The PREDIMED trial, Mediterranean diet and health outcomes: How strong is the evidence?

Intermittent fasting in the management of diabetes: a review of glycemic control and safety

Intermittent fasting (IF) regimens have emerged as a dietary tool to improve the glycemic profile, but a critical appraisal of clinical studies assessing the effects of IF regimens in patients with diabetes is needed. Thus, this review encompasses clinical studies examining the impact of different IF regimens on markers of glycemic control in patients with diabetes. Furthermore, clinical nuances relative to pharmacological treatment are also addressed, mainly insulin therapy, to discuss the risk of hypoglycemic events. Only a handful of clinical studies have investigated the effects of IF on patients with diabetes. Overall, IF regimens may elicit modest benefits on glycemic parameters in patients with diabetes, but their effects are not necessarily greater than those of control diets. Last, although IF regimens may be considered safe for patients receiving insulin therapy within interventional and observational research, markers of glycemic control must be constantly monitored in clinical practice to reduce the risk of hypoglycemia and its related complications.

An Interdisciplinary Intervention Based on Prescription of Physical Activity, Diet, and Positive Mental Health to Promote Healthy Lifestyle in Patients with Obesity: A Randomized Control Trial

This study used a multimodal approach to address the issue of obesity among individuals with a Body Mass Index (BMI) between 30 and 40 residing in a rural region of north-east Spain. A pretest-posttest model was employed in a clinical trial design, comparing an intervention group with a control group. The intervention, which lasted for a period of nine months, was based on three main strategies: the prescription of physical activity, the promotion of healthy nutritional habits, and the management of emotional wellbeing through Positive Mental Health (PMH). A variety of assessment tools were employed, including the CLASS-AF scale and a stress test for physical activity levels; advanced anthropometry and blood analysis for metabolic and body composition variables; a Mediterranean diet adherence questionnaire for nutritional habits; and a PMH multifactorial questionnaire for the assessment of emotional management. The results revealed significant improvements in the level of physical activity and adherence to the Mediterranean diet in favor of the intervention group, where 89.4% (n = 17) of the participants went from being not very active/sedentary to being active. Also, adherence to the Mediterranean diet improved with a mean increase of 2.2 points on the scale [mean: 10.5 (CI 95%: 9.90, 11.09)]. In addition, significant reductions in body fat [mean: -2.50 kg (CI 95%: -3.56, -1.44)] and free fat mass [mean: -3.38% (IC 95%: -4.34, -2.41), along with decreased cholesterol levels (196 vs. 182 mg/dL), were observed, suggesting a decrease in cardiovascular and metabolic risk. In conclusion, this multimodal intervention was effective at improving the lifestyle of people with obesity and reducing their cardiovascular and metabolic risk. The combination of interventions focused on physical activity, diet, Positive Mental Health, and metabolic changes and were perceived as a comprehensive and complementary strategy in obesity care. These findings highlight the importance of approaching this condition from multiple perspectives to ensure optimal health outcomes.

Functional Foods and Adapted Physical Activity as New Adjuvant Therapy for Chronic Kidney Disease Patients

BACKGROUND

Chronic kidney disease (CKD) will become the fifth leading cause of death in the world by 2040. It is fundamental to prevent and treat this pathology to reduce its impact on national health costs. This trial's aim is to evaluate the effects induced by a combination of consumed functional foods (FFs) with adapted physical activity (APA) on the progression of CKD-related comorbidities.

METHODS

The study lasted 12 weeks. We divided 40 CKD patients into four groups: mixed (FF + APA), APA, FF and control group (usual care). The FFs were characterized by their total antioxidant capacity and antiradical activity. The APA was performed though an online training protocol, three times per week, 1 h each session.

RESULTS

At the end of the study, we observed, in the mixed group, a decrease in azotemia (p = 0.0272), diastolic blood pressure (p = 0.0169), and C-reactive protein (p = 0.0313), with increases in the FORD test (p = 0.0203) and fat free mass (p = 0.0258). The APA group showed a reduction in total cholesterol (p = 0.0039).

CONCLUSIONS

The combination of FFs and APA can help counteract several CKD-related comorbidities, such as arterial hypertension, dyslipidemia and uremic sarcopenia, and improve the CKD patients' quality of life.

Health Literacy and Its Association with the Adoption of the Mediterranean Diet: A Cross-Sectional Study

Health literacy (HL) is a crucial factor influencing health-related decisions, including dietary patterns. The Mediterranean diet is widely recognized as one of the healthiest eating patterns. This study aims to explore the association between HL levels among adults in socially vulnerable contexts and their adoption of the Mediterranean diet. Conducted as part of a cluster-randomized trial in primary schools, the research involved 557 parents of children aged 6 to 10 who consented to participate. HL was assessed using the HLS questionnaire, while adoption of the Mediterranean diet was evaluated using the MEDAS questionnaire. Participants also provided anthropometric and sociodemographic data via a questionnaire, from which BMI was calculated (weight/height2). Education level was categorized as higher education or lower and professional status was classified based on occupational categories. Generalized linear models and logistic regression were employed for analysis. The findings indicate a direct association between HL level and adoption of the Mediterranean diet (B = 0.022, 95% CI 0.010-0.035, p < 0.001), underscoring the influence of HL on dietary choices. Specifically, the healthcare dimension of HL emerges as pivotal in shaping dietary behaviors, particularly towards the Mediterranean diet. These results underscore the importance of policies and programs aimed at enhancing HL, especially among socially vulnerable populations. Prioritizing public health interventions to improve HL is critical for promoting better dietary decision-making.

The Academic Basis of Lifestyle Medicine

There is no longer any serious doubt that daily habits and actions profoundly impact on both short- and long-term health and quality of life. An overwhelming body of scientific and medical literature supports this contention. Thousands of studies support the concept that regular physical activity, healthy nutrition and maintaining a healthy body weight, not smoking cigarettes, obtaining healthy sleep, reducing stress and maintaining positive connections with other individuals all profoundly impact on health. The scientific literature the supports the health impact of these daily habits and actions is underscored by its incorporation into virtually every evidence-based clinical guideline in the area of metabolic diseases. Thus, the scientific basis for lifestyle medicine rests on an enormous body of evidence-based literature. The key issue in lifestyle medicine is to provide an overall framework where these studies, which are often spread over scientific literature in multiple disciplines, can be made accessible to the medical community and to the public at large. This is the essence of the field of lifestyle medicine. The academic basis of lifestyle medicine is robust and needs to be emphasized by all practitioners of lifestyle medicine. This is the key to moving this field forward into the future.

The Role of Parental Adherence to the Mediterranean Diet and Family Time Together in Children's Weight Status: The BeE-School Project

The family context has been associated with children's weight status. This study aims to investigate the association of parents' adherence to the Mediterranean diet and family time with the weight status of children. The research is part of BeE-school, a cluster-randomized trial implemented in primary schools located in socially vulnerable contexts. A total of 735 children (380 boys and 355 girls) aged 6 to 10 participated in the study. Anthropometrics were assessed during school time, and weight status was categorized, while parents self-reported sociodemographic variables, adherence to the Mediterranean diet (MEDAS questionnaire), and family time. Children from families with higher education levels whose parents have a high adherence to the Mediterranean diet have lower odds of overweight/obesity (odds ratio (OR) 0.301, 95% CI 0.143-0.634, p = 0.002). Also, children from families with lower education levels who have more time together with their family have lower odds of overweight/obesity (OR 0.731, 95% CI 0.573-0.934, p = 0.012). The family environment, mainly family time together and adherence to the Mediterranean diet, exerts a significant influence on children's weight status. Professionals working in children's health should consider the family when fostering health-promoting behaviors.

