) has been previously validated as a measure of Mediterranean diet adherence. The aim of this study was to examine associations between the mMDS and anthropometric indices, blood pressure, and biochemical parameters in a sample of career firefighters. The participants were from Indiana Fire Departments, taking part in the "Feeding America's Bravest" study, a cluster-randomized controlled trial that aimed to assess the efficacy of a Mediterranean diet intervention. We measured Mediterranean diet adherence using the mMDS. Anthropometric, blood pressure, and biochemical measurements were also collected. Univariate and multivariate linear regression models were used. In unadjusted analyses, many expected favorable associations between the mMDS and cardiovascular disease risk factors were found among the 460 firefighters. After adjustment for age, gender, ethnicity, physical activity, and smoking, a unitary increase in the mMDS remained associated with a decrease of the total cholesterol/HDL ratio (β-coefficient -0.028, p = 0.002) and an increase of HDL-cholesterol (β-coefficient 0.254, p = 0.004). In conclusion, greater adherence to the Mediterranean diet was associated with markers of decreased cardiometabolic risk. The mMDS score is a valid instrument for measuring adherence to the Mediterranean diet and may have additional utility in research and clinical practice.

The Effects of a Mediterranean Diet Intervention on Targeted Plasma Metabolic Biomarkers among US Firefighters: A Pilot Cluster-Randomized Trial

Metabolomics is improving the understanding of the mechanisms of the health effects of diet. Previous research has identified several metabolites associated with the Mediterranean Diet (MedDiet), but knowledge about longitudinal changes in metabolic biomarkers after a MedDiet intervention is scarce. A subsample of 48 firefighters from a cluster-randomized trial at Indianapolis fire stations was randomly selected for the metabolomics study at 12 months of follow up (time point 1), where Group 1 (n = 24) continued for another 6 months in a self-sustained MedDiet intervention, and Group 2 (n = 24), the control group at that time, started with an active MedDiet intervention for 6 months (time point 2). A total of 225 metabolites were assessed at the two time points by using a targeted NMR platform. The MedDiet score improved slightly but changes were non-significant (intervention: 24.2 vs. 26.0 points and control group: 26.1 vs. 26.5 points). The MedDiet intervention led to favorable changes in biomarkers related to lipid metabolism, including lower LDL-C, ApoB/ApoA1 ratio, remnant cholesterol, M-VLDL-CE; and higher HDL-C, and better lipoprotein composition. This MedDiet intervention induces only modest changes in adherence to the MedDiet and consequently in metabolic biomarkers. Further research should confirm these results based on larger study samples in workplace interventions with powerful study designs.

Mediterranean Lifestyle to Promote Physical, Mental, and Environmental Health: The Case of Chile

Chile is currently experiencing a progressive epidemiological transition towards chronic diseases. In this country, >50% of annual deaths are attributed to cardiovascular disease and cancer. Moreover, health surveys have shown high prevalence of obesity, diabetes, hypertension, and elevated cardiovascular disease risk. In addition, mental health issues are also frequent among Chilean adults. On the other hand, the agri-food system contributes to 21-37% of greenhouse gases emissions worldwide. Overall, current health and food chain situation calls out for design and implementation of evidence-based feasible and effective nutritional interventions needed to promote physical and mental health along with addressing food sustainability in Chile. Nowadays, the Mediterranean diet is recognized as one of the healthiest dietary patterns based on observational and interventional studies linked to a wide variety of health outcomes. However, a Mediterranean lifestyle goes well beyond food intake: it includes promotion of psychosocial resources, community life as well as cultural traditions. Indeed, Mediterranean lifestyle is a true modus vivendi that integrally promotes physical, mental, and social well-being. In addition, the Mediterranean diet stands out for its environmental sustainability because it is characterized mainly as a plant-based dietary pattern with low carbon and water footprints. Remarkably, Central Chile has a Mediterranean-like setting with plant and animal food production and availability patterns comparable to those present in countries located around the Mediterranean Sea. Therefore, this article reviews how promotion of Mediterranean lifestyle adherence in Chile offers great potential for management of the ongoing epidemiological transition to chronic diseases as well to promote psychological well-being within a unique food system and dietary sustainability vision for this Latin American country.

Association between Dietary Inflammatory Index and Risk of Cardiovascular Diseases Among Firefighters

Background

Diet has an important role in systemic inflammation and development of cardiovascular diseases (CVD). Dietary Inflammatory Index (DII) is a new tool for evaluating the inflammatory potential of the diet. Firefighting is one of the most important occupations with stressful situations and high rates of CVD. In this study, we aimed to investigate the association between dietary inflammatory index (DII) and risk of cardiovascular diseases (CVD) among firefighters.

