Adherence to the 2015 Dietary Guidelines for Americans and mortality risk in a Mediterranean cohort: The SUN project

The association between diet quality, plant-based diets, systemic inflammation, and mortality risk: findings from NHANES

PURPOSE

To our knowledge, no studies have examined the association of diet quality and plant-based diets (PBD) with inflammatory-related mortality in obesity. Therefore, this study aimed to determine the joint associations of Healthy Eating Index-2015 (HEI-2015), plant-based dietary index (PDI), healthy PDI (hPDI), unhealthy PDI (uPDI), pro-vegetarian dietary index (PVD), and systemic inflammation with all-cause, cardiovascular disease (CVD), and cancer mortality risks by obesity status.

METHODS

Participants from NHANES were included in cross-sectional (N = 27,915, cycle 1999-2010, 2015-2018) and longitudinal analysis (N = 11,939, cycle 1999-2008). HEI-2015, PDI, hPDI, uPDI, and PVD were constructed based on the 24-h recall dietary interview. The grade of inflammation (low, moderate, and high) was determined based on C-reactive protein (CRP) values and multivariable ordinal logistic regression was used to determine the association. Cox proportional hazard models were used to determine the joint associations of diet and inflammation with mortality.

RESULTS

In the fully adjusted model, HEI-2015 (ORT3vsT1 = 0.76, 95% CI 0.69-0.84; p-trend =  < 0.001), PDI (ORT3vsT1 = 0.83, 95% CI 0.75-0.91; p trend =  < 0.001), hPDI (ORT3vsT1 = 0.79, 95% CI 0.71-0.88; p trend =  < 0.001), and PVD (ORT3vsT1 = 0.85, 95% CI 0.75-0.97; p trend = 0.02) were associated with lower systemic inflammation. In contrast, uPDI was associated with higher systemic inflammation (ORT3vsT1 = 1.18, 95% CI 1.06-1.31; p-trend = 0.03). Severe inflammation was associated with a 25% increase in all-cause mortality (ORT3vsT1 = 1.25, 95% CI 1.03-1.53, p trend = 0.02). No association was found between PDI, hPDI, uPDI, and PVD with mortality. The joint association, between HEI-2015, levels of systemic inflammation, and all-cause, CVD and cancer mortality, was not significant. However, a greater reduction in mortality risk with an increase in HEI-2015 scores was observed in individuals with low and moderate inflammation, especially those with obesity.

CONCLUSION

Higher scores of HEI-2015 and increased intake of a healthy plant-based diet were associated with lower inflammation, while an unhealthy plant-based diet was associated with higher inflammation. A greater adherence to the 2015 dietary guidelines may reduce the risk of mortality associated with inflammation and may also benefit individuals with obesity who had low and moderate inflammation.

Pharmacological interventions for preventing venous thromboembolism in people undergoing bariatric surgery

BACKGROUND

Venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is the leading cause of preventable death in hospitalised people and the third most common cause of mortality in surgical patients. People undergoing bariatric surgery have the additional risk factor of being overweight. Although VTE prophylaxis in surgical patients is well established, the best way to prevent VTE in those undergoing bariatric surgery is less clear.

OBJECTIVES

To evaluate the benefits and harms of pharmacological interventions (alone or in combination) on venous thromboembolism and other health outcomes in people undergoing bariatric surgery compared to the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention or started at a different time point, another pharmacological intervention, no intervention or placebo.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 1 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in males and females of any age undergoing bariatric surgery comparing pharmacological interventions for VTE (alone or in combination) with the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention started at a different time point, a different pharmacological intervention, no treatment or placebo.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. VTE and 2. major bleeding. Our secondary outcomes were 1. all-cause mortality, 2. VTE-related mortality, 3. PE, 4. DVT, 5. adverse effects and 6. quality of life. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included seven RCTs with 1045 participants. Data for meta-analysis were available from all participants. Four RCTs (597 participants) compared higher-dose heparin to standard-dose heparin: one of these studies (139 participants) used unfractionated heparin (UFH) and the other three (458 participants) used low-molecular-weight heparin (LMWH). One study compared heparin versus pentasaccharide (198 participants), and one study compared starting heparin before versus after bariatric surgery (100 participants). One study (150 participants) compared combined mechanical and pharmacological (enoxaparin) prophylaxis versus mechanical prophylaxis alone. The duration of the interventions ranged from seven to 15 days, and follow-up ranged from 10 to 180 days. Higher-dose heparin versus standard-dose heparin Compared to standard-dose heparin, higher-dose heparin may result in little or no difference in the risk of VTE (RR 0.55, 95% CI 0.05 to 5.99; 4 studies, 597 participants) or major bleeding (RR 1.19, 95% CI 0.48 to 2.96; I2 = 8%; 4 studies, 597 participants; low-certainty) in people undergoing bariatric surgery. The evidence on all-cause mortality, VTE-related mortality, PE, DVT and adverse events (thrombocytopenia) is uncertain (effect not estimable or very low-certainty evidence). Heparin versus pentasaccharide Heparin compared to a pentasaccharide after bariatric surgery may result in little or no difference in the risk of VTE (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants) or DVT (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants). The evidence on major bleeding, PE and mortality is uncertain (effect not estimable or very low-certainty evidence). Heparin started before versus after the surgical procedure Starting prophylaxis with heparin 12 hours before surgery versus after surgery may result in little or no difference in the risk of VTE (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants) or DVT (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants). The evidence on major bleeding, all-cause mortality and VTE-related mortality is uncertain (effect not estimable or very low-certainty evidence). We were unable to assess the effect of this intervention on PE or adverse effects, as the study did not measure these outcomes. Combined mechanical and pharmacological prophylaxis versus mechanical prophylaxis alone Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery compared to mechanical prophylaxis alone (RR 0.05, 95% CI 0.00 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 9; 1 study, 150 participants; low-certainty). We were unable to assess the effect of this intervention on major bleeding or morality (effect not estimable), or on PE or adverse events (not measured). No studies measured quality of life.