Association of a High Healthy Eating Index Diet with Long-Term Visceral Fat Loss in a Large Longitudinal Study

We aimed to investigate the association of a sustainable diet with a long-term reduction in waist circumference (WC) while identifying novel biomarkers for WC reduction (WCR). The participants were recruited initially during 2004-2013 in a large hospital-based cohort, and the follow-up measurements were conducted during 2012-2016. The 65,611 adults aged 45-75 were categorized into WC-loss (n = 22,290) and WC-gain (n = 43,321). Each study investigated demographic, anthropometric, biochemical, genetic, and dietary factors. The modified Healthy Eating Index (MHEI), dietary patterns, and glycemic index were calculated from a validated semi-quantitative food frequency questionnaire. Novel biomarkers influencing WC reduction were identified using machine learning approaches. A WCR was inversely associated with metabolic syndrome (MetS) risk and its components. Daily energy intake did not differ between those with and without WCR. However, MHEI, which represents diet quality, demonstrated a positive association with WCR. Among various dietary patterns, the Asian-style balanced diet (ABD), including more fermented soybeans and less restricted salt than the Diet Approach to Stop Hypertension, was positively associated with WCR. However, an inverse association was observed between the diet that was high in noodle and processed meat consumption and that which was high in rice consumption. However, the PRS for abdominal obesity did not significantly interrupt WCR. The receiver operating characteristic curve in the prediction model for WCR was about 0.86. The biomarkers in the models included MetS components, inflammation index, diet components, alcohol consumption, and smoking status, but not genetic factors. In conclusion, adopting a high-quality diet with a high MHEI like ABD leads to WCR, irrespective of genetic influences. These results could be applied to develop effective strategies for preventing and managing abdominal obesity.

The role of statins in diabetic retinopathy

Diabetes mellitus is a growing global public health issue estimated to affect around 600 million people by 2040 [1]. It occurs in populations throughout the world, is increasing in both the developing world and high-income countries and also affects young, working-age people. Ocular involvement in diabetes occurs early in the disease and is present in over a third of diabetes mellitus Type 2 patients at the time of diagnosis. Blindness due to diabetic retinopathy (DR) remains a leading cause of adult-onset blindness, [1] which results from disruption of retinal vasculature, ischemia and its consequences and exudation causing macular edema. The prevalence of diabetic retinopathy is increasing at a greater rate than other causes of blindness including cataract, refractive errors, age-related macular degeneration and glaucoma. Compared to cataract and refractive error, management of diabetic retinopathy requires vast medical resources, including trained medical practitioners able to perform ocular injections and ophthalmologists for laser treatments and retinal surgery. This creates a significant burden on medical services as care for these patients lasts decades.

Evaluation of food insecurity and associated factors in women of childbearing age: A community-based study from Turkey

Food security is an important factor in ensuring a healthy diet. However, it has been reported that women are more vulnerable to food insecurity than men in many countries. In addition, there is little evidence that Mediterranean diet (MD) adherence is associated with a lower risk of food insecurity. Therefore, this study aimed to evaluate food insecurity and associated factors in women of childbearing age. In addition, women's adherence to MD and its relationship with food insecurity were evaluated. This descriptive and cross-sectional study was conducted with 2675 adult women aged 18-49. The demographic characteristics, anthropometric measurements, nutritional habits, compliance with the MD, and the level of food insecurity were evaluated using the structured, self-administered, web-based questionnaire form. The mean age of the individuals was 29.5 ± 10.35 years. 21.6% of individuals had food insecurity, and 5.2% had severe food insecurity. 36.4% of the individuals adhere to the MD. There was a statistically significant difference between the individuals with and without food security regarding age, marital status, and income status (p < .05). However, there was no statistically significant difference in terms of the Mediterranean diet adherence score (MEDAS) and MEDAS classification between individuals with and without food security (p > .05). It was determined that age, marital status, and income status affected food insecurity (R 2 = 0.374; p < .001). Also, it was determined that age, number of main meals and snacks, and income status affected adherence to MD (R 2 = 0.286; p < .001). In conclusion, considering the fragility of women in food insecurity, more comprehensive studies should be conducted in this area to better define the factors associated with food insecurity in women and inform policymakers. In addition, the results of this study can shed light on comprehensive intervention studies in this area.

The Effects of the Mediterranean Diet on Health and Gut Microbiota

The Mediterranean Diet (MD) is plant-based and consists of multiple daily portions of vegetables, fruit, cereals, and olive oil. Although there are challenges with isolating the MD from the typical Mediterranean lifestyle and culture (including prolonged 'social' meals and siestas), much evidence supports the health benefits of the MD that include improved longevity, reduced metabolic risk of Diabetes Mellitus, obesity, and Metabolic Syndrome, reduced risk of malignancy and cardiovascular disease, and improved cognitive function. The MD is also associated with characteristic modifications to gut microbiota, mediated through its constituent parts (primarily dietary fibres, extra virgin olive oil, and polyunsaturated fatty acids [including ω-3]). These include enhanced growth of species that produce short-chain fatty acids (butyrate), such as Clostridium leptum and Eubacterium rectale, enhanced growth of Bifidobacteria, Bacteroides, and Faecalibacterium prausnitzii species, and reduced growth of Firmicutes and Blautia species. Such changes in gut microbiota are known to be associated favourably with inflammatory and oxidative status, propensity for malignancy and overall metabolic health. A key challenge for the future is to explore the extent to which the health benefits of the MD are mediated by such changes to gut microbiota. The MD confers both health and environmental benefits. Adoption of the MD should perhaps be encouraged and facilitated more generally and not just restricted to populations from Mediterranean regions. However, there are key challenges to this approach that include limited perennial availability of the constituent parts of the MD in some non-Mediterranean regions, intolerability of a high-fibre diet for some people, and potential cultural disconnects that juxtapose some traditional (including Western) diets with the MD.

Influence of the Mediterranean Diet on Healthy Aging

The life expectancy of the global population has increased. Aging is a natural physiological process that poses major challenges in an increasingly long-lived and frail population. Several molecular mechanisms are involved in aging. Likewise, the gut microbiota, which is influenced by environmental factors such as diet, plays a crucial role in the modulation of these mechanisms. The Mediterranean diet, as well as the components present in it, offer some proof of this. Achieving healthy aging should be focused on the promotion of healthy lifestyle habits that reduce the development of pathologies that are associated with aging, in order to increase the quality of life of the aging population. In this review we analyze the influence of the Mediterranean diet on the molecular pathways and the microbiota associated with more favorable aging patterns, as well as its possible role as an anti-aging treatment.

Design and Implementation of a Culturally-Tailored Randomized Pilot Trial: Puerto Rican Optimized Mediterranean-Like Diet

Background

Adhering to a Mediterranean Diet (MedDiet) is associated with a healthier cardiometabolic profile. However, there are limited studies on the MedDiet benefits for non-Mediterranean racial/ethnic minorities, for whom this diet may be unfamiliar and inaccessible and who have a high risk of chronic diseases.

Objectives

To describe the study design of a pilot trial testing the efficacy of a MedDiet-like tailored to adults in Puerto Rico (PR).

Methods

The Puerto Rican Optimized Mediterranean-like Diet (PROMED) was a single-site 4-mo parallel two-arm randomized pilot trial among a projected 50 free-living adults (25-65 y) living in PR with at least two cardiometabolic risk factors (clinicaltrials.gov registration #NCT03975556). The intervention group received 1 individual nutritional counseling session on a portion-control culturally-tailored MedDiet. Daily text messages reinforced the counseling content for 2 mo, and we supplied legumes and vegetable oils. Participants in the control group received cooking utensils and one standard portion-control nutritional counseling session that was reinforced with daily texts for 2 mo. Text messages for each group were repeated for two more months. Outcome measures were assessed at baseline, 2 and 4 m. The primary outcome was a composite cardiometabolic improvement score; secondary outcomes included individual cardiometabolic factors; dietary intake, behaviors, and satisfaction; psychosocial factors; and the gut microbiome.

