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Jiang K, Albert MS, Coresh J, Couper DJ, Gottesman RF, Hayden KM, Jack CR, Knopman DS, Mosley TH, Pankow JS, Pike JR, Reed NS, Sanchez VA, Sharrett AR, Lin FR, Deal JA. Cross-Sectional Associations of Peripheral Hearing, Brain Imaging, and Cognitive Performance With Speech-in-Noise Performance: The Aging and Cognitive Health Evaluation in Elders Brain Magnetic Resonance Imaging Ancillary Study. Am J Audiol 2024; 33:683-694. [PMID: 38748919 DOI: 10.1044/2024_aja-23-00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Population-based evidence in the interrelationships among hearing, brain structure, and cognition is limited. This study aims to investigate the cross-sectional associations of peripheral hearing, brain imaging measures, and cognitive function with speech-in-noise performance among older adults. METHOD We studied 602 participants in the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) brain magnetic resonance imaging (MRI) ancillary study, including 427 ACHIEVE baseline (2018-2020) participants with hearing loss and 175 Atherosclerosis Risk in Communities Neurocognitive Study Visit 6/7 (2016-2017/2018-2019) participants with normal hearing. Speech-in-noise performance, as outcome of interest, was assessed by the Quick Speech-in-Noise (QuickSIN) test (range: 0-30; higher = better). Predictors of interest included (a) peripheral hearing assessed by pure-tone audiometry; (b) brain imaging measures: structural MRI measures, white matter hyperintensities, and diffusion tensor imaging measures; and (c) cognitive performance assessed by a battery of 10 cognitive tests. All predictors were standardized to z scores. We estimated the differences in QuickSIN associated with every standard deviation (SD) worse in each predictor (peripheral hearing, brain imaging, and cognition) using multivariable-adjusted linear regression, adjusting for demographic variables, lifestyle, and disease factors (Model 1), and, additionally, for other predictors to assess independent associations (Model 2). RESULTS Participants were aged 70-84 years, 56% female, and 17% Black. Every SD worse in better-ear 4-frequency pure-tone average was associated with worse QuickSIN (-4.89, 95% confidence interval, CI [-5.57, -4.21]) when participants had peripheral hearing loss, independent of other predictors. Smaller temporal lobe volume was associated with worse QuickSIN, but the association was not independent of other predictors (-0.30, 95% CI [-0.86, 0.26]). Every SD worse in global cognitive performance was independently associated with worse QuickSIN (-0.90, 95% CI [-1.30, -0.50]). CONCLUSIONS Peripheral hearing and cognitive performance are independently associated with speech-in-noise performance among dementia-free older adults. The ongoing ACHIEVE trial will elucidate the effect of a hearing intervention that includes amplification and auditory rehabilitation on speech-in-noise understanding in older adults. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.25733679.
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Affiliation(s)
- Kening Jiang
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marilyn S Albert
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - David J Couper
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill
| | - Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, National Institutes of Health, Bethesda, MD
| | - Kathleen M Hayden
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC
| | | | | | - Thomas H Mosley
- The MIND Center, University of Mississippi Medical Center, Jackson, MS
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - James R Pike
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill
| | - Nicholas S Reed
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Victoria A Sanchez
- Department of Otolaryngology, Morsani College of Medicine, University of South Florida, Tampa
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Frank R Lin
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer A Deal
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD
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Bhatt IS, Garay JAR, Bhagavan SG, Ingalls V, Dias R, Torkamani A. A genome-wide association study reveals a polygenic architecture of speech-in-noise deficits in individuals with self-reported normal hearing. Sci Rep 2024; 14:13089. [PMID: 38849415 PMCID: PMC11161523 DOI: 10.1038/s41598-024-63972-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 06/04/2024] [Indexed: 06/09/2024] Open
Abstract
Speech-in-noise (SIN) perception is a primary complaint of individuals with audiometric hearing loss. SIN performance varies drastically, even among individuals with normal hearing. The present genome-wide association study (GWAS) investigated the genetic basis of SIN deficits in individuals with self-reported normal hearing in quiet situations. GWAS was performed on 279,911 individuals from the UB Biobank cohort, with 58,847 reporting SIN deficits despite reporting normal hearing in quiet. GWAS identified 996 single nucleotide polymorphisms (SNPs), achieving significance (p < 5*10-8) across four genomic loci. 720 SNPs across 21 loci achieved suggestive significance (p < 10-6). GWAS signals were enriched in brain tissues, such as the anterior cingulate cortex, dorsolateral prefrontal cortex, entorhinal cortex, frontal cortex, hippocampus, and inferior temporal cortex. Cochlear cell types revealed no significant association with SIN deficits. SIN deficits were associated with various health traits, including neuropsychiatric, sensory, cognitive, metabolic, cardiovascular, and inflammatory conditions. A replication analysis was conducted on 242 healthy young adults. Self-reported speech perception, hearing thresholds (0.25-16 kHz), and distortion product otoacoustic emissions (1-16 kHz) were utilized for the replication analysis. 73 SNPs were replicated with a self-reported speech perception measure. 211 SNPs were replicated with at least one and 66 with at least two audiological measures. 12 SNPs near or within MAPT, GRM3, and HLA-DQA1 were replicated for all audiological measures. The present study highlighted a polygenic architecture underlying SIN deficits in individuals with self-reported normal hearing.
