Pre-stroke adherence to a Mediterranean diet pattern is associated with lower acute ischemic stroke severity: a cross-sectional analysis of a prospective hospital-register study

Impact of adherence to the Mediterranean diet on stroke risk

Stroke is a leading cause of morbidity and mortality worldwide, and dietary patterns have emerged as a significant modifiable factor in stroke prevention. The Mediterranean diet, characterized by high intake of fruits, vegetables, whole grains, nuts, olive oil, and fish, has been widely recognized for its cardiovascular benefits. However, its specific impact on stroke risk requires further elucidation. We conducted a comprehensive meta-analysis of 30 studies, including both cohort and case-control designs, to evaluate the relationship between adherence to the Mediterranean diet and the risk of stroke. A systematic search was performed across multiple databases, and a random-effects model was used to estimate pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistic, and publication bias was examined through funnel plots and Egger's regression test. Additionally, trial sequential analysis was conducted to determine the adequacy of the sample size. The meta-analysis revealed a significant reduction in stroke risk among individuals adhering to the Mediterranean diet, with a pooled HR of 0.88 (95% CI: 0.84-0.91). Notably, a significant heterogeneity was detected (I2 = 34%). The Z-score plot from trial sequential analysis confirmed that the sample sizes were sufficient to draw definitive conclusions. However, a potential publication bias was identified. The case-control studies confirmed a highly significant effect (HR = 0.54, 95% CI: 0.4-0.73). The funnel plots in both settings hinted at the presence of a potential publication bias, supported by a significant Egger's test. Our findings provide robust evidence supporting the protective effect of the Mediterranean diet against stroke. Despite the presence of some heterogeneity and potential publication bias, the cumulative evidence suggests that promoting the Mediterranean diet could serve as an effective public health strategy for stroke prevention. Further research is recommended to explore the underlying mechanisms and to assess the diet's impact across diverse populations.

Adherence to the Mediterranean diet and risk of stroke in a Chilean population: a case-control study

Introduction

Introduction: Ñuble is the region of Chile with the highest stroke incidence rates in the country. The aim was to estimate the association between adherence to the MED diet and the first ischemic stroke in adult patients living in the Ñuble region. Methods: a case-control hospital-based study. The cases (n = 89) were patients with first ischemic stroke, and controls (n = 178) were admitted to the same hospital during the same month the cases were recruited. We selected two controls for one case and paired them for sex and age (± 5 years). We used the food frequency questionnaire and the adherence Mediterranean diet questionnaire. A descriptive analysis of the variables and a conditional logistic regression to determine the association between variables. Results: 71 % of the sample was ≥ 65 years old and 64 % were male. Cases smoked (11.2 %), consumed at least one drink per month (41.6 %), and had a diagnosis of hypertension (76.4 %) more frequently than controls. In the model adjusted for all variables, it is observed that those who are in quartile 2 of adherence (6-7 points) are 42 % less likely to have a cerebral infarction compared to those who have a lower score (p < 0.005). Conclusions: our findings suggest that moderate adherence to a Mediterranean diet, defined by the PREDIMED score and adjustment for other variables, reduces the probability to first ischemic stroke.

Mediterranean Diet Prior to Ischemic Stroke and Potential Circulating Mediators of Favorable Outcomes

Background/Objectives. A Mediterranean diet (MD) has been associated with neuroprotective effects. We aimed to assess the MD's association with stroke prognosis and the potential mediators involved. Methods. Seventy patients with acute anterior circulation ischemic stroke were included. Dietary patterns were evaluated using the MEDAS scale, a food-frequency questionnaire, and a 24 h recall. Circulating biomarkers including insulin resistance (HOMA index), adipokines (resistin, adiponectin, leptin), choline pathway metabolites (TMAO, betaine, choline), and endothelial progenitor cells (EPCs) were measured. Early neurological improvement (ENI) at 24 h, final infarct volume, and functional outcome at 3 months were assessed. Results. Adherence to MD and olive oil consumption were associated with a lower prevalence of diabetes and atherothrombotic stroke, and with lower levels of fasting glycemia, hemoglobinA1C, insulin resistance, and TMAO levels. Monounsaturated fatty acids and oleic acid consumption correlated with lower resistin levels, while olive oil consumption was significantly associated with EPC mobilization. Multivariate analysis showed that higher MD adherence was independently associated with ENI and good functional prognosis at 3 months. EPC mobilization, lower HOMA levels, and lower resistin levels were associated with ENI, a smaller infarct volume, and good functional outcome. Conclusions. MD was associated with better prognosis after ischemic stroke, potentially mediated by lower insulin resistance, increased EPC mobilization, and lower resistin levels, among other factors.