Results

PROMED was designed to be culturally appropriate, acceptable, accessible, and feasible for adults in PR. Strengths of the study include applying deep-structure cultural components, easing structural barriers, and representing a real-life setting. Limitations include difficulty with blinding and with monitoring adherence, and reduced timing and sample size. The COVID-19 pandemic influenced implementation, warranting replication.

Conclusions

If PROMED is proven efficacious in improving cardiometabolic health and diet quality, the findings would strengthen the evidence on the healthfulness of a culturally-appropriate MedDiet and support its wider implementation in clinical and population-wide disease-prevention programs.

Dietary Patterns, Cardiometabolic and Lifestyle Variables in Greeks with Obesity and Metabolic Disorders

There is considerable evidence that some dietary patterns contribute to obesity and metabolic disorders but there is less data on diet's association with different health parameters. We investigated the interaction between different dietary patterns and anthropometric, biochemical, lifestyle, and psychological health parameters in a Greek population with obesity and metabolic disorders. To the best of our knowledge, this is the first study in Greece with a thorough and holistic approach in analyzing such relationships. For assessing food patterns, revealing underlying structures, and reducing the number of variables we applied exploratory factor analysis (EFA). Principal Component Analysis was chosen as the extraction method using Varimax rotation, and three regression sets were computed. The study involved 146 Greek metabolically unhealthy obese adults, both men and women. Our cohort was categorized into four dietary patterns: "Western type diet", "Mediterranean-like diet", "Healthy diet", and "Animal meat and sauces diet". Dietary patterns characterized by a high consumption of energy-dense and animal-derived foods were positively associated with anthropometric and biochemical parameters related to metabolic disorders. Plant-based, healthier dietary patterns, on the other hand, were associated with better biochemical and mental health profiles among metabolically unhealthy obese individuals.

Body Weight, Central Adiposity, and Fasting Hyperglycemia Are Associated with Tumor Characteristics in a Brazilian Cohort of Women with Breast Cancer

The aim of this study was to evaluate the association of overweight, obesity, excess central adiposity, hyperglycemia, and diabetes mellitus with tumor characteristics in breast cancer. In this retrospective cohort study that enrolled 2127 women with breast cancer, the independent variables collected were fasting blood glucose, body mass index, central adiposity (waist circumference and waist-to-hip circumference ratio (WHR)), and waist-to-height ratio. The tumor characteristics (infiltrating, ductal grade, hormone receptor-positive (HR+), human epidermal growth factor receptor, triple negative, size, lymph node involvement, and clinical stage) were the dependent variables. Most of the women were postmenopausal (73.5%), with an infiltrating tumor (83.0%), HR+ (82.0%), and overweight or obese (71.0%). For the premenopausal women, obesity was associated with grade 3 ductal tumor (odds ratio (OR): 1.70; 95% confidence interval (95% CI): 1.09-2.66), triple negative (OR: 1.37, 95% CI: 1.08-3.24), and size ≥ 2 cm (OR: 2.20, 95% CI: 1.36-3.56). For the postmenopausal women, obesity was associated with WHR, infiltrating tumor (OR: 1.73, 95% CI: 1.56-1.95), size ≥ 2 cm (OR: 1.38, 95% CI: 1.11-1.71), lymph node involvement (OR: 1.24, 95% CI: 1.02-1.56), and stages III-IV (OR: 1.76, 95% CI: 1.30-2.65). Excess body weight and central adiposity were associated with tumor aggressiveness characteristics in women with breast cancer, confirming the importance of nutritional status.

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.

Kommentar zu den neuen Leitlinien (2021) der Europäischen Gesellschaft für Kardiologie (ESC) zur kardiovaskulären Prävention

Die bedeutendste Veränderung in den neuen ESC-Leitlinien zur kardiovaskulären Prävention von 2021 betrifft die Risikoevaluation gesunder Menschen: Durch die Einführung von SCORE2 wird eine neue epidemiologische Studienbasis für die Risikoeinschätzung eingeführt, die erstmals die Berechnung der kardiovaskulären Erkrankungswahrscheinlichkeit und der kardiovaskulären Mortalität erlaubt. Zudem ermöglicht SCORE2 OP nun auch eine zuverlässige Risikobestimmung bei Menschen oberhalb des 65. Lebensjahres bis in die 9. Lebensdekade. Die Altersdynamisierung der Risikoschwellen für hohes und sehr hohes kardiovaskuläres Risiko trägt dem Gedanken der Lebenszeitexposition Rechnung, führt aber evtl. zu einer höheren Zahl behandlungspflichtiger Patienten. Mit dem 2‑Step-Approach empfiehlt die ESC eine pragmatische Herangehensweise an die Risikofaktoreinstellung: Während in Step 1 basale Präventionsziele für alle Patienten vorgegeben werden, soll der Arzt im Gespräch mit dem Patienten in Abhängigkeit von 10-Jahres-Risiko, Lebenszeitnutzen, Begleiterkrankungen und Patientenwunsch die optimalen Präventionsziele besprechen und anschließend anstreben. Leider werden in den Leitlinien die Kriterien, wer für die optimalen Präventionsziele geeignet ist, nicht klar definiert. Damit besteht die Gefahr einer subjektiven Fehleinschätzung seitens der behandelnden Ärzte, die möglicherweise vielen Patienten den Nutzen einer optimalen kardiovaskulären Prävention vorenthält. Der von den Autoren der Leitlinie hervorgehobene Gedanke des „Freedom of Choice“ könnte insofern zum Bumerang werden und zur Verwässerung der Implementierung einer optimalen Prävention führen. Hierzu und zu möglichen Verschiebungen beim Anteil behandlungsbedürftiger Patienten in der Primär- und Sekundärprävention sind in den nächsten Jahren Längsschnittstudien erforderlich, um Umsetzungsqualität und Prognosewirksamkeit zu objektivieren.

Mediterranean Diet and Cardiovascular Prevention: Why Analytical Observational Designs Do Support Causality and Not Only Associations

Causal reductions in cardiovascular disease (CVD) with the Mediterranean diet (MedDiet) are supported by randomized trials, but the ability of nonrandomized studies to provide causal inferences in nutritional epidemiology is questioned. The "Seguimiento Universidad de Navarra" (SUN) project, conducted during 1999-2019 with 18,419 participants, was used to try to refute non-causal explanations for the inverse association found between adherence to the MedDiet and reduced CVD risk. A framework of different analytical strategies is proposed: alternative definitions of the exposure, exploration of residual confounding, resampling methods, depiction of absolute risks across the follow-up period, trial emulation, and negative controls. Additionally, we calculated the rate advancement period (RAP). We found that one standard deviation increase in the most frequently used MedDiet score was associated with a 29% relative reduction in CVD risk (95% Confidence Interval [CI] 14-41%), which is almost identical to that found in 2 randomized trials. The RAP of CVD would be postponed by an average of 7.9 years (95% CI: 1.6 to 14.2 years) by switching from low (MDS = 0 to2) to high (MDS = 7 to 9) adherence to the MedDiet in the fully adjusted model. Sensitivity analyses, graphical representations of absolute risks, trial emulation, and negative controls also supported causality. In conclusion, a framework of analytical approaches supported the causal effect of the MedDiet on CVD prevention using observational data. Similar methodology could be applied for causal inferences regarding other hypotheses.

