Reliability and validity of a Mediterranean diet and culinary index (MediCul) tool in an older population with mild cognitive impairment

The LEISURE Study: A Longitudinal Randomized Controlled Trial Protocol for a Multi-Modal Lifestyle Intervention Study to Reduce Dementia Risk in Healthy Older Adults

Dementia is understood to arise from a mixed etiology, enveloping chronic inflammatory and vascular impacts on the brain, driven by a constellation of modifiable risk factors which are largely mediated by lifestyle-related behaviors. These risk factors manifest over a prolonged preclinical period and account for up to 40% of the population attributable risk for dementia, representing viable targets for early interventions aimed at abating disease onset and progression. Here we outline the protocol for a 12-week randomized control trial (RCT) of a multimodal Lifestyle Intervention Study for Dementia Risk Reduction (LEISURE), with longitudinal follow-up at 6-months and 24-months post-intervention. This trial integrates exercise, diet, sleep, and mindfulness to simultaneously target multiple different etiopathogenetic mechanisms and their interplay in a healthy older adult population (aged 50-85 years), and assesses dementia risk reduction as the primary endpoint. The LEISURE study is located in the Sunshine Coast region of Australia, which has one of the nation's highest proportions of adults aged over 50 years (36.4%), and corresponding dementia prevalence. This trial is novel in its inclusion of mindfulness and sleep as multidomain lifestyle targets, and in its comprehensive suite of secondary outcomes (based on psychological, physical health, sleep activity, and cognitive data) as well as exploratory neuroimaging (magnetic resonance imaging and electroencephalography) and molecular biology measures. These measures will provide greater insights into the brain-behavioral underpinnings of dementia prevention, as well as the predictors and impacts of the proposed lifestyle intervention. The LEISURE study was prospectively registered (ACTRN12620000054910) on 19 January 2020.

Adherence to a Mediterranean Diet is associated with physical and cognitive health: A cross-sectional analysis of community-dwelling older Australians

Poor cognitive function is associated with reduced functional independence, risk of institutionalization and reduced health-related quality of life. The ability to independently perform instrumental activities of daily living (iADLs) is compromised in patients with mild cognitive impairment (MCI) or dementia. Emerging evidence suggests that adherence to a Mediterranean diet (MedDiet), may play an important protective role against cognitive decline and dementia risk, whilst preserving functional status. This cross-sectional study aimed to explore the independent associations between MedDiet adherence, cognitive risk, and functional status in community-dwelling older adults living in Australia. MedDiet adherence was assessed using the Mediterranean Diet Adherence Screener (MEDAS); a modified Lawton's iADL scale was used for the assessment of functional status and risk of cognitive impairment was assessed using the AD8 dementia screening intervention. A total of n = 294 participants were included in the final analyses (70.4 ± 6.2 years; Females, n = 201; Males, n = 91; n = 2 unspecified). Adherence to a MedDiet was positively associated with functional ability (β = 0.172; CI: 0.022, 0.132; P = 0.006) independent of age, gender, Body Mass Index (BMI), smoking status, sleep duration, physical activity duration, diabetes status, and level of education. Furthermore, MedDiet adherence was inversely associated with cognitive risk (β = -0.134; CI: -0.198, -0.007; P = 0.035) independent of all covariates. However, our sensitivity analyses further showed that adherence to a MedDiet was not associated with cognitive risk in older adults free from cognitive impairment. We showed that adherence to a MedDiet is associated with healthy physical and cognitive aging. Nevertheless, exploration of these findings in larger cohorts, using longitudinal analyses and controlling for important confounders to ascertain the direction of the relationship is warranted.

Relative validity of a short screener to assess diet quality in patients with severe obesity before and after bariatric surgery

OBJECTIVE

To determine the relative validity and reproducibility of the Eetscore FFQ, a short screener for assessing diet quality, in patients with (severe) obesity before and after bariatric surgery (BS).