Methods

Two hundred and seventy-three male firefighters aged 18-50 years in various regions of Tehran participated in this cross-sectional study. Assessment of anthropometric, blood pressure, and biochemical parameters including glucose, total cholesterol, triglyceride, high-density lipoproteins (HDL-C), low-density lipoproteins (LDL-C), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and high-sensitivity C-reactive protein (hs-CRP) was done in all firefighters. A validated semi-quantitative questionnaire (168 items) was used for assessment of DII.

Results

HDL (P-value = 0.03) and hs-CRP (P-value = 0.05) were significantly higher in third tertile of DII scores than first. After adjustment for confounding factors, there was no significant difference in means (P-value >0.05). The association between DII and hs-CRP was not significant (P-value >0.05).

Conclusions

Participants in higher DII scores intake less polyunsaturated fatty acids (PUFAs), monounsaturated fatty acids (MUFAs), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and some antioxidant. The association between hs-CRP and DII was not significant among firefighters.

Anthocyanin Intake and Physical Activity: Associations with the Lipid Profile of a US Working Population

While growing evidence exists on the independent associations between anthocyanins and physical activity on cardiovascular disease (CVD) risk determinants, the possible interaction between these exposures has not yet been studied. We aimed to study the potential synergism between anthocyanin intake and physical activity on lipid profile measures. This cross-sectional study was conducted among 249 US career firefighters participating in the Feeding America’s Bravest trial. Anthocyanin intake was calculated using a validated food frequency questionnaire (FFQ) and physical activity level by a validated questionnaire. Multivariable linear regression models determined the extent to which anthocyanin intake and physical activity predicted lipid parameters. Generalized linear models were used for joint effect and interaction analyses on the multiplicative and additive scales. Both anthocyanins and physical activity were independently inversely associated with total cholesterol:high density lipoprotein (HDL) cholesterol. Only physical activity was inversely associated with triglycerides, low density lipoprotein (LDL) cholesterol:HDL, and triglycerides (TG):HDL. Although the combined exposure of low anthocyanin intake and low physical activity was associated with lower (RR = 2.83; 95% CI: 1.42 to 5.67) HDL cholesterol <40 mg/dL, neither multiplicative (p = 0.72) nor additive interactions were detected (relative excess risk due to interaction (RERI): 0.02; 95% CI: −1.63 to 1.66; p = 0.98). Our findings provide insight on the potential synergism between anthocyanin intake and physical activity on the lipid profile.

Mediterranean Diet: Origin History, Main Components, Evidence of Benefits and Feasibility to Adapt to the Russian Reality

An unhealthy diet takes the lead in the concept of cardiovascular risk factors. It contributes to the development of various so-called “alimentary-dependent” risk factors and conditions: overweight/obesity, hyperglycemia, high blood pressure and hypercholesterolemia. This, in turn, leads to high cardiovascular morbidity and mortality. Many ways to rationalize and improve nutrition have been suggested. But the supremacy in prevention of cardiovascular diseases over the past decades steadily belongs to the Mediterranean diet. The history of origin, its main components, as well as the studies in which its usefulness has been proven, became the subject of this review. In addition, issues of adaptation of the Mediterranean diet to the Russian reality are submitted for discussion.

Sex Differences in Cardiovascular Disease Risk by Socioeconomic Status (SES) of Workers Using National Health Information Database

The socioeconomic status (SES) and health behaviors of workers are associated with the risks of developing obesity, diabetes, hypertension, hyperlipidemia, and other cardiovascular diseases. Herein, we investigated the factors influencing cardiovascular disease (CVD) risk based on the SES of male and female workers. This cross-sectional analysis used the National Health Information Database to assess the associations between gender, SES (income level, residential area), health behaviors, and CVD-related health status of workers, through multinomial logistic regression. Upon analysis of a large volume of data on workers during 2016, the smoking and drinking trends of male and female workers were found to differ, causing different odds ratio (OR) tendencies of the CVD risk. Also, while for male workers, higher ORs of obesity or abdominal obesity were associated with higher incomes or residence in metropolitan cities, for female workers, they were associated with lower incomes or residence in rural areas. Additionally, among the factors influencing CVD risk, lower income and residence in rural areas were associated with higher CVD risk for male and female workers. The study findings imply the importance of developing gender-customized intervention programs to prevent CVD, due to gender-specific associations between CVD-related health status and health behaviors according to SES.