Associations of the Paleolithic Diet Pattern Scores and the Risk of Breast Cancer among Adults: A Case-Control Study

Evidence suggests the role of changing traditional lifestyle patterns such as Paleolithic to modern lifestyle in the incidence and epidemic of chronic diseases. Thus, this study aimed to investigate the association between Paleolithic diet (PD) and risk of Breast Cancer (BC) in adult Iranian women. This matched case-control study included 253 women with BC and 267 healthy women aged >18 years. PD score was evaluated using a validated 168-item quantitative food frequency questionnaire. Conditional logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (95%CIs), and dose-response was investigated. Mean of PD score was 39.00 ± 6.39. Among the food groups of the PD components, BC patients significantly had lower consumption of healthy food groups as vegetables, fruits, fish, and nuts, higher intakes of sugar-sweetened beverages as well as grains and starches. After adjustment for potential confounders, comparing the highest quartile of PD scores with the lowest quartile, a decrease in the risk of BC was observed for all women (OR: 0.26; 95% CI: 0.13-0.53), as well as those premenopausal (OR: 0.29; 95% CI: 0.11), and postmenopausal (OR: 0.17; 95% CI: 0.05 - 0.56). Our findings show that adherence to the PD pattern significantly reduces the risk of BC in the population studied. However, prospective studies are needed to further investigate this association.

Higher Adherence to the Mediterranean Dietary Pattern Is Inversely Associated With Severity of COVID-19 and Related Symptoms: A Cross-Sectional Study

Background and Aims

Adherence to the Mediterranean diet (MD) has been associated with a decreased risk of developing a variety of chronic diseases that are comorbidities in COVID-19 patients. However, its association to the severity and symptoms of COVID-19 are still unknown. This study aimed to examine the association between adherence to the MD pattern and COVID-19 severity and symptoms in Iranian hospitalized patients.

Methods

In this cross-sectional study, 250 COVID-19 patients aged 18 to 65 were examined. We employed a food frequency questionnaire (FFQ) to obtain data on dietary intake of participants in the year prior to their COVID-19 diagnosis. COVID-19 severity was determined using the National Institutes of Health's Coronavirus Disease 2019 report. Additionally, symptoms associated with COVID-19, inflammatory markers, and other variables were evaluated. The scoring method proposed by Trichopoulou et al. was used to assess adherence to the MD.

Results

The participants' mean age was 44.1 ± 12.1 years, and 46% of them had severe COVID-19. Patients who adhered more closely to the MD had lower serum C-reactive protein levels (7.80 vs. 37.36 mg/l) and erythrocyte sedimentation rate (14.08 vs. 42.65 mm/h). Those with the highest MD score were 77% less likely to have severe COVID-19 after controlling for confounding variables. The MD score was also found to be inversely associated with COVID-19 symptoms, including dyspnea, cough, fever, chills, weakness, myalgia, nausea and vomiting, and sore throat.

Conclusion

Higher adherence to the MD was associated with a decreased likelihood of COVID-19 severity and symptoms, as well as a shorter duration of hospitalization and convalescence, and inflammatory biomarkers.

Application of Mediterranean Diet in Cardiovascular Diseases and Type 2 Diabetes Mellitus: Motivations and Challenges

Objective: Cardiovascular disease (CVD) is the leading cause of disability and death in many countries. Together with CVD, Type 2 diabetes mellitus (T2DM) accounts for more than 80% of all premature non-communicable disease deaths. The protective effect of the Mediterranean diet (MedDiet) on CVD and its risk factors, including T2DM, has been a constant topic of interest. Notwithstanding, despite the large body of evidence, scientists are concerned about the challenges and difficulties of the application of MedDiet. This review aims to explore the motivations and challenges for using MedDiet in patients with CVD and T2DM. Design: An electronic search was conducted for articles about MedDiet published in PubMed, ScienceDirect, Scopus, and Web of Science up to December 2021, particularly on CVD and T2DM patients. From a total of 1536 studies, the final eligible set of 108 studies was selected. Study selection involved three iterations of filtering. Results: Motivation to apply MedDiet was driven by the importance of studying the entire food pattern rather than just one nutrient, the health benefits, and the distinct characteristics of MedDiet. Challenges of the application of MedDiet include lacking universal definition and scoring of MedDiet. Influences of nutritional transition that promote shifting of traditional diets to Westernized diets further complicate the adherence of MedDiet. The challenges also cover the research aspects, including ambiguous and inconsistent findings, the inexistence of positive results, limited evidence, and generalization in previous studies. The review revealed that most of the studies recommended that future studies are needed in terms of health benefits, describing the potential benefits of MedDiet, identifying the barriers, and mainly discussing the effect of MedDiet in different populations. Conclusions: In general, there is consistent and strong evidence that MedDiet is associated inversely with CVD risk factors and directly with glycemic control. MedDiet is the subject of active and diverse research despite the existing challenges. This review informs the health benefits conferred by this centuries-old dietary pattern and highlights MedDiet could possibly be revolutionary, practical, and non-invasive approach for the prevention and treatment CVD and T2DM.

Where Do We Stand in the Behavioral Pathogenesis of Inflammatory Bowel Disease? The Western Dietary Pattern and Microbiota-A Narrative Review

Despite the increasing knowledge with regard to IBD (inflammatory bowel disease), including ulcerative colitis (UC) and Crohn’s disease (CD), the etiology of these conditions is still not fully understood. Apart from immunological, environmental and nutritional factors, which have already been well documented, it is worthwhile to look at the possible impact of genetic factors, as well as the composition of the microbiota in patients suffering from IBD. New technologies in biochemistry allow to obtain information that can add to the current state of knowledge in IBD etiology.

Sustainability Dimensions of the Mediterranean Diet: A Systematic Review of the Indicators Used and Its Results

The concern about sustainability is growing and the Mediterranean diet has been extensively identified as a promising model, with benefits for human and environmental health. This systematic review aims to identify and describe the indicators that have been used to evaluate the sustainability of the Mediterranean diet and the results from their application. A methodology using PRISMA guidelines was followed, and searches were performed in Web of Science, PubMed, Scopus, and GreenFile. A total of 32 studies assessing the sustainability of the Mediterranean diet were identified. Twenty-five of these studies quantified the environmental impact, 7 studies evaluated the nutritional quality, and 12 studies assessed the daily cost of this dietary pattern. A total of 33 distinct indicators were identified, of which 10 were used to assess the environmental dimension (mainly, carbon, water, and ecological footprint), 8 were used to assess the nutritional dimension (mainly Health score and Nutrient Rich Food Index), 1 was used to assess the economic dimension (dietary cost), and 8 used combined indicators. The remaining 6 indicators for the assessment of sociocultural dimension were only identified in 1 study but were not measured. The Mediterranean diet had a lower environmental impact than Western diets and showed a carbon footprint between 0.9 and 6.88 kg CO2/d per capita, a water footprint between 600 and 5280 m3/d per capita, and an ecological footprint between 2.8 and 53.42 m2/d per capita. With regard to the nutritional dimension, the Mediterranean diet had a high nutritional quality and obtained 122 points on the Health score and ranged between 12.95 and 90.6 points on the Nutrient Rich Food Index. The cost of the Mediterranean diet is similar to other diets and varied between 3.33 and 14.42€/d per capita. These findings show that no uniformity in assessing the MDiet's sustainability exists.

Low Adherence to the Mediterranean Diet Is Associated with Poor Socioeconomic Status and Younger Age: A Cross-Sectional Analysis of the EpiDoC Cohort

The Mediterranean diet (MD) is recognized as one of the healthiest dietary patterns as it has been consistently associated with several beneficial health outcomes. Adherence to the MD pattern has been decreasing in southern European countries for the last decades, especially among low socioeconomic groups. The aim of this study was to assess the adherence to the MD in Portugal, to evaluate regional differences, and explore associated factors (sociodemographic, economic, and lifestyles behaviors). This study used the third data collection wave of the Epidemiology of Chronic Diseases Cohort Study (EpiDoC 3). MD adherence was assessed using the Portuguese-validated MD adherence score (MEDAS) questionnaire. Non-adjusted and adjusted logistic regression models were used to assess the risk factors for low MD adherence and individual MEDAS items. In this cross-sectional evaluation of the EpiDoC 3 cohort study (n = 5647), 28.8% of the Portuguese population had low adherence to a MD. Azores and Madeira had lower adherence to the MD than the rest of the country. Younger individuals in lower income categories (e.g., OR_{finding it very difficult} = 1.48; 95% CI 1.16-1.91) and with a lower educational level (e.g., OR_{0-4 years} = 2.63; 95% CI 2.09-3.32) had higher odds of having a lower adherence to the MD. Portuguese adults have a high prevalence of low adherence to the MD, especially among those who are younger and have lower socioeconomic status. Public health policies to promote adherence to the MD should pay special attention to these groups.