DESIGN

The Eetscore FFQ was evaluated against 3-d food records (3d-FR) before (T0) and 6 months after BS (T6) by comparing index scores of the Dutch Healthy Diet index 2015 (DHD2015-index). Relative validity was assessed using paired t tests, Kendall's tau-b correlation coefficients (τb), cross-classification by tertiles, weighted kappa values (k w ) and Bland-Altman plots. Reproducibility of the Eetscore FFQ was assessed using intraclass correlation coefficients (ICC).

SETTING

Regional hospital, the Netherlands.

PARTICIPANTS

Hundred and forty participants with obesity who were scheduled for BS.

RESULTS

At T0, mean total DHD2015-index score derived from the Eetscore FFQ was 10·2 points higher than the food record-derived score (P < 0·001) and showed an acceptable correlation (τb = 0·42, 95 % CI: 0·27, 0·55). There was a fair agreement with a correct classification of 50 % (k w = 0·37, 95 % CI: 0·25, 0·49). Correlation coefficients of the individual DHD components varied from 0·01-0·54. Similar results were observed at T6 (τb = 0·31, 95 % CI: 0·12, 0·48, correct classification of 43·7 %; k w = 0·25, 95 % CI: 0·11, 0·40). Reproducibility of the Eetscore FFQ was good (ICC = 0·78, 95 % CI: 0·69, 0·84).

CONCLUSION

The Eetscore FFQ showed to be acceptably correlated with the DHD2015-index derived from 3d-FR, but absolute agreement was poor. Considering the need for dietary assessment methods that reduce the burden for patients, practitioners and researchers, the Eetscore FFQ can be used for ranking according to diet quality and for monitoring changes over time.

Development, implementation and evaluation of the online Movement, Interaction and Nutrition for Greater Lifestyles in the Elderly (MINGLE) program: The protocol for a pilot trial

Introduction

People with age-related macular degeneration (AMD) are more likely to experience loneliness, have poorer diets and be less physically active than people without AMD. The online Movement, Interaction and Nutrition for Greater Lifestyles in the Elderly (MINGLE) program is a holistic evidence-based intervention aiming to support people with AMD by incorporating physical activity, social interaction and nutrition education components all delivered via a COVID-19-safe Zoom platform. This study will involve two phases: 1) a formative qualitative study with AMD patients to identify the barriers and facilitators to participating in the proposed MINGLE program; and 2) a 10-week pilot study to evaluate the feasibility, acceptability and preliminary efficacy of MINGLE.

Methods and analysis

Phase 1 involves AMD patients who will be recruited from an eye clinic in Western Sydney, Australia to participate in audio-recorded semi-structured interviews. Verbatim interview transcripts will be coded using the Capability, Opportunity, Motivation and Behaviour (COM-B) model and themes established. These themes will be used as a guide to specifically tailor the proposed MINGLE program to people with AMD. Phase 2 involves 52 AMD patients who will then be recruited from the same clinic to participate in the MINGLE program. Pre-post questionnaires will be administered to intervention participants to collect information on the following variables: demographics, socioeconomic status, vision function, loneliness, quality of life (including depression), falls risk, physical activity (level), and dietary intake. The acceptability and feasibility of the MINGLE program will also be evaluated using descriptive statistics.

Trial registration number

ACTRN12621000939897p.

Effect of 3-Month Aerobic Dance on Hippocampal Volume and Cognition in Elderly People With Amnestic Mild Cognitive Impairment: A Randomized Controlled Trial