The paradigm change from reactive medical services to 3PM in ischemic stroke: a holistic approach utilising tear fluid multi-omics, mitochondria as a vital biosensor and AI-based multi-professional data interpretation

Worldwide stroke is the second leading cause of death and the third leading cause of death and disability combined. The estimated global economic burden by stroke is over US$891 billion per year. Within three decades (1990-2019), the incidence increased by 70%, deaths by 43%, prevalence by 102%, and DALYs by 143%. Of over 100 million people affected by stroke, about 76% are ischemic stroke (IS) patients recorded worldwide. Contextually, ischemic stroke moves into particular focus of multi-professional groups including researchers, healthcare industry, economists, and policy-makers. Risk factors of ischemic stroke demonstrate sufficient space for cost-effective prevention interventions in primary (suboptimal health) and secondary (clinically manifested collateral disorders contributing to stroke risks) care. These risks are interrelated. For example, sedentary lifestyle and toxic environment both cause mitochondrial stress, systemic low-grade inflammation and accelerated ageing; inflammageing is a low-grade inflammation associated with accelerated ageing and poor stroke outcomes. Stress overload, decreased mitochondrial bioenergetics and hypomagnesaemia are associated with systemic vasospasm and ischemic lesions in heart and brain of all age groups including teenagers. Imbalanced dietary patterns poor in folate but rich in red and processed meat, refined grains, and sugary beverages are associated with hyperhomocysteinaemia, systemic inflammation, small vessel disease, and increased IS risks. Ongoing 3PM research towards vulnerable groups in the population promoted by the European Association for Predictive, Preventive and Personalised Medicine (EPMA) demonstrates promising results for the holistic patient-friendly non-invasive approach utilising tear fluid-based health risk assessment, mitochondria as a vital biosensor and AI-based multi-professional data interpretation as reported here by the EPMA expert group. Collected data demonstrate that IS-relevant risks and corresponding molecular pathways are interrelated. For examples, there is an evident overlap between molecular patterns involved in IS and diabetic retinopathy as an early indicator of IS risk in diabetic patients. Just to exemplify some of them such as the 5-aminolevulinic acid/pathway, which are also characteristic for an altered mitophagy patterns, insomnia, stress regulation and modulation of microbiota-gut-brain crosstalk. Further, ceramides are considered mediators of oxidative stress and inflammation in cardiometabolic disease, negatively affecting mitochondrial respiratory chain function and fission/fusion activity, altered sleep-wake behaviour, vascular stiffness and remodelling. Xanthine/pathway regulation is involved in mitochondrial homeostasis and stress-driven anxiety-like behaviour as well as molecular mechanisms of arterial stiffness. In order to assess individual health risks, an application of machine learning (AI tool) is essential for an accurate data interpretation performed by the multiparametric analysis. Aspects presented in the paper include the needs of young populations and elderly, personalised risk assessment in primary and secondary care, cost-efficacy, application of innovative technologies and screening programmes, advanced education measures for professionals and general population-all are essential pillars for the paradigm change from reactive medical services to 3PM in the overall IS management promoted by the EPMA.

Association between a lifestyle score and all-cause mortality: a prospective analysis of the Chilean National Health Survey 2009-2010

OBJECTIVE

To investigate the association between a lifestyle score and all-cause mortality in the Chilean population.

DESIGN

Prospective study.

SETTINGS

The score was based on seven modifiable behaviours: salt intake, fruit and vegetable intake, alcohol consumption, sleep duration, smoking, physical activity and sedentary behaviours. 1-point was assigned for each healthy recommendation. Points were summed to create an unweighted score from 0 (less healthy) to 7 (healthiest). According to their score, participants were then classified into: less healthy (0-2 points), moderately healthy (3-4 points) and the healthiest (5-7 points). Associations between the categories of lifestyle score and all-cause mortality were investigated using Cox proportional hazard models adjusted for confounders. Nonlinear associations were also investigated.

PARTICIPANTS

2706 participants from the Chilean National Health Survey 2009-2010.

RESULTS

After a median follow-up of 10·9 years, 286 (10·6 %) participants died. In the maximally adjusted model, and compared with the healthiest participants, those less healthy had 2·55 (95 % CI 1·75, 3·71) times higher mortality risk due to any cause. Similar trends were identified for the moderately healthy group. Moreover, there was a significant trend towards increasing the mortality risk when increasing unhealthy behaviours (hazard ratio model 3: 1·61 (95 % CI 1·34, 1·94)). There was no evidence of nonlinearity between the lifestyle score and all-cause mortality.