Healthy Lifestyle Score and Incidence of Glaucoma: The Sun Project

Background: The relationship between modifiable risk factors, such as diet and lifestyle, and glaucoma remains controversial. We analyse the effect of the Mediterranean lifestyle (ML) on glaucoma incidence in the “Seguimiento Universidad de Navarra” (SUN) Project. Methods: The SUN Healthy Lifestyle Score (SHLS) includes 10 healthy habits: never having smoked, moderate to high physical activity, Mediterranean diet adherence, moderate alcohol consumption, low television exposure, no binge drinking, short afternoon napping, meeting up with friends, working at least 40 h/wk, and low body mass index. The information was collected biennially through self-reported questionnaires. The relationship between new glaucoma cases and the SHLS was assessed by Cox regression using hazard ratios. Crude, multi-adjusted, and sensitivity analyses were performed. Results: During a median of 12 years of follow-up, 261 (1.42%) new cases of glaucoma were identified among 18,420 participants. After adjusting for potential confounders, participants in the healthiest SHLS category showed a significantly reduced risk of glaucoma compared to those in the lowest SHLS category (adjusted HR = 0.51, 95% CI = 0.28–0.93). For each point added to the SHLS, the risk of glaucoma relatively dropped 5%. Conclusions: Higher adherence to a ML, measured by the SHLS, was significantly associated with a lower risk of developing glaucoma. Based on our study, the ML is a protective factor for glaucoma incidence.

[Nutrition in Case of Heart Failure]

Nutrition in Case of Heart Failure Abstract. Despite the complexity of the subject, nutritional medicine has made important advances in recent years, especially regarding cardiovascular health and for patients with heart failure. There is quite good evidence on specific diets, such as the Mediterranean and plant-based diets, but also on individual micronutrients, such as intravenous iron supplementation of iron deficiency in heart failure. No precise quantities can yet be named when dealing with the recommended amount of salt in heart failure patients, but the intake of high amounts of salt (>12 g/day) should be avoided. Considering the risk of malnutrition in this vulnerable patient population, an individualized nutritional therapy is advisable for some patients. This requires targeted screening for malnutrition. Nutritional medicine research still lacks many answers to further questions regarding heart failure patients. More randomized controlled trials and their meta-analyses are therefore required. Studies available so far have - among other shortcomings - paid too little attention to differences in nutrition in the different types and stages of heart failure. Interdisciplinary collaboration between cardiologists, hospital internists, general practitioners and nutritional therapists is in any case crucial for optimal treatment of patients with heart failure.

Female Fertility and the Nutritional Approach: The Most Essential Aspects

Infertility is an increasing problem that affects couples attempting pregnancy. A growing body of evidence points to a link between diet and female fertility. In fact, data show that a diet high in trans fats, refined carbohydrates, and added sugars can negatively affect fertility. Conversely, a diet based on the Mediterranean dietary patterns, i.e., rich in dietary fiber, omega-3 (ɷ-3) fatty acids, plant-based protein, and vitamins and minerals, has a positive impact on female fertility. An unhealthy diet can disrupt microbiota composition, and it is worth investigating whether the composition of the gut microbiota correlates with the frequency of infertility. There is a lack of evidence to exclude gluten from the diet of every woman trying to become pregnant in the absence of celiac disease. Furthermore, there are no data concerning adverse effects of alcohol on female fertility, and caffeine consumption in the recommended amounts also does not seem to affect fertility. On the other hand, phytoestrogens presumably have a positive influence on female fertility. Nevertheless, there are many unanswered questions with regard to supplementation in order to enhance fertility. It has been established that women of childbearing age should supplement folic acid. Moreover, most people experience vitamin D and iodine deficiency; thus, it is vital to control their blood concentrations and consider supplementation if necessary. Therefore, since diet and lifestyle seem to be significant factors influencing fertility, it is valid to expand knowledge in this area.

Physical Activity and Nutritional Influence on Immune Function: An Important Strategy to Improve Immunity and Health Status

Physical activity (PA) and nutrition are the essential components of a healthy lifestyle, as they can influence energy balance, promote functional ability of various systems and improve immunity. Infections and their associated symptoms are the common and frequent challenges to human health that are causing severe economic and social consequences around the world. During aging, human immune system undergoes dramatic aging-related changes/dysfunctions known as immunosenescence. Clinically, immunosenescence refers to the gradual deterioration of immune system that increases exposure to infections, and reduces vaccine efficacy. Such phenomenon is linked to impaired immune responses that lead to dysfunction of multiple organs, while lack of physical activity, progressive loss of muscle mass, and concomitant decline in muscle strength facilitate immunosenescence and inflammation. In the present review, we have discussed the role of nutrition and PA, which can boost the immune system alone and synergistically. Evidence suggests that long-term PA is beneficial in improving immune system and preventing various infections. We have further discussed several nutritional strategies for improving the immune system. Unfortunately, the available evidence shows conflicting results. In terms of interaction with food intake, PA does not tend to increase energy intake during a short time course. However, overcoming nutritional deficiencies appears to be the most practical recommendation. Through the balanced nutritious diet intake one can fulfill the bodily requirement of optimal nutrition that significantly impacts the immune system. Supplementation of a single nutrient as food is generally not advisable. Rather incorporating various fruits and vegetables, whole grains, proteins and probiotics may ensure adequate nutrient intake. Therefore, multi-nutrient supplements may benefit people having deficiency in spite of sufficient diet. Along with PA, supplementation of probiotics, bovine colostrum, plant-derived products and functional foods may provide additional benefits in improving the immune system.

Translating the advanced glycation end products (AGEs) knowledge into real-world nutrition strategies

Advanced glycation end products (AGEs) are glycated proteins or lipids derived from complex metabolic pathways involved in the pathophysiology of various diseases, especially diabetes and diabetes-related complications. These compounds are omnipresent in human life, with both endogenous and exogenous sources. Despite the well-elucidated disease mechanisms, little is known about the AGEs/nutrition nexus in the circles of clinical practice recommendations. This review seeks to translate the accumulated knowledge about the biochemistry and pathophysiology of AGEs into a nutritional intervention based on real-world prescriptions.

Intelligent Coaching Assistant for the Promotion of Healthy Habits in a Multidomain mHealth-Based Intervention for Brain Health

Brain Health is defined as the development and preservation of optimal brain integrity and neural network functioning for a given age. Recent studies have related healthy habits with better maintenance of brain health across the lifespan. As a part of the Barcelona Brain Health Initiative (BBHI), a mHealth platform has been developed with the purpose of helping people to improve and monitor their healthy habits, facilitating the delivery of health coaching strategies. A decision support system (DSS), named Intelligent Coaching Assistant (ICA), has been developed to ease the work of professional brain health coaches, helping them design and monitor adherence to multidomain interventions in a more efficient manner. Personalized recommendations are based on users’ current healthy habits, individual preferences, and motivational aspects. Taking these inputs, an initial user profile is defined, and the ICA applies an algorithm for determining the most suitable personalized intervention plan. An initial validation has been done focusing on assessing the feasibility and usability of the solution, involving 20 participants for three weeks. We conclude that this kind of technology-based intervention is feasible and implementable in real-world settings. Importantly, the personalized intervention proposal generated by the DSS is feasible and its acceptability and usability are high.