AUTHORS' CONCLUSIONS

Higher-dose heparin may make little or no difference to venous thromboembolism or major bleeding in people undergoing bariatric surgery when compared to standard-dose heparin. Heparin may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to pentasaccharide. There are inadequate data to draw conclusions about the effects of heparin compared to pentasaccharide on major bleeding. Starting prophylaxis with heparin 12 hours before bariatric surgery may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to starting heparin after bariatric surgery. There are inadequate data to draw conclusions about the effects of heparin started before versus after surgery on major bleeding. Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery when compared to mechanical prophylaxis alone. No data are available relating to major bleeding. The certainty of the evidence is limited by small sample sizes, few or no events, and risk of bias concerns. Future trials must be sufficiently large to enable analysis of relevant clinical outcomes, and should standardise the time of treatment and follow-up. They should also address the effect of direct oral anticoagulants and antiplatelets, preferably grouping them according to the type of intervention.

Adherence to emerging plant-based dietary patterns and its association with cardiovascular disease risk in a nationally representative sample of Canadian adults

BACKGROUND

Little is known about the role of emerging plant-based dietary patterns in cardiovascular disease (CVD) risk at the national population level.

OBJECTIVES

The objectives of this research were to assess the validity and reliability of newly established plant-based dietary indices, and to evaluate their associations with CVD risk among Canadian adults.

METHODS

Data were obtained from repeated 24-h dietary recalls of adult participants in the cross-sectional, nationally representative Canadian Community Health Survey cycle 2004 linked to health administrative databases (n = 12,323) and cycle 2015 (n = 14,026). Plant-based diet quality was assessed with a revised Plant-based Dietary Index (PDI), EAT-Lancet Reference Diet (ERD) score, and the latest Dietary Guidelines for Americans Adherence Index (DGAI) 2020. Weighted multivariate analyses were used for testing associations between diet quality and lifestyle characteristics, and weighted multivariable-adjusted Cox proportional hazards models for associations with CVD risk.

RESULTS

Construct validity was confirmed for the revised PDI and DGAI 2020 (but not the ERD) because participants in the highest (healthiest) quartile, compared to those in the lowest (least healthy), were more likely to be female (mean ± SE: 52.63% ± 1.27% compared with 44.80% ± 1.65% for revised PDI; 59.37% ± 2.01% compared with 40.84% ± 1.71% for DGAI 2020), older (mean ± SE: 50.55 ± 0.39 y compared with 45.56 ± 0.43 y for revised PDI; 51.57 ± 0.39 y compared with 46.35 ± 0.54 y for DGAI 2020), to have postsecondary education (mean ± SE: 32.36% ± 1.55% compared with 21.12% ± 1.31% for revised PDI; 34.17% ± 2.69% compared with 17.87% ± 0.98% for DGAI 2020), and less likely to be daily smokers (mean ± SE: 8.21% ± 1.0% compared with 17.06% ± 1.45% for revised PDI; 7.36% ± 1.71% compared with 21.53% ± 1.58% for DGAI 2020) (P-trend < 0.0001). No significant associations were observed between dietary index scores and CVD risk.

CONCLUSIONS

The revised PDI and DGAI 2020 provided valid and meaningful measures of plant-based eating among Canadians, whereas the validity of the ERD was not directly confirmed. Adherence to the plant-based dietary patterns was not associated with CVD risk. Future large-scale studies are necessary to further evaluate the role of plant-based eating in CVD prevention.

Dietary changes based on food purchase patterns following a type 2 diabetes diagnosis

OBJECTIVE

The study explores whether type 2 diabetes (T2D) diagnosis affects food consumption patterns in line with the dietary recommendations provided to individuals in relation to a diagnosis.