Obesity prevalence in Brazilian firefighters and the association of central obesity with personal, occupational and cardiovascular risk factors: a cross-sectional study

OBJECTIVES

This study aimed to investigate the obesity prevalence in a population of Brazilian firefighters and the association of central obesity (CO) with sociodemographic, occupational, life habits, fitness and health status variables.

DESIGN

Cross-sectional study.

SETTINGS

The data were collected during annual health inspections of firefighters from the Military Fire Service of the State of Espírito Santo, a state in Southeast Brazil.

PARTICIPANTS

The study encompassed 1018 active military firefighters. After exclusion criteria, 892 male firefighters were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The collected data included: sociodemographic, occupational, lifestyle, fitness and health status variables. The associations between these factors and CO were calculated by adjusted OR through a hierarchical logistic regression model.

RESULTS

Obesity estimation by body mass index indicated that 48.65% of the firefighters were overweight and 10.99% were obese. Concerning the body fat percentage, 26.23% of the participants were considered obese, while 18.61% of the firefighters were considered centrally obese or at risk using the waist circumference measure. After adjusted OR analysis, CO was more likely associated with the age range of 50 to 59 years old (OR 2.93; 95% CI 1.05 to 8.14), low self-reported physical activity (OR 1.95; 95% CI 1.14 to 3.34), low cardiorespiratory fitness (OR 5.15; 95% CI 3.22 to 8.23), hyperglycaemia (OR 1.70; 95% CI 1.07 to 2.72) and hypertriglyceridaemia fasting status (OR 3.12; 95% CI 1.75 to 5.55).

CONCLUSIONS

Our study identified an overall high prevalence of overweight and obese individuals in the examined firefighter population. Age and cardiovascular risk factors were directly associated with CO among the firefighters. Cardiovascular risk factors should be routinely inspected within the Brazilian firefighters' corporations in order to improve the health condition and wellness of these workers. These endeavours will improve the performance of the services provided to the population.

Prevalence of the risk factors for cardiometabolic disease among firefighters in the Western Cape province of South Africa

BACKGROUND

Cardiometabolic disease (CMD) risk factors have reached epidemic proportions, with many people at risk of premature disability and death. There is insufficient data regarding the prevalence of CMD risk factors among firefighters in the Western Cape Province of South Africa. The purpose of this study was to examine the prevalence of CMD risk factors among South African firefighters in the Western Cape Province. Additional outcomes were to determine the relationship between BMI and CMD risk factors among firefighters.

METHODS

A total of 219 healthy male firefighters with mean age 37.8±9.80 years volunteered to participate in the study. Anthropometric (ISAK protocol compliant) and physiological variables (ACSM protocol compliant) were assessed. Descriptive statistics, such as mean, standard deviation and percentages were used to examine the CMD risk factors prevalence among the participants.

RESULTS

Based on the BMI categorization, majority (42.5%) of the participants were obese, 17.4% were overweight, 39.7% had a normal BMI, while 0.5% were underweight. The participants with systolic prehypertension were 45.7%, while 14.2% were hypertensive. Furthermore, 39.3% were prediabetic, 18.3% were diabetic, while 1.4% had blood sugar below normal level (hypoglycemic). In terms of total blood cholesterol levels, 45.7% were normal, 38.8% were borderline high, while 15.5% were high in hypercholesterolemia. The majority (51.1%) of the participants reported non-participation in regular physical activity. Between BMI and the typical risk factors, there is a significant correlation with abdominal obesity (r=0.71; P<0.001), systolic blood pressure (r=0.33; P<0.001), diastolic blood pressure (r=0.31; P<0.001), fasting blood glucose (r=0.22; P<0.01) and total cholesterol (r=0.15; P<0.05).

CONCLUSIONS

There was a high prevalence of cardiometabolic disease risk factors among firefighters. Furthermore, urgent intervention focusing on the lifestyle modification and weight management is a necessity.