Modulation of Telomere Length by Mediterranean Diet, Caloric Restriction, and Exercise: Results from PREDIMED-Plus Study

Telomere length (TL) has been associated with aging and is determined by lifestyle. However, the mechanisms by which a dietary pattern such as the Mediterranean diet (MedDiet) affects TL homeostasis are still unknown. Our aim was to analyse the effect of an energy-restricted MedDiet with physical activity promotion (intervention group) versus an unrestricted-caloric MedDiet with no weight-loss advice (control group) on TL and 8-hydroxydeoxyguanosine (8-OHdG) plasma levels. In total, 80 non-diabetic participants with metabolic syndrome were randomly selected from the PREDIMED (PREvención con DIeta MEDiterránea)-Plus-Reus study. TL was measured by a hybridisation method and 8-OHdG levels by ELISA at baseline and after one year of intervention. Linear mixed models (LMM)—raw and after adjusting for potential confounders—were used to examine the associations between TL or 8-OHdG plasma levels by intervention group and/or time. A total of 69 subjects with available DNA samples were included in the analyses. A significant β-coefficient was found for time towards increasing values through the year of follow-up for TL (unadjusted β of 0.740 (95% CI: 0.529 to 0.951), and multivariable model β of 0.700 (95% CI: 0.477 to 0.922)). No significant βs were found, neither for the intervention group nor for the interaction between the intervention group and time. Regarding 8-OHdG plasma levels, no significant βs were found for the intervention group, time, and its interaction. Our results suggest that MedDiet could have an important role in preventing telomere shortening, but calorie restriction and exercise promotion did not provide an additional advantage concerning telomere length after one year of MedDiet intervention.

The Mediterranean diet and health: a comprehensive overview

The Mediterranean diet (MedDiet), one of the most studied and well-known dietary patterns worldwide, has been associated with a wide range of benefits for health. In the present narrative review, we aimed to provide a comprehensive overview of the current knowledge on the relation of the MedDiet to important health outcomes, considering both observational and intervention studies with both risk factors and clinical diseases as outcomes. In addition, we considered the clinical and public health impacts of the MedDiet on both human and planetary health. Earlier research confirmed by recent studies has provided strong evidence for the benefits of the MedDiet on cardiovascular health, including reduction in the incidence of cardiovascular outcomes as well as risk factors including obesity, hypertension, metabolic syndrome, and dyslipidaemia. There is also evidence that MedDiet is associated with lower rates of incident diabetes, and better glycaemic control in diabetic patients compared to control diets. In prospective studies, adherence to the MedDiet reduced mortality, especially cardiovascular mortality, hence increased longevity. In addition, it has been associated with less age-related cognitive dysfunction and lower incidence of neurodegenerative disorders, particularly Alzheimer's disease. Furthermore, the relatively low environmental impacts (water, nitrogen and carbon footprint) of the MedDiet is an additional positive aspect of the Mediterranean dietary model. It is likely that the combination of a healthy diet with social behaviours and the way of life of Mediterranean regions makes the MedDiet a sustainable lifestyle model that could likely be followed in other regions with country-specific and culturally appropriate variations.

Impact of Plant-Based Meat Alternatives on the Gut Microbiota of Consumers: A Real-World Study

Eating less meat is increasingly seen as a healthier, more ethical option. This is leading to growing numbers of flexitarian consumers looking for plant-based meat alternatives (PBMAs) to replace at least some of the animal meat they consume. Popular PBMA products amongst flexitarians, including plant-based mince, burgers, sausages and meatballs, are often perceived as low-quality, ultra-processed foods. However, we argue that the mere industrial processing of ingredients of plant origin does not make a PBMA product ultra-processed by default. To test our hypothesis, we conducted a randomised controlled trial to assess the changes to the gut microbiota of a group of 20 participants who replaced several meat-containing meals per week with meals cooked with PBMA products and compared these changes to those experienced by a size-matched control. Stool samples were subjected to 16S rRNA sequencing. The resulting raw data was analysed in a compositionality-aware manner, using a range of innovative bioinformatic methods. Noteworthy changes included an increase in butyrate metabolising potential-chiefly in the 4-aminobutyrate/succinate and glutarate pathways-and in the joint abundance of butyrate-producing taxa in the intervention group compared to control. We also observed a decrease in the Tenericutes phylum in the intervention group and an increase in the control group. Based on our findings, we concluded that the occasional replacement of animal meat with PBMA products seen in flexitarian dietary patterns can promote positive changes in the gut microbiome of consumers.

What Can We Change in Diet and Behaviour in Order to Decrease Carotid Intima-Media Thickness in Patients with Obesity?

Atherosclerosis-considered the major cause of cardiovascular diseases (CVDs)-is strongly associated with obesity, to which it strongly contributes. Moreover, atherosclerosis is characterised by a long asymptomatic phase, and its progression can lead to serious cardiovascular (CV) events. The carotid intima-media thickness (cIMT) has been determined as a predictor of CV events, as well as a marker of subclinical atherosclerosis, and has been used in clinical trials as an alternative assessment method or a surrogate endpoint. It should be noted that several behavioural approaches can directly influence the cIMT values, and decrease or increase the CV risk. In our paper, we aimed to summarize the current knowledge regarding IMT measurement among patients with obesity as a risk group-also in terms of the obesity paradox where the diagnosis of subclinical atherosclerosis is especially essential and implements the early therapeutic approach. We also summarized behavioural, modifiable factors, such as the Mediterranean diet, the Dietary Approach to Stop Hypertension Diets, body weight reduction or the intake of micro- and macronutrients, with a particular focus on the studies where the cIMT values were one of the outcomes. In order to collect the literature data related to the presented topic, the PubMed database was explored.

A Review of the Role of Micronutrients and Bioactive Compounds on Immune System Supporting to Fight against the COVID-19 Disease

Micronutrients are critical for an adequate function of the immune system and play a vital role in promoting health and nutritional well-being. The present work is aimed at reviewing (1) the role of micronutrients in helping the immune system to fight against the COVID-19 disease through the diet with food or food supplements and (2) the potential use of food health claims regarding immune function according to the European Food Safety Authority (EFSA) requirements. Till date, there are some health claims authorized by the European Commission that refer to the role of certain essential nutrients (vitamins B6, B9, B12, A, D, C, and Cu, Fe, Se) to contribute to the proper functioning of the immune system. Vitamins D, C, Zn, and Se, have been thoroughly studied as a strategy to improve the immune system to fight against COVID-19 disease. From all the micronutrients, Vitamin D is the one with more scientific evidence suggesting positive effects against COVID-19 disease as it is linked to a reduction of infection rates, as well as an improved outcomes in patients. To validate scientific evidence, different clinical trials are ongoing currently, with promising preliminary results although inconclusive yet.

Relationship between diet quality scores and the risk of frailty and mortality in adults across a wide age spectrum

BACKGROUND

Beyond intakes of total energy and individual nutrient, eating patterns may influence health, and thereby the risk of adverse outcomes. How different diet measures relate to frailty-a general measure of increased vulnerability to unfavorable health outcomes-and mortality risk, and how this might vary across the life course, is not known. We investigated the associations of five dietary indices (Nutrition Index (NI), the energy-density Dietary Inflammatory Index (E-DII™), Healthy Eating Index-2015 (HEI-2015), Mediterranean Diet Score (MDS), and Dietary Approaches to Stop Hypertension (DASH)) with frailty and mortality.

METHODS

We included 15,249 participants aged ≥ 20 years from the 2007-2012 cohorts of the National Health and Nutrition Examination Survey (NHANES). The NI combined 31 nutrition-related deficits. The E-DII is a literature-derived dietary index associated with inflammation. The HEI-2015 assesses adherence to the Dietary Guidelines of Americans. The MDS represents adherence to the traditional Mediterranean diet. DASH combines macronutrients and micronutrients to prevent hypertension. Frailty was evaluated using a 36-item frailty index. Mortality status was ascertained up to December 31, 2015.