DESIGN

Based on detailed food purchase data, we explore which dietary changes are most common following a T2D diagnosis. Changes are investigated for several energy-adjusted nutrients and food groups and overall adherence to dietary guidelines.

SETTING

We use data on diagnosis of T2D and hospitalisation in relation to T2D for a sample of adult Danes registered in the official patient register. This is combined with detailed scanner data on food purchases, which are used as a proxy for dietary intake.

PARTICIPANTS

We included 274 individuals in Denmark who are diagnosed during their participation in a consumer panel where they report their food purchases and 16 395 individuals who are not diagnosed.

RESULTS

Results suggest some changes in dietary composition following diagnosis, as measured by a Healthy Eating Index and for specific food groups and nutrients, although the long-term effects are limited. Socio-economic characteristics are poor predictors of dietary changes following diagnosis. Change in diet following diagnosis vary with the pre-diagnosis consumption patterns, where individuals with relatively unhealthy overall diets prior to diagnosis improve overall healthiness more compared to individuals with relatively healthy diets prior to diagnosis.

CONCLUSIONS

Adherence to dietary advice is low, on average, but there is large variation in behavioural change between the diagnosed individuals. Our results stress the difficulty for diagnosed individuals to shift dietary habits, particularly in the long term.

Evaluation of Dietary Patterns and All-Cause Mortality: A Systematic Review

Importance

The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)?

Objective

To ascertain the association between dietary patterns consumed and ACM.

Evidence Review

Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements.

Findings

A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings.

Conclusions and Relevance

In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

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.

Pharmacological Primary Cardiovascular Prevention and Subclinical Atherosclerosis in Men: Evidence from the Aragon Workers' Health Study

The objective of this study is to describe the profile of primary preventive treatment for cardiovascular disease in adult males and to analyze the association between treatment profile and subclinical atherosclerosis. We selected male workers who had undergone ultrasound imaging and had no previous history of cardiovascular disease (n = 2138). Data on the consumption of primary cardiovascular drugs from the previous year were obtained. We performed bivariate analyses to compare patient characteristics according to cardiovascular treatment and the presence of subclinical atherosclerosis, and logistic regression models to explore the association between these two variables. Among participants with no personal history of cardiovascular disease, subclinical atherosclerosis was present in 77.7% and 31.2% had received some form of preventive treatment. Of those who received no preventive treatment, 73.6% had subclinical atherosclerosis. Cardiovascular preventive treatment was associated only with CACS > 0 (odds ratio (OR), 1.37; 95% confidence interval (95% CI), 1.06-1.78). Statin treatment was associated with a greater risk of any type of subclinical atherosclerosis (OR, 1.73) and with CACS > 0 (OR, 1.72). Subclinical atherosclerosis existed in almost 75% of men who had no personal history of cardiovascular disease and had not received preventive treatment for cardiovascular disease.

A three-dimensional dietary index (nutritional quality, environment and price) and reduced mortality: The "Seguimiento Universidad de Navarra" cohort

Several healthy diet indices have been associated with mortality risk. However, the ideal diet should not only be healthy but also environmentally friendly and affordable. The study aimed to determine if a new Sustainable Diet Index (SDI), which takes into account the nutritional quality, environmental impacts and market price of diets, was associated with all-cause and cause-specific mortality. Using data from the "Seguimiento Universidad de Navarra" Project, a prospective cohort study of Spanish university graduates, the study included 15,492 participants who were recruited between December 1999 and March 2014 and followed-up for a median of 10 years. Cox regression was used to determine the relationship of SDI and its components with all-cause and cause-specific mortality risk. Hazard ratios with adjustment for several confounders were calculated. The weights for the foods contributing to the SDI were assessed with multiple regression analyses and variability with nested regression analyses. The highest quartile of the SDI scores was associated with a 59% relative reduction in all-cause mortality (HR 0.41, 95% CI 0.23-0.75; p_trend < 0.001) and 79% reduction in cardiovascular mortality (HR 0.21, 95% CI 0.05-0.85; p_trend < 0.001). SDI was positively correlated with beans and potato consumption but negatively correlated with red meat intake. Red and processed meats, fatty dairy products and fish consumption accounted for most of the variability in the SDI. Altogether, dietary patterns accounting not only for nutritional quality of the food but also the impact on the environment and affordability could still provide health benefits.