Assessing Validity of Self-Reported Dietary Intake within a Mediterranean Diet Cluster Randomized Controlled Trial among US Firefighters

Collecting dietary intake data is associated with challenges due to the subjective nature of self-administered instruments. Biomarkers may objectively estimate the consumption of specific dietary items or help assess compliance in dietary intervention studies. Our aim was to use a panel of plasma and urine biomarkers to assess the validity of self-reported dietary intake using a modified Mediterranean Diet Scale (mMDS) among firefighters participating in Feeding America's Bravest (FAB), an MD cluster-randomized controlled trial. In our nested biomarker pilot study, participants were randomly selected from both the MD intervention group (n = 24) and the control group (n = 24) after 12-months of dietary intervention. At baseline data collection for the pilot study (t = 12-months of FAB), participants in the control group crossed-over to receive the MD intervention (active intervention) for 6-months. Participants in the intervention group continued in a self-sustained continuation phase (SSP) of the intervention. Food frequency questionnaires (FFQ), 13-item-mMDS questionnaires, 40 plasma fatty acids, inflammatory biomarkers and urinary hydroxytyrosol and tyrosol were analyzed at both time points. Spearman's correlation, t-tests and linear regression coefficients were calculated using SAS software. Overall, the mMDS derived from the FFQ was highly correlated with the specific 13-domain-mMDS (r = 0.74). The concordance between the two questionnaires for low and high adherence to MD was high for all the participants in the parent trial (κ = 0.76). After 6 months of intervention in the pilot study, plasma saturated fatty acid decreased in both groups (active intervention: -1.3 ± 1.7; p = 0.002; SSP: -1.12 ± 1.90; p = 0.014) and oleic acid improved in the SSP (p = 0.013). Intake of olive oil was positively associated with plasma omega-3 (p = 0.004) and negatively with TNF-α (p < 0.001) at baseline. Choosing olive oil as a type of fat was also associated with higher levels of plasma omega-3 (p = 0.019) at baseline and lower TNF-α (p = 0.023) at follow up. Intake of red and processed meats were associated with lower serum omega-3 (p = 0.04) and fish consumption was associated with lower IL-6 at baseline (p = 0.022). The overall mMDS was associated with an increase in plasma omega-3 (p = 0.021). Good correlation was found between nutrient intake from the FFQ and the corresponding plasma biomarkers (omega-3, EPA and DHA). In this MD randomized controlled trial, some key plasma biomarkers were significantly associated with key MD diet components and the overall mMDS supporting the validity of the mMDS questionnaire as well as compliance with the intervention.

Mediterranean-style diet for the primary and secondary prevention of cardiovascular disease

BACKGROUND

The Seven Countries study in the 1960s showed that populations in the Mediterranean region experienced lower coronary heart disease (CHD) mortality probably as a result of different dietary patterns. Later observational studies have confirmed the benefits of adherence to a Mediterranean dietary pattern on cardiovascular disease (CVD) risk factors but clinical trial evidence is more limited.

OBJECTIVES

To determine the effectiveness of a Mediterranean-style diet for the primary and secondary prevention of CVD.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9); MEDLINE (Ovid, 1946 to 25 September 2018); Embase (Ovid, 1980 to 2018 week 39); Web of Science Core Collection (Thomson Reuters, 1900 to 26 September 2018); DARE Issue 2 of 4, 2015 (Cochrane Library); HTA Issue 4 of 4, 2016 (Cochrane Library); NHS EED Issue 2 of 4, 2015 (Cochrane Library). We searched trial registers and applied no language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) in healthy adults and adults at high risk of CVD (primary prevention) and those with established CVD (secondary prevention). Both of the following key components were required to reach our definition of a Mediterranean-style diet: high monounsaturated/saturated fat ratio (use of olive oil as main cooking ingredient and/or consumption of other traditional foods high in monounsaturated fats such as tree nuts) and a high intake of plant-based foods, including fruits, vegetables and legumes. Additional components included: low to moderate red wine consumption; high consumption of whole grains and cereals; low consumption of meat and meat products and increased consumption of fish; moderate consumption of milk and dairy products. The intervention could be dietary advice, provision of relevant foods, or both. The comparison group received either no intervention, minimal intervention, usual care or another dietary intervention. Outcomes included clinical events and CVD risk factors. We included only studies with follow-up periods of three months or more defined as the intervention period plus post intervention follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We conducted four main comparisons:1. Mediterranean dietary intervention versus no intervention or minimal intervention for primary prevention;2. Mediterranean dietary intervention versus another dietary intervention for primary prevention;3. Mediterranean dietary intervention versus usual care for secondary prevention;4. Mediterranean dietary intervention versus another dietary intervention for secondary prevention.