RESULTS

Participants' mean age was 47.2 ± 16.7 years and 51.7% were women. After adjusting for age, sex, race, educational level, marital and employment status, smoking, BMI, and study cohort, higher NI and E-DII scores and lower HEI-2015, MDS, and DASH scores were individually significantly associated with frailty. All dietary scores were significantly associated with 8-year mortality risk after adjusting for basic covariates and frailty: NI (hazard ratio per 0.1 point, 1.15, 95%CI 1.10-1.21), E-DII (per 1 point, 1.05, 1.01-1.08), HEI-2015 (per 10 points, 0.93, 0.89-0.97), MDS (per 1 point, 0.94, 0.90-0.97), and DASH (per 1 point, 0.96, 0.93-0.99). The associations of E-DII, HEI-2015, and MDS scores with 8-year mortality risk persisted after additionally adjusting for NI.

CONCLUSIONS

NI, E-DII, HEI-2015, MDS, and DASH scores are associated with frailty and 8-year mortality risk in adults across all ages. Nevertheless, their mechanisms and sensitivity to predict health outcomes may differ. Nutrition scores have the potential to include measures of both consumption and laboratory and physical measures of exposure.

Adherence to the Mediterranean diet and grade group progression in localized prostate cancer: An active surveillance cohort

BACKGROUND

The Mediterranean diet (MD) may be beneficial for men with localized prostate cancer (PCa) on active surveillance (AS) because of its anti-inflammatory, antilipidemic, and chemopreventive properties. This study prospectively investigated adherence to the MD with Gleason score progression and explored associations by diabetes status, statin use, and other factors.

METHODS

Men with newly diagnosed PCa on an AS protocol (n = 410) completed a baseline food frequency questionnaire, and the MD score was calculated across 9 energy-adjusted food groups. Cox proportional hazards models were fit to evaluate multivariable-adjusted associations of the MD score with progression-free survival; progression was defined as an increase in the Gleason grade group (GG) score over a biennial monitoring regimen.

RESULTS

In this cohort, 15% of the men were diabetic, 44% of the men used statins, and 76 men progressed (median follow-up, 36 months). After adjustments for clinical factors, higher adherence to the MD was associated with a lower risk of GG progression among all men (hazard ratio [HR] per 1-unit increase in MD score, 0.88; 95% confidence interval [CI], 0.77-1.01), non-White men (HR per 1-unit increase in MD score, 0.64; 95% CI, 0.45-0.92; P for interaction = .07), and men without diabetes (HR per 1-unit increase in MD score, 0.82; 95% CI, 0.71-0.96; P for interaction = .03). When joint effects of the MD score and statin use were examined, a similar risk reduction was observed among men with high MD scores who did not use statins in comparison with men with low/moderate MD scores with no statin use.

CONCLUSIONS

The MD is associated with a lower risk of GG progression in men on AS, and this is consistent with prior reports about the MD and reduced cancer morbidity and mortality.

Adherence to the Mediterranean Diet and Healthy Aging: A Narrative Review over the Last Decade

Objective: Even though modern medicine has significantly contributed to the extension of human lifespan, it has failed to delay the upsurge of chronic diseases. Health benefits of the Mediterranean diet are well established. Thus, adherence to this diet pattern may be the key to healthy aging. Ôhe aim of this review is to investigate the potential benefits of the Mediterranean diet on healthy aging. Methods: A literature search of three databases (ScienceDirect, MEDLINE and The Cochrane Library) was conducted in order to trace all relevant studies published between January 1st 2010 and June 6th 2020 that focused on the impact of adherence to the Mediterranean diet on the physical and mental well-being of individuals aged 60 or older. Results:Twenty-two studies fulfilled the selection criteria and were classified into six groups, according to the main outcome of each study: mental health (eight studies), frailty (6), cardiovascular risk factors (3), plasma levels of uric acid (1), length of hospital stay (1), and aging mechanisms (3). Based on these studies, the protective role of Mediterranean diet on depression, cardiovascular and frailty risk was established. Moreover, adherence to the Mediterranean diet resulted in reduced plasma uric acid levels as well as decreased length of hospital stay and mortality risk among patients who were urgently admitted for any cause in a tertiary hospital. In contrast, results on the effect of Mediterranean diet on cognition were controversial, as studies presented positive or neutral correlations. Conclusions: This review provides evidence on the association between adherence to the Mediterranean diet and healthy aging and highlights the importance of conducting more studies among seniors in order to provide further insight into this matter.

Deep dive to the secrets of the PREDIMED trial

PURPOSE OF REVIEW

The aim of this study was to briefly summarize the contribution of the PREDIMED (PREvención con DIeta MEDiterránea) trial on cardiovascular evidence and examine in depth its groundbreaking trajectory.PREDIMED was conducted during 2003-2010 and represented the largest primary prevention trial ever testing the effects of changes in a complete food pattern (namely, the Mediterranean diet) on cardiovascular disease (CVD). Major contributions relied on the relevant changes in the food pattern attained by the behavioural intervention and their robust effect in reducing hard clinical end-points. Given some potential concerns, which were appropriately addressed with supporting analyses, this review is timely and relevant.

RECENT FINDINGS

PREDIMED has continued contributing to the existing literature with extensive, robust and abundant new evidence on the benefits of the Mediterranean diet, particularly on cardiovascular health, including recent studies using high-throughput metabolomic techniques. After robustly addressing some controversies, the conclusions of the original trial remained unaltered.

SUMMARY

The Mediterranean diet represents an effective and robust nutritional strategy against CVD in high cardiovascular risk populations. Recent findings from the PREDIMED have identified a metabolic signature of the Mediterranean diet that can objectively determine dietary adherence and predict CVD risk. This metabolomic signature opens up a new era for nutritional epidemiology and personalized nutrition.

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.

Mediterranean Diet In Healthy Aging

The World elderly population is expected to double before 2050. Unhealthy habits and unhealthy lifestyles are commonly associated with age-related diseases or their worsening. Modification in daily lifestyle and diet may help preventing age-related diseases onset and efficiently affecting their evolution, thus promoting the Healthy Aging process, concept recently coined to describe the disease-free aging process. This review highlights the role of nutrition science in promoting healthy aging. Since the Mediterranean Model demonstrated to be a useful style in supporting healthy aging, promotion of this correct lifestyle by health policies seems to be the best approach to achieve this target.

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.

Association among Adherence to the Mediterranean Diet, Cardiorespiratory Fitness, Cardiovascular, Obesity, and Anthropometric Variables of Overweight and Obese Middle-Aged and Older Adults

The aim of this study was to evaluate the independent and combined associations between adherence to the Mediterranean diet (AMedDiet), cardiorespiratory fitness (CRF), and different parameters of overweight and obese middle-aged and older adults. Sixty-two participants were enrolled in this cross-sectional study. Fat mass was measured with Dual energy X-ray absorptiometry. AMedDiet and physical activity (PA) were assessed with the PREDIMED and Global PA Questionnaire (GPAQ). Maximal aerobic power was assessed using the 6-min walk test. Systolic (SBP) and diastolic (DBP) blood pressure (BP) were measured with Omron M6, and double product (DP) and mean BP (MBP) were calculated. Kinanthropometry proportionality variables related to obesity were also calculated. Participants with a low CRF as an independent factor or together with a low AMedDiet obtained significantly higher BP, total and trunk fat mass, and proportionality variables (all p ˂ 0.0001). According to the multiple nonlinear regression analysis, Vo2max, AMedDiet, and sex explained 53.4% of SBP, with this formula: 238.611 − (3.63*Vo2max) + (0.044*Vo2max²) − (13.051*AMedDiet) + (0.68*AMedDiet²) + (12.887*sex). SBP and p rediction SBP with the new formula showed a correlation of 0.731 (p ˂ 0.0001); showing a difference between the values of −0.278 (p = 0.883). In conclusion, CRF as an independent factor and combined with AMedDiet can be associated with BP, body composition, and proportionality in overweight and obese middle-aged and older adults.