CONCLUSION

Individuals in the less healthy lifestyle category had higher mortality risk than the healthiest group. Therefore, public health strategies should be implemented to promote adherence to a healthy lifestyle across the Chilean population.

Impact of the level of adherence to the Mediterranean Diet on blood pressure: A systematic review and meta-analysis of observational studies

BACKGROUND

High blood pressure (BP) constitutes a common and serious medical condition which is rising globally, and is among preventable factors for cardiovascular, renal, brain and other diseases. Modifiable risk factors of high BP include unhealthy dietary patterns, presence of obesity, excess alcohol consumption and lack of physical activity. Data in regard to the different types of diets show that Mediterranean diet (MD) is associated with healthy levels of BP. In this study we aimed to investigate the impact of the level of adherence to MD in BP.

AIMS-METHODS

A systematic literature search (up to 08.2021) in PubMed, Scopus, Embase, Web of Science, Cochrane and Google Scholar databases was conducted, and 54 observational studies were included.

RESULTS

Systolic blood pressure (SBP) was found to be lower in the high adherence to MD group SMD: -0.08, (95%CI: -0.15, -0.02) whereas no differences regarding diastolic blood pressure (DBP) were observed between the high and low adherence to MD groups [SMD: -0.07, (95%CI: -0.13, 0.00)]. Mean DBP of all included studies for both high and low adherence groups were in healthy levels (<90 mmHg).

CONCLUSIONS

Higher adherence to MD could positively influence SBP, but further research is needed in this field due to the heterogeneous definitions of low/high adherence and the type of studies used (observational).

Risk Factors and Diet Components Determining Adherence to the Mediterranean Diet in Acute Ischemic Stroke Patients: A Cross-Sectional Analysis of a Prospective Hospital Register Study

OBJECTIVES

Low adherence to a Mediterranean diet (MeDi) is associated with increased incidence, mortality, and severity of acute ischemic strokes (AIS). Nevertheless, the explanatory factors associated with such results are unclear. Our aim was to investigate stroke risk factors associated with adherence to a MeDi in a prospective cohort of AIS patients.

MATERIALS AND METHODS

Patients admitted from February 2017 to February 2020 were included in this study. Adherence was measured using the 14-point Mediterranean Diet Adherence Screener (MEDAS). Demographic and clinical characteristics were compared with adherence with a univariate analysis. A binomial regression was used to investigate the independent association of premorbid factors and MeDi components with adherence.

RESULTS

There were 413 patients. Mean age was 68.6 (17.4), 176 (42.6%) women. Median MEDAS score was 6 (IQR 4-7) points. 253 patients (61.2%) had a low adherence (MEDAS ≤ 6). In the univariate analysis, a low MEDAS was associated with lower education, diabetes, sedentary lifestyle, greater body mass index (BMI), lower alcohol consumption, and higher LDLc. In the regression analysis, younger age, lower education, functional disability, hypertension, sedentary lifestyle, and higher BMI were associated with lower MEDAS scores. Six MeDi components had particularly low patient adherence: seafood, legumes, olive oil, nuts, wine, and fruit.

DISCUSSION

These data indicate low adherence to MeDi in younger patients who are less educated and have existing cardiovascular risk factors, in particular hypertension, sedentary lifestyle, and higher BMI. Some components of the diet had a particularly low adherence.

CONCLUSIONS

Tailoring diet prevention interventions to these specific populations, focusing on components with known less adherence, could improve adherence to a MeDi and the opportunity for secondary stroke prevention.

Effects of an Avocado-based Mediterranean Diet on Serum Lipids for Secondary Prevention after Ischemic Stroke Trial (ADD-SPISE): Study protocol

BACKGROUND:

A poor or unhealthy diet is responsible for an important fraction of ischemic stroke risk. Adherence to dietary patterns, such as the Mediterranean diet, rich in monounsaturated fatty acids mainly from olive oil, is associated with a lower stroke risk. Furthermore, lowering low-density cholesterol (LDL-C) levels decreases stroke recurrence. Interestingly, Avocado-substituted diets, which are also rich in monounsaturated fatty acids, significantly decrease LDL cholesterol levels. This study aims to evaluate whether a Mediterranean diet based on Avocados reduces LDL-C compared to a low-fat high-complex carbohydrate diet after 3 months of the intervention in patients who had a recent acute ischemic stroke. The trial will also assess safety and feasibility.