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Affiliation(s)
- Ishan Sunilkumar Bhatt
- Department of Communication Sciences and Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA.
| | - Juan Antonio Raygoza Garay
- Department of Communication Sciences and Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, 52242, USA
| | - Srividya Grama Bhagavan
- Department of Communication Sciences and Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Valerie Ingalls
- Department of Communication Sciences and Disorders, University of Iowa, 250 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Raquel Dias
- Department of Microbiology and Cell Science, University of Florida, Gainesville, FL, 32608, USA
| | - Ali Torkamani
- Department of Integrative Structural and Computational Biology, Scripps Research Institute, La Jolla, CA, 92037, USA
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Avci NB, Cicek Cinar B. Does Hearing Impairment Impact Spatial Orientation, Navigation, and Rotation Abilities? Ann Otol Rhinol Laryngol 2024; 133:330-336. [PMID: 38130098 DOI: 10.1177/00034894231219127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Spatial cognition is a perceptual-motor function that pertains to the comprehension and processing of two-dimensional and three-dimensional space. The impairment of any sensory system can have adverse effects on cognitive functioning. The objective of this study is to examine spatial cognition in adults with hearing impairments. METHODS There were a total of 61 individuals in this study: thirty-six with hearing loss and 25 with normal hearing. The Spatial Orientation Test (SOT), the Mental Rotation test (MR), and the Money's Road Map Test (RMT) were administered to assess participants' spatial learning-orientation, mental imagery-rotation, and spatial navigation abilities. A high number of errors in RMT, high angle difference in SOT and a low score in MR suggest poor spatial abilities. RESULTS Participants with hearing loss had a greater number of RMT errors and SOT angle difference, but lower MR scores than those with normal hearing (P < .001). Hearing impairment negatively impacted all 3 spatial cognitive assessments. Hearing loss was associated with a 6.9 increase in the number of RMT errors (95% Confidence Interval (CI): 4.8, 9), a 23.6 increase in the SOT angle difference (95% CI: 16, 31.2), and an 8.5 decrease in the MR score (95% CI: -10.8, -6.2). CONCLUSIONS The study found that individuals with hearing loss exhibited lower performance in various cognitive tasks related to spatial orientation, navigation, spatial learning, mental imagery, and rotation abilities when compared to an age and sex matched control group. In future study, it is imperative to place greater emphasis on hearing loss as a potential detrimental factor in the prediction of spatial cognition impairment.
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Affiliation(s)
- Nizamettin Burak Avci
- Department of Audiology, Faculty of Health Sciences, Trakya University, Edirne, Turkiye
| | - Betul Cicek Cinar
- Department of Audiology, Faculty of Health Sciences, Hacettepe University, Ankara, Turkiye
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Accelerated Cognitive Decline Associated With Hearing Loss and Bilateral Vestibulopathy: Insights From a Prospective Cross-Sectional Study Using the Repeatable Battery for the Assessment of Neuropsychological Status Adjusted for the Hearing Impaired in the DFNA9 Population. Ear Hear 2022:00003446-990000000-00090. [PMID: 36607747 PMCID: PMC10262994 DOI: 10.1097/aud.0000000000001315] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND DeaFNess Autosomal dominant 9 (DFNA9) is a hereditary disorder known to affect both hearing and vestibular function in its carriers. Its phenotype is characterized by progressive sensorineural hearing loss (SNHL) and vestibular dysfunction evolving towards bilateral vestibulopathy (BV) by the 3rd to 5th life decade. Recent studies have identified the impact of hearing loss and vestibular dysfunction on cognitive functioning. OBJECTIVE The main objective of this study was to investigate how the cognitive functioning of carriers of the p.Pro51Ser variant in the COCH gene is affected by the disease and compare these results with a matched healthy control group. STUDY DESIGN Forty-six carriers of the pathogenic p.Pro51Ser variant in the COCH gene were included in this study, of which 38 met the Bárány Society criteria and were thus diagnosed with BV. All subjects were between the age of 22 and 72 years old. Each control was individually matched based on age, gender, and education level. A cognitive, vestibular, and hearing assessment was performed in all subjects. All participants completed the Repeatable Battery for the Assessment of Neuropsychological Status, adjusted for the Hearing Impaired (RBANS-H), a cognitive test battery that includes subtests probing Immediate and Delayed Memory, Visuospatial/Constructional, Language, and Attention. RESULTS Overall, the DFNA9 patients demonstrated significantly lower scores on the Immediate Memory subscale and lower Total Scale scores than their healthy matched controls. The total sample was divided into two groups: age <55 years old and age ≥55 years old. The DFNA9 group aged ≥55 years old obtained significantly lower scores on the Attention subscale and lower Total Scale scores than their matched controls. Cognition of DFNA9 patients aged <55 years old no longer differed significantly from their matched controls. CONCLUSION This cross-sectional study found that DFNA9 patients demonstrated cognitive deficits in comparison with their healthy matched controls. The DFNA9 group aged ≥ 55 years old obtained significantly lower scores on the Total Scale and Attention subscale. This finding; however, was not observed for the age group younger than 55 years old. Further research is needed on the individual trajectory of SNHL and vestibular function, and how hearing rehabilitation affects cognitive functioning.