Multiple Health Benefits and Minimal Risks Associated with Vegetarian Diets

PURPOSE OF REVIEW

Understand the current prevalence, health benefits, and health risks of vegetarian diets.

RECENT FINDINGS

Since the publishing of the Adventist Health Study 2 in 2013, there have been several prospective diet studies demonstrating and challenging the health benefits and risks of the vegetarian diet. The definition of the vegetarian diet has become more specific over time and requires standardization for research purposes. Despite an uptrend in sales rates of plant-based foods per year, a 2018 Gallup poll showed overall stagnation of the percentage of self-reported vegetarians and vegans compared to percentages obtained 6 years prior. Compared to the Adventist Health Study, more recent vegetarian diet studies have demonstrated significant although smaller risk reductions for mortality in cardiovascular disease, cerebrovascular disease, diabetes mellitus, and chronic kidney disease. Recent studies have correlated certain food groups with early death or increased longevity. In addition, the vegetarian health risks of deficiencies of protein, omega-3 fatty acids, vitamin D, vitamin B12, iron, calcium, and zinc are explored.

Mediterranean Diet and its Benefits on Health and Mental Health: A Literature Review

Mediterranean Diet (MD) is currently considered one of the most healthy dietary models worldwide. It is generally based on the daily intake of fruit and vegetables, whole grains, legumes, nuts, fish, white meats, and olive oil. It may also include moderate consumption of fermented dairy products, a low intake of red meat, and red/white wine during the main course. Even if the effect of MD on cancer prevention as well as on human metabolic and cardiovascular balance has been discussed, including the quality of life of the exposed population, the putative effects on mental health are still not properly investigated. This narrative review reports on some emerging pieces of evidence on the possible impact of MD on general health and the outcome of psychiatric disorders (e.g., major depression, anxiety) and encourages further studies to test the benefits of healthy food selection on the health of the general population.

Development and Validation of a Questionnaire to Assess Adherence to the Healthy Food Pyramid in Spanish Adults

We aimed to design and validate a new questionnaire of adherence to healthy food pyramid (HFP) (AP-Q), to improve previous instruments. The questionnaire was self-administered and included 28 questions from 10 categories (physical activity, health habits, hydration, grains, fruits, vegetables, oil type, dairy products, animal proteins, and snacks). A population of 130 Spanish adults answered it, obtaining scores from each category and a global score of HFP adherence (AP-Q score). Validation was performed through principal components analysis (PCA) and internal consistency by Cronbach's alpha. AP-Q was also externally validated with Kidmed-test, answered by 45 individuals from the cohort. The global AP-Q score was 5.1 ± 1.3, with an internal consistency of 64%. The PCA analysis extracted seven principal components, which explained 68.5% of the variance. The global AP-Q score was positively associated with Kidmed-test score. Our data suggest that AP-Q is a complete and robust questionnaire to assess HFP adherence, with several advantages: easy to complete, cost-effective, timesaving and has the competency to assess, besides diet, several features affecting health status, lacking in other instruments. We suggest that AP-Q could be useful in epidemiological research, although it requires additional calibration to analyze its reproducibility and validation in other populations.

Validation of the Telephone-Administered Version of the Mediterranean Diet Adherence Screener (MEDAS) Questionnaire

A 14-Item Mediterranean Diet Adherence Screener (MEDAS) questionnaire was developed and validated in face-to-face interviews, but not via telephone. The aims of this study were to evaluate the validity and reliability of a telephone-administered version of the MEDAS as well as to validate the Portuguese version of the MEDAS questionnaire. A convenience community-based sample of adults (n = 224) participated in a three-stage survey. First, trained researchers administered MEDAS via a telephone. Second, the Portuguese version of Food Frequency Questionnaire (FFQ), and MEDAS were administered in a semi-structured face-to-face interview. Finally, MEDAS was again administered via telephone. The telephone-administered MEDAS questionnaire was compared with the face-to-face-version using several metrics. The telephone-administered MEDAS was significantly correlated with the face-to-face-administered MEDAS [r = 0.805, p < 0.001; interclass correlation coefficient (ICC) = 0.803, p < 0.001] and showed strong agreement (k = 0.60). The MEDAS scores that were obtained in the first and second telephone interviews were significantly correlated (r = 0.661, p < 0.001; ICC = 0.639, p < 0.001). The overall agreement between the Portuguese version of MEDAS and the FFQ-derived Mediterranean diet adherence score had a Cohen's k = 0.39. The telephone-administered version of MEDAS is a valid tool for assessing the adherence to the Mediterranean diet and acquiring data for large population-based studies.

Is Extra Virgin Olive Oil an Ally for Women's and Men's Cardiovascular Health?

Noncommunicable diseases are long-lasting and slowly progressive and are the leading causes of death and disability. They include cardiovascular diseases (CVD) and diabetes mellitus (DM) that are rising worldwide, with CVD being the leading cause of death in developed countries. Thus, there is a need to find new preventive and therapeutic approaches. Polyphenols seem to have cardioprotective properties; among them, polyphenols and/or minor polar compounds of extra virgin olive oil (EVOO) are attracting special interest. In consideration of numerous sex differences present in CVD and DM, in this narrative review, we applied "gender glasses." Globally, it emerges that olive oil and its derivatives exert some anti-inflammatory and antioxidant effects, modulate glucose metabolism, and ameliorate endothelial dysfunction. However, as in prescription drugs, also in this case there is an important gender bias because the majority of the preclinical studies are performed on male animals, and the sex of donors of cells is not often known; thus a sex/gender bias characterizes preclinical research. There are numerous clinical studies that seem to suggest the benefits of EVOO and its derivatives in CVD; however, these studies have numerous limitations, presenting also a considerable heterogeneity across the interventions. Among limitations, one of the most relevant in the era of personalized medicine, is the non-attention versus women that are few and, also when they are enrolled, sex analysis is lacking. Therefore, in our opinion, it is time to perform more long, extensive and lessheterogeneous trials enrolling both women and men.

Mediterranean diet and health: A systematic review of epidemiological studies and intervention trials

Diet is a crucial variable for a healthy life. A rapidly growing number of studies in recent years support the hypothesis that the Mediterranean diet (MedDiet) has a beneficial effect on certain body systems, but the highly varied objectives and quality of these publications warrants an updated assessment. In the present review we performed a comprehensive evaluation of current evidence on the impact of the MedDiet on human health, assessing its effect on the incidence or progression of the main non-communicable diseases and their intermediate outcomes and risk factors. We scrutinised the clinical evidence from observational studies and randomised controlled trials. Cardiovascular disease was the condition with most information. The MedDiet showed a general preventive effect, which was reproduced to varying degrees for certain intermediate cardiovascular outcomes such as blood pressure, lipids, obesity, metabolic syndrome and diabetes. Benefits were also found for several types of cancer, brain function (including cognition, mood and to a lesser extent Parkinson's disease) and mortality. The quality of the published evidence was, however, generally moderate or low. In conclusion, the MedDiet shows a favourable impact on health. General adoption of a MedDiet is concordant with current policies promoting healthy and sustainable nutrition worldwide. Nonetheless, more high-quality research is needed to improve the consistency of the findings.

Non-Systematic Review of Diet and Nutritional Risk Factors of Cardiovascular Disease in Obesity

Although cardiovascular disease and its risk factors have been widely studied and new methods of diagnosis and treatment have been developed and implemented, the morbidity and mortality levels are still rising-cardiovascular disease is responsible for more than four million deaths each year in Europe alone. Even though nutrition is classified as one of the main and changeable risk factors, the quality of the diet in the majority of people does not follow the recommendations essential for prevention of obesity and cardiovascular disease. It demonstrates the need for better nutritional education in cardiovascular disease prevention and treatment, and the need to emphasize dietary components most relevant in cardiovascular disease. In our non-systematic review, we summarize the most recent knowledge about nutritional risk and prevention in cardiovascular disease and obesity.