As an intermediate state between normal aging and dementia, mild cognitive impairment (MCI), especially amnestic MCI (aMCI), is a key stage in the prevention and intervention of Alzheimer’s disease (AD). Whether dancing could increase the hippocampal volume of seniors with aMCI remains debatable. The aim of this study was to investigate the influence of aerobic dance on hippocampal volume and cognition after 3 months of aerobic dance in older adults with aMCI. In this randomized controlled trial, 68 elderly people with aMCI were randomized to either the aerobic dance group or the control group using a 1:1 allocation ratio. Ultimately, 62 of 68 participants completed this study, and the MRI data of 54 participants were included. A specially designed aerobic dance routine was performed by the dance group three times per week for 3 months, and all participants received monthly healthcare education after inclusion. MRI with a 3.0T MRI scanner and cognitive assessments were performed before and after intervention. High-resolution three-dimensional (3D) T1-weighted anatomical images were acquired for the analysis of hippocampal volume. A total of 35 participants (mean age: 71.51 ± 6.62 years) were randomized into the aerobic dance group and 33 participants (mean age: 69.82 ± 7.74 years) into the control group. A multiple linear regression model was used to detect the association between intervention and the difference of hippocampal volumes as well as the change of cognitive scores at baseline and after 3 months. The intervention group showed greater right hippocampal volume (β [95% CI]: 0.379 [0.117, 0.488], p = 0.002) and total hippocampal volume (β [95% CI]: 0.344 [0.082, 0.446], p = 0.005) compared to the control group. No significant association of age or gender was found with unilateral or global hippocampal volume. There was a correlation between episodic memory and intervention, as the intervention group showed a higher Wechsler Memory Scale-Revised Logical Memory (WMS-RLM) score (β [95% CI]: 0.326 [1.005, 6.773], p = 0.009). Furthermore, an increase in age may cause a decrease in the Mini-Mental State Examination (MMSE) score (β [95% CI]: −0.366 [−0.151, −0.034], p = 0.002). In conclusion, 3 months of aerobic dance could increase the right and total hippocampal volumes and improve episodic memory in elderly persons with aMCI.

Clinical Trial Registration: This study was registered on the Chinese Clinical Trial Registry [www.chictr.org.cn], identifier [ChiCTR-INR-15007420].

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

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

Nutrition Module design in Maintain Your Brain: an internet-based randomised controlled trial to prevent cognitive decline and dementia

The Maintain Your Brain (MYB) trial is one of the largest internet-delivered multidomain randomised controlled trial designed to target modifiable risk factors for dementia. It comprises four intervention modules: physical activity, nutrition, mental health and cognitive training. This paper explains the MYB Nutrition Module, which is a fully online intervention promoting the adoption of the 'traditional' Mediterranean Diet (MedDiet) pattern for those participants reporting dietary intake that does not indicate adherence to a Mediterranean-type cuisine or those who have chronic diseases/risk factors for dementia known to benefit from this type of diet. Participants who were eligible for the Nutrition Module were assigned to one of the three diet streams: Main, Malnutrition and Alcohol group, according to their medical history and adherence to the MedDiet at baseline. A short dietary questionnaire was administered weekly during the first 10 weeks and then monthly during the 3-year follow-up to monitor whether participants adopted or maintained the MedDiet pattern during the intervention. As the Nutrition Module is a fully online intervention, resources that promoted self-efficacy, self-management and process of change were important elements to be included in the module development. The Nutrition Module is unique in that it is able to individualise the dietary advice according to both the medical and dietary history of each participant; the results from this unique intervention will contribute substantively to the evidence that links the Mediterranean-type diet with cognitive function and the prevention of dementia and will increase our understanding of the benefits of a MedDiet in a Western country.

Evaluation of a Novel Tool for Screening Inadequate Food Intake in Age-Related Macular Degeneration Patients

Diet assessment tools provide valuable nutrition information in research and clinical settings. With growing evidence supporting dietary modification to delay development and progression of age-related macular degeneration (AMD), an AMD-specific diet assessment tool could encourage eye-care practitioners to refer patients in need of further dietary behavioural support to a dietitian and/or support network. Therefore, the aim of this study was to evaluate clinical use of a novel, short dietary questionnaire (SDQ-AMD) to screen for inadequate food intake in AMD patients by comparing it against a validated food frequency questionnaire (FFQ). Recruitment sources included Sydney-based private eye clinics and research databases (N = 155; 57% female; 78 ± 8 years). Scoring criteria based on the Australian Dietary Guidelines and dietary recommendations for AMD in literature were developed and applied to dietary data from the FFQ and SDQ-AMD. Bland-Altman plot of difference suggests agreement between the FFQ and SDQ-AMD as most mean difference scores were within the 95% CI (6.91, -9.94), and no significant bias between the scores as the mean score increased ((regression equation: y = 0.11x - 2.60) (95% CI: -0.058, 0.275, p-value = 0.20)). Scores were also significantly correlated (0.57, p ≤ 0.0001). The SDQ-AMD shows potential as a diet screening tool for clinical use, however, additional studies are warranted to validate the SDQ-AMD.