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Jiang K, Armstrong NM, Agrawal Y, Gross AL, Schrack JA, Lin FR, Ferrucci L, Resnick SM, Deal JA, Powell DS. Associations of audiometric hearing and speech-in-noise performance with cognitive decline among older adults: The Baltimore Longitudinal Study of Aging (BLSA). Front Neurol 2022; 13:1029851. [PMID: 36570462 PMCID: PMC9784219 DOI: 10.3389/fneur.2022.1029851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background Established associations between hearing loss and cognitive decline were primarily defined by pure-tone audiometry, which reflects peripheral hearing ability. Speech-in-noise performance, which reflects central hearing ability, is more limited in prior literature. We examined the longitudinal associations of audiometric hearing and speech-in-noise performance with cognitive decline. Methods We studied 702 participants aged ≥60 years in the Baltimore Longitudinal Study of Aging 2012-2019. Global and domain-specific (language, memory, attention, executive function, visuospatial ability) cognitive performance were assessed by the cognitive assessment battery. Hearing thresholds at 0.5, 1, 2, and 4 kilohertz obtained from pure-tone audiometry were averaged to calculate better-ear pure-tone average (PTA) and participants were categorized as having hearing loss (>25 decibels hearing level [dB HL]) or normal hearing (≤25 dB HL). Speech-in-noise performance was assessed by the Quick Speech-in-Noise (QuickSIN) test, and participants were categorized as having below-median (worse) or above-median performance. Linear mixed effects models with random intercepts and slopes were used to assess baseline cognitive performance and cognitive decline by hearing status. Models adjusted for demographic, lifestyle and disease factors. Results Participants with audiometric hearing loss showed similar baseline cognitive performance but faster decline in global cognitive function, language, executive function, and attention. Participants with below-median QuickSIN score showed worse baseline cognitive performance in all domains and faster decline in global cognitive function, language, memory, executive function and attention. Conclusions Audiometric hearing might be targeted to delay cognitive decline. Speech-in-noise performance might be a novel marker and might be more sensitive to memory decline.
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Affiliation(s)
- Kening Jiang
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Nicole M. Armstrong
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, United States
- Intramural Research Program, National Institute on Aging, Baltimore, MD, United States
| | - Yuri Agrawal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD, United States
| | - Jennifer A. Schrack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD, United States
| | - Frank R. Lin
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD, United States
| | - Luigi Ferrucci
- Intramural Research Program, National Institute on Aging, Baltimore, MD, United States
| | - Susan M. Resnick
- Intramural Research Program, National Institute on Aging, Baltimore, MD, United States
| | - Jennifer A. Deal
- Cochlear Center for Hearing and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Danielle S. Powell
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Uchida Y, Nishita Y, Otsuka R, Sugiura S, Sone M, Yamasoba T, Kato T, Iwata K, Nakamura A. Aging Brain and Hearing: A Mini-Review. Front Aging Neurosci 2022; 13:791604. [PMID: 35095475 PMCID: PMC8792606 DOI: 10.3389/fnagi.2021.791604] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/24/2021] [Indexed: 02/03/2023] Open
Abstract
Brain reserve is a topic of great interest to researchers in aging medicine field. Some individuals retain well-preserved cognitive function until they fulfill their lives despite significant brain pathology. One concept that explains this paradox is the reserve hypothesis, including brain reserve that assumes a virtual ability to mitigate the effects of neuropathological changes and reduce the effects on clinical symptoms flexibly and efficiently by making complete use of the cognitive and compensatory processes. One of the surrogate measures of reserve capacity is brain volume. Evidence that dementia and hearing loss are interrelated has been steadily accumulating, and age-related hearing loss is one of the most promising modifiable risk factors of dementia. Research focused on the imaging analysis of the aged brain relative to auditory function has been gradually increasing. Several morphological studies have been conducted to understand the relationship between hearing loss and brain volume. In this mini review, we provide a brief overview of the concept of brain reserve, followed by a small review of studies addressing brain morphology and hearing loss/hearing compensation, including the findings obtained from our previous study that hearing loss after middle age could affect hippocampal and primary auditory cortex atrophy.