MAIN RESULTS

In this substantive review update, 30 RCTs (49 papers) (12,461 participants randomised) and seven ongoing trials met our inclusion criteria. The majority of trials contributed to primary prevention: comparisons 1 (nine trials) and 2 (13 trials). Secondary prevention trials were included for comparison 3 (two trials) and comparison 4 (four trials plus an additional two trials that were excluded from the main analyses due to published concerns regarding the reliability of the data).Two trials reported on adverse events where these were absent or minor (low- to moderate-quality evidence). No trials reported on costs or health-related quality of life.Primary preventionThe included studies for comparison 1 did not report on clinical endpoints (CVD mortality, total mortality or non-fatal endpoints such as myocardial infarction or stroke). The PREDIMED trial (included in comparison 2) was retracted and re-analysed following concerns regarding randomisation at two of 11 sites. Low-quality evidence shows little or no effect of the PREDIMED (7747 randomised) intervention (advice to follow a Mediterranean diet plus supplemental extra-virgin olive oil or tree nuts) compared to a low-fat diet on CVD mortality (hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.50 to 1.32) or total mortality (HR 1.0, 95% CI 0.81 to 1.24) over 4.8 years. There was, however, a reduction in the number of strokes with the PREDIMED intervention (HR 0.60, 95% CI 0.45 to 0.80), a decrease from 24/1000 to 14/1000 (95% CI 11 to 19), moderate-quality evidence). For CVD risk factors for comparison 1 there was low-quality evidence for a possible small reduction in total cholesterol (-0.16 mmol/L, 95% CI -0.32 to 0.00) and moderate-quality evidence for a reduction in systolic (-2.99 mmHg (95% CI -3.45 to -2.53) and diastolic blood pressure (-2.0 mmHg, 95% CI -2.29 to -1.71), with low or very low-quality evidence of little or no effect on LDL or HDL cholesterol or triglycerides. For comparison 2 there was moderate-quality evidence of a possible small reduction in LDL cholesterol (-0.15 mmol/L, 95% CI -0.27 to -0.02) and triglycerides (-0.09 mmol/L, 95% CI -0.16 to -0.01) with moderate or low-quality evidence of little or no effect on total or HDL cholesterol or blood pressure.Secondary preventionFor secondary prevention, the Lyon Diet Heart Study (comparison 3) examined the effect of advice to follow a Mediterranean diet and supplemental canola margarine compared to usual care in 605 CHD patients over 46 months and there was low-quality evidence of a reduction in adjusted estimates for CVD mortality (HR 0.35, 95% CI 0.15 to 0.82) and total mortality (HR 0.44, 95% CI 0.21 to 0.92) with the intervention. Only one small trial (101 participants) provided unadjusted estimates for composite clinical endpoints for comparison 4 (very low-quality evidence of uncertain effect). For comparison 3 there was low-quality evidence of little or no effect of a Mediterranean-style diet on lipid levels and very low-quality evidence for blood pressure. Similarly, for comparison 4 where only two trials contributed to the analyses there was low or very low-quality evidence of little or no effect of the intervention on lipid levels or blood pressure.

AUTHORS' CONCLUSIONS

Despite the relatively large number of studies included in this review, there is still some uncertainty regarding the effects of a Mediterranean-style diet on clinical endpoints and CVD risk factors for both primary and secondary prevention. The quality of evidence for the modest benefits on CVD risk factors in primary prevention is low or moderate, with a small number of studies reporting minimal harms. There is a paucity of evidence for secondary prevention. The ongoing studies may provide more certainty in the future.

Barriers and solutions to improving nutrition among fire academy recruits: a qualitative assessment

The primary health concerns among US firefighters are cardiovascular disease, cancer, and depression and occur in an occupational setting where dietary habits are suboptimal. To understand if a diet or lifestyle modification works in a fire academy training setting, it is important to evaluate the cultural barriers and challenges that might be faced. A semi-structured telephone interview method followed by a focus group was used to gather common themes among fire service leaders. Twelve leaders participated in the telephonic interviews and a subset of five in the subsequent group session. Five main themes were identified. The study identified a need for staff and recruits to develop a cohesive culture that facilitates long-term change. Participants reported that incentives for good choices and the elimination of certain poor choices from the food environment would promote healthier choices. The study supports an intervention using education of fire recruits and modifications of the fire academy food environment.