Mediterranean food pattern vs. Mediterranean diet: a necessary approach?

"Food pattern" and "diet" sometimes are referred with the same meaning. "Food pattern" can be defined by a priori and a posteriori approaches and refers to the characterisation of foods and frequency of consumption within a population combining with various characteristics. "Diet" may be represented as an individual way of life and considers the food consumption and others like culture, history, society, economy, sustainability, culinary activities, conviviality, physical activity and rest. Mediterranean diet fits on these two concepts. The question is if we are measuring Mediterranean diet as a whole, or whether we are only measuring one of its parts, neglecting the rest of components. Can this compromise the way we monitor its adherence and evolution, with the possibility of losing the perception of certain aspects? How can we preserve and promote the concept if we do not monitor all the pieces of the puzzle?

Maintain Your Brain: Protocol of a 3-Year Randomized Controlled Trial of a Personalized Multi-Modal Digital Health Intervention to Prevent Cognitive Decline Among Community Dwelling 55 to 77 Year Olds

BACKGROUND

Maintain Your Brain (MYB) is a randomized controlled trial of an online multi-modal lifestyle intervention targeting modifiable dementia risk factors with its primary aim being to reduce cognitive decline in an older age cohort.

METHODS

MYB aims to recruit 8,500 non-demented community dwelling 55 to 77 year olds from the Sax Institute's 45 and Up Study in New South Wales, Australia. Participants will be screened for risk factors related to four modules that comprise the MYB intervention: physical activity, nutrition, mental health, and cognitive training. Targeting risk factors will enable interventions to be personalized so that participants receive the most appropriate modules. MYB will run for three years and up to four modules will be delivered sequentially each quarter during year one. Upon completing a module, participants will continue to receive less frequent booster activities for their eligible modules (except for the mental health module) until the end of the trial.

DISCUSSION

MYB will be the largest internet-based trial to attempt to prevent cognitive decline and potentially dementia. If successful, MYB will provide a model for not just effective intervention among older adults, but an intervention that is scalable for broad use.

Validity of the Mediterranean Diet and Culinary Index (MediCul) for Online Assessment of Adherence to the 'Traditional' Diet and Aspects of Cuisine in Older Adults

The Mediterranean diet is associated with multiple health benefits. Yet, no tool has been specifically developed to assess adherence to the 'traditional' Mediterranean diet and cuisine within a Western cohort, and validated for online use. We tested the reliability and validity of online administration of the Mediterranean Diet and Culinary Index (MediCul) among middle-aged and older adults. Participants were recruited in January⁻March 2017 from the 45 and Up Study, completing MediCul twice. Test-retest reliability was assessed using the paired t-test, intra-class correlation coefficient (ICC) and Bland-Altman plot. Validity was tested against a three-day food record (FR)-derived MediCul score using Bland-Altman and nutrient trends across the MediCul score tertiles. Participants (n = 84; 60% female; 65.4 years (SD = 5.9)), were overweight (BMI 26.1; SD = 4.0) with 1.7 (SD = 1.5) chronic illnesses/conditions. Sequential MediCul tool scores were 56.1/100.0 and 56.8/100.0, respectively (t = -1.019; p = 0.311). Reliability via ICC (ICC = 0.86, 95% CI: 0.789, 0.910, p < 0.0001) and Bland-Altman was good. In Bland-Altman validity analyses, the tool over-reported FR MediCul score by 5.6 points with no systematic bias ((y = 8.7 - 0.06*x) (95% CI: -0.278, 0.158, p = 0.584)). Nutrient trends were identified for MediCul consistent with expected Mediterranean patterns. Online MediCul administration demonstrated good reliability and moderate validity for assessing adherence to a 'traditional' Mediterranean pattern among older Australians.