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Affiliation(s)
- Yasue Uchida
- Department of Otolaryngology, Aichi Medical University, Nagakute, Japan
- Department of Otorhinolaryngology, National Center for Geriatrics and Gerontology, Obu, Japan
- *Correspondence: Yasue Uchida,
| | - Yukiko Nishita
- Department of Epidemiology of Aging, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Rei Otsuka
- Section of NILS-LSA, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Saiko Sugiura
- Department of Otorhinolaryngology, National Center for Geriatrics and Gerontology, Obu, Japan
- Toyota Josui Mental Clinic, Toyota, Japan
| | - Michihiko Sone
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tatsuya Yamasoba
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Kato
- Department of Clinical and Experimental Neuroimaging, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kaori Iwata
- Department of Clinical and Experimental Neuroimaging, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Akinori Nakamura
- Department of Clinical and Experimental Neuroimaging, National Center for Geriatrics and Gerontology, Obu, Japan
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Yévenes-Briones H, Caballero FF, Struijk EA, Lana A, Rodríguez-Artalejo F, Lopez-Garcia E. Dietary fat intake and risk of disabling hearing impairment: a prospective population-based cohort study. Eur J Nutr 2021; 61:231-242. [PMID: 34287672 PMCID: PMC8783872 DOI: 10.1007/s00394-021-02644-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/16/2021] [Indexed: 11/25/2022]
Abstract
Purpose To examine the associations of specific dietary fats with the risk of disabling hearing impairment in the UK Biobank study. Methods This cohort study investigated 105,592 participants (47,308 men and 58,284 women) aged ≥ 40 years. Participants completed a minimum of one valid 24-h recall (Oxford Web-Q). Dietary intake of total fatty acids, polyunsaturated fatty acids (PUFA), saturated fatty acids (SFA), and monounsaturated fatty acids (MUFA) was assessed at baseline. Functional auditory capacity was measured with a digit triplet test (DTT), and disabling hearing impairment was defined as a speech reception threshold in noise > − 3.5 dB in any physical exam performed during the follow-up. Results Over a median follow-up of 3.2 (SD: 2.1) years, 832 men and 872 women developed disabling hearing impairment. After adjustment for potential confounders, including lifestyles, exposure to high-intensity sounds, ototoxic medication and comorbidity, the hazard ratios (HRs), and 95% confidence interval (CI) of disabling hearing function, comparing extreme quintiles of intakes were 0.91 (0.71–1.17) for total fat, 1.09 (0.83–1.44) for PUFA, 0.85 (0.64–1.13) for SFA and 1.01 (0.74–1.36) for MUFA among men. Among women, HRs comparing extreme intakes were 0.98 (0.78–1.24) for total fat, 0.69 (0.53–0.91) for PUFA, 1.26 (0.96–1.65) for SFA, and 0.91 (0.68–1.23) for MUFA. Replacing 5% of energy intake from SFA with an equivalent energy from PUFA was associated with 25% risk reduction (HR: 0.75; 95% CI: 0.74–0.77) among women. Conclusions PUFA intake was associated with decreased risk of disabling hearing function in women, but not in men. Supplementary Information The online version contains supplementary material available at 10.1007/s00394-021-02644-7.
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Affiliation(s)
- Humberto Yévenes-Briones
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz and CIBERESP (CIBER of Epidemiology and Public Health), C/ Arzobispo Morcillo, s/n, 28029, Madrid, Spain.
| | - Francisco Félix Caballero
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz and CIBERESP (CIBER of Epidemiology and Public Health), C/ Arzobispo Morcillo, s/n, 28029, Madrid, Spain
| | - Ellen A Struijk
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz and CIBERESP (CIBER of Epidemiology and Public Health), C/ Arzobispo Morcillo, s/n, 28029, Madrid, Spain
| | - Alberto Lana
- Department of Medicine, School of Medicine and Health Sciences, Universidad de Oviedo /ISPA, Oviedo, Spain
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz and CIBERESP (CIBER of Epidemiology and Public Health), C/ Arzobispo Morcillo, s/n, 28029, Madrid, Spain
- IMDEA-Food Institute, CEI UAM+CSIC, Madrid, Spain
| | - Esther Lopez-Garcia
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz and CIBERESP (CIBER of Epidemiology and Public Health), C/ Arzobispo Morcillo, s/n, 28029, Madrid, Spain.
- IMDEA-Food Institute, CEI UAM+CSIC, Madrid, Spain.
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