Effectiveness of A Multifactorial Intervention in Increasing Adherence to the Mediterranean Diet among Patients with Diabetes Mellitus Type 2: A Controlled and Randomized Study (EMID Study)

The Mediterranean diet (MD) is recognized as one of the healthiest dietary patterns and has benefits such as improving glycaemic control among patients with type 2 diabetes (T2DM). Our aim is to assess the effectiveness of a multifactorial intervention to improve adherence to the MD, diet quality and biomedical parameters. The EMID study is a randomized and controlled clinical trial with two parallel groups and a 12-month follow-up period. The study included 204 subjects between 25⁻70 years with T2DM. The participants were randomized into intervention group (IG) and control group (CG). Both groups received brief advice about healthy eating and physical activity. The IG participants additionally took part in a food workshop, five walks and received a smartphone application for three months. The population studied had a mean age of 60.6 years. At the 3-month follow-up visit, there were improvements in adherence to the MD and diet quality of 2.2 and 2.5 points, compared to the baseline visit, respectively, in favour of the IG. This tendency of the improvement was maintained, in favour of the IG, at the 12-month follow-up visit. In conclusion, the multifactorial intervention performed could improve adherence to the MD and diet quality among patients with T2DM.

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.

Mediterranean Diet and Cardiometabolic Diseases in Racial/Ethnic Minority Populations in the United States

The Mediterranean diet (MedDiet) has been recommended to the general population by many scientific organizations as a healthy dietary pattern, based on strong evidence of association with improved cardiometabolic health, including lower risk of cardiovascular disease, diabetes, and obesity. However, most studies have been conducted in Mediterranean or European countries or among white populations in the United States (US), while few exist for non-Mediterranean countries or racial/ethnic minority populations in the US. Because most existing studies evaluating adherence to the MedDiet use population-specific definitions or scores, the reported associations may not necessarily apply to other racial/ethnic populations that may have different distributions of intake. Moreover, racial/ethnic groups may have diets that do not comprise the typical Mediterranean foods captured by these scores. Thus, there is a need to determine if similar positive effects from following a MedDiet are observed in diverse populations, as well as to identify culturally-relevant foods reflected within Mediterranean-like patterns, that can facilitate implementation and promotion of such among broader racial/ethnic groups. In this narrative review, we summarize and discuss the evidence from observational and intervention studies on the MedDiet and cardiometabolic diseases in racial/ethnic minority populations in the US, and offer recommendations to enhance research on MedDiet for such populations.

Survival Mediterranean Style: Lifestyle Changes to Improve the Health of the US Fire Service

Cardiovascular disease (CVD) causes almost half of all on-duty deaths in US firefighters and is an important and costly cause of morbidity. In addition, cancer is a growing health concern in this population. Obesity and obesity-associated, cardiometabolic risk clustering are major, modifiable risk factors for fire service CVD and cancer risk. The Mediterranean diet (MedDiet) is proven effective in primary and secondary CVD prevention. It is also associated with a decreased risk of cancer and other chronic diseases. Moreover, it can be adapted into successful workplace interventions. Emerging data from our group regarding the US Fire Service show that greater compliance with the MedDiet is associated with improved CVD risk profiles and less weight gain among career firefighters. Moreover, the fact that career firefighters take a considerable number of meals communally on the job also represents an excellent opportunity for a workplace Mediterranean Diet Nutritional Intervention (MDNI). The devastating effects of obesity, CVD, and cancer on the US fire service are recognized, but currently few effective preventive programs exist. The consistently positive health benefits from following a MedDiet and promising preliminary data in the fire service justify translational research to determine the most effective means of delivering MDNIs to US firefighters. Therefore, a high priority should be assigned to efforts, which can help further disseminate and implement our program of novel behavior change strategies, "Survival Mediterranean Style," throughout the US fire service and eventually to other occupations.

Transferability of the Mediterranean Diet to Non-Mediterranean Countries. What Is and What Is Not the Mediterranean Diet

Substantial evidence has verified the Mediterranean diet's (MedDiet) nutritional adequacy, long-term sustainability, and effectiveness for preventing hard clinical events from cardiovascular disease (CVD), as well as increasing longevity. This article includes a cumulative meta-analysis of prospective studies supporting a strong inverse association between closer adherence to the MedDiet and the incidence of hard clinical events of CVD. The MedDiet has become an increasingly popular topic of interest when focusing on overall food patterns rather than single nutrient intake, not only in Mediterranean countries, but also globally. However, several myths and misconceptions associated with the traditional Mediterranean diet should be clearly addressed and dispelled, particularly those that label as "Mediterranean" an eating pattern that is not in line with the traditional Mediterranean diet. The transferability of the traditional MedDiet to the non-Mediterranean populations is possible, but it requires a multitude of changes in dietary habits. New approaches for promoting healthy dietary behavior consistent with the MedDiet will offer healthful, sustainable, and practical strategies at all levels of public health. The following article presents practical resources and knowledge necessary for accomplishing these changes.