Defining diet quality: a synthesis of dietary quality metrics and their validity for the double burden of malnutrition

Achieving most of the UN Sustainable Development Goals requires a strong focus on addressing the double burden of malnutrition, which includes both diet-related maternal and child health (MCH) and non-communicable diseases (NCDs). Although, the most optimal dietary metric for assessing malnutrition remains unclear. Our aim was to review available global dietary quality metrics (hereafter referred to as dietary metrics) and evidence for their validity to assess MCH and NCD outcomes, both separately and together. A systematic search of PubMed was done to identify meta-analyses or narrative reviews evaluating validity of diet metrics in relation to nutrient adequacy or health outcomes. We identified seven dietary metrics aiming to address MCH and 12 for NCDs, no dietary metrics addressed both together. Four NCD dietary metrics (Mediterranean Diet Score, Alternative Healthy Eating Index, Healthy Eating Index, and Dietary Approaches to Stop Hypertension) had convincing evidence of protective associations with specific NCD outcomes, mainly mortality, cardiovascular disease, type 2 diabetes, and total cancer. The remaining NCD dietary metrics and all MCH dietary metrics were not convincingly validated against MCH or NCD health outcomes. None of the dietary metrics had been validated against both MCH and NCD outcomes. These findings highlight major gaps in assessing and addressing diet to achieve global targets and effective policy action.

Healthy Eating, Physical Activity, and Sleep Hygiene (HEPAS) as the Winning Triad for Sustaining Physical and Mental Health in Patients at Risk for or with Neuropsychiatric Disorders: Considerations for Clinical Practice

Neuropsychiatric disorders stem from gene-environment interaction and their development can be, at least in some cases, prevented by the adoption of healthy and protective lifestyles. Once full blown, neuropsychiatric disorders are prevalent conditions that patients live with a great burden of disability. Indeed, the determinants that increase the affliction of neuropsychiatric disorders are various, with unhealthy lifestyles providing a significant contribution in the interplay between genetic, epigenetic, and environmental factors that ultimately represent the pathophysiological basis of these impairing conditions. On one hand, the adoption of Healthy Eating education, Physical Activity programs, and Sleep hygiene promotion (HEPAS) has the potential to become one of the most suitable interventions to reduce the risk to develop neuropsychiatric disorders, while, on the other hand, its integration with pharmacological and psychological therapies seems to be essential in the overall management of neuropsychiatric disorders in order to reduce the disability and improve the quality of life of affected patients. We present an overview of the current evidence in relation to HEPAS components in the prevention and management of neuropsychiatric disorders and provide suggestions for clinical practice.

Protective factors for diabetic retinopathy in Type 2 diabetes mellitus patients: Long duration of no less than 10 years

AIM

To study the factors protecting against diabetic retinopathy (DR) in patients with over a decade-long history of type 2 diabetes mellitus.

METHODS

A total of 490 patients with type 2 diabetes mellitus lasting for ≥10 years were divided into DR and no diabetic retinopathy (no DR) groups. Their basic information was collected, including age, sex, and duration of diabetes mellitus, as well as pertinent laboratory data. Potential correlations between these factors and DR were evaluated using multivariate analysis.

RESULTS

Overall, 208 patients met the diagnostic criteria for DR. Multivariate logistic regression was used to evaluate factors with P < 0.10 after univariate analysis. Age, total bilirubin, and total cholesterol were found to be protective factors against DR. Presence of diabetic kidney disease and diabetic peripheral neuropathy, duration of diabetes mellitus, apolipoprotein B, blood urea nitrogen, and prothrombin time were found to be risk factors for DR.

CONCLUSIONS

We conclude that total cholesterol is a protective factor against DR. Specifically, it was confirmed that high levels of total cholesterol reduce the risk of DR. These findings may provide a basis for new diet and lifestyle guidelines for patients with diabetes mellitus.

Vitamin D, cancer, and dysregulated phosphate metabolism

Recently reported findings from major clinical trials show no cancer protection from vitamin D supplementation, and results from observational studies of vitamin D in cancer prevention are inconsistent. There is a need for new hypotheses to guide investigations of the controversies surrounding vitamin D supplementation and cancer. Bioactive vitamin D, 1,25(OH)2D, is an endocrine factor that regulates phosphate homeostasis by increasing dietary phosphate intestinal absorption. When phosphorus serum levels are high, as in hyperphosphatemia, an endocrine feedback mechanism lowers bioactive vitamin D which reduces intestinal phosphate absorption. Low vitamin D levels have been associated with cancer incidence, and tumorigenesis is associated with high levels of dysregulated phosphate in the body. In this mini-review, the author hypothesizes that hyperphosphatemia may be an intermediating factor in the association of lowered vitamin D levels and increased risk for tumorigenesis. Furthermore, this article challenges the UVB-vitamin D-cancer hypothesis which proposes that reduced cancer incidence at lower geographic latitudes is related to high levels of vitamin D from UVB exposure. The author proposes that reduced phosphorus content and availability in tropical and subtropical soil, and lower dietary phosphate intake from consumption of tropical and subtropical crops (as in the Mediterranean diet), may mediate the association of reduced cancer risk with lower latitudes.