Combined associations of body mass index and adherence to a Mediterranean-like diet with all-cause and cardiovascular mortality: A cohort study

Association of oxidative balance score with chronic kidney disease: NHANES 1999-2018

Background

The Oxidative Balance Score (OBS), which quantifies the balance between antioxidants and pro-oxidants influenced by diet and lifestyle, is crucial given oxidative stress's significant role in Chronic Kidney Disease (CKD). This study aims to determine the association between OBS and CKD using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018.

Methods

We analyzed data from the National Health and Nutrition Examination Survey (NHANES) spanning 1999 to 2018. OBS was constructed from a detailed array of 20 factors, including dietary nutrients and lifestyle behaviors. The relationship between OBS and CKD risk was evaluated using weighted logistic regression models, adjusted for potential confounders, with a generalized additive model (GAM) examining non-linear associations. Subgroup analyses and interaction effects across diverse demographic and clinical groups, along with sensitivity analyses, were performed to validate the findings.

Results

Among 32,120 participants analyzed, 4,786 were identified with CKD. Fully adjusted weighted logistic regression analysis revealed that each unit increase in OBS was associated with a 2% reduction in CKD prevalence [OR