PATIENTS AND METHODS:

Prospective, randomized open-label, blinded outcome assessment clinical trial. Participants are patients within a month of being admitted with an ischemic stroke, who consent and fulfil the eligibility criteria. Patients are randomly assigned to either diet intervention in a 1:1 ratio on top of the usual secondary prevention treatment. The intervention diet is: A).. Avocado-based Mediterranean diet with intake of 1/2 portion of Avocado per day and B).. The control diet is a low-fat high-complex carbohydrate diet. The main efficacy outcome is a reduction in plasma LDL-C levels at 3 months of the dietary intervention. Secondary outcomes include changes in the levels of serum lipid profile and serum inflammation markers, safety, and feasibility. A sample size of 200 patients was estimated to provide 80% power and 5% level of significance (10% loss and 5% crossover) to detect a minimum difference of 4.6 mg/dL in LDL-C after 3 months of intervention.

CONCLUSION:

We hypothesize that an Avocado-based Mediterranean diet will further reduce the levels of LDL-cholesterol at 3 months compared to the control diet, and that the intervention is safe and feasible.

REGISTRATION:

The study is registered under ADDSPISE at www.clinicaltrials.gov. Identifier NCT03524742. Protocol ID CAS-605 version 3.0 (May 2nd, 2019).

Impact of the Level of Adherence to Mediterranean Diet on the Parameters of Metabolic Syndrome: A Systematic Review and Meta-Analysis of Observational Studies

High adherence to the Mediterranean diet (MD) has been associated with a lower prevalence of Metabolic Syndrome (MetS). The present study aimed to investigate the impact of MD adherence on parameters of MetS. A systematic literature search was performed in PubMed, Cochrane Central Registry of Clinical Trials (CENTRAL), Scopus, EMBASE, Web of Science and Google Scholar databases. Observational studies that recorded adherence to MD and components/measures of the MetS, such as waist circumference (WC), blood pressure (BP), fasting blood glucose (FBG), high-density lipoprotein (HDL) cholesterol and triglycerides (TG), were included in this study. A total of 58 studies were included in our study. WC and TG were significantly lower in the high adherence MD group (SMD: -0.20, (95%CI: -0.40, -0.01), SMD: -0.27 (95%CI: -0.27, -0.11), respectively), while HDL cholesterol was significantly higher in the same group (SMD: -0.28 (95%CI: 0.07, 0.50). There was no difference in FBG and SBP among the two groups (SMD: -0.21 (95%CI: -0.54, 0.12) & SMD: -0.15 (95%CI: -0.38, 0.07), respectively). MD may have a positive impact on all parameters of MetS. However, further research is needed in this field.

Development of a predictive model for integrated medical and long-term care resource consumption based on health behaviour: application of healthcare big data of patients with circulatory diseases

BACKGROUND

Medical costs and the burden associated with cardiovascular disease are on the rise. Therefore, to improve the overall economy and quality assessment of the healthcare system, we developed a predictive model of integrated healthcare resource consumption (Adherence Score for Healthcare Resource Outcome, ASHRO) that incorporates patient health behaviours, and examined its association with clinical outcomes.

METHODS

This study used information from a large-scale database on health insurance claims, long-term care insurance, and health check-ups. Participants comprised patients who received inpatient medical care for diseases of the circulatory system (ICD-10 codes I00-I99). The predictive model used broadly defined composite adherence as the explanatory variable and medical and long-term care costs as the objective variable. Predictive models used random forest learning (AI: artificial intelligence) to adjust for predictors, and multiple regression analysis to construct ASHRO scores. The ability of discrimination and calibration of the prediction model were evaluated using the area under the curve and the Hosmer-Lemeshow test. We compared the overall mortality of the two ASHRO 50% cut-off groups adjusted for clinical risk factors by propensity score matching over a 48-month follow-up period.

RESULTS

Overall, 48,456 patients were discharged from the hospital with cardiovascular disease (mean age, 68.3 ± 9.9 years; male, 61.9%). The broad adherence score classification, adjusted as an index of the predictive model by machine learning, was an index of eight: secondary prevention, rehabilitation intensity, guidance, proportion of days covered, overlapping outpatient visits/clinical laboratory and physiological tests, medical attendance, and generic drug rate. Multiple regression analysis showed an overall coefficient of determination of 0.313 (p < 0.001). Logistic regression analysis with cut-off values of 50% and 25%/75% for medical and long-term care costs showed that the overall coefficient of determination was statistically significant (p < 0.001). The score of ASHRO was associated with the incidence of all deaths between the two 50% cut-off groups (2% vs. 7%; p < 0.001).

CONCLUSIONS

ASHRO accurately predicted future integrated healthcare resource consumption and was associated with clinical outcomes. It can be a valuable tool for evaluating the economic usefulness of individual adherence behaviours and optimising clinical outcomes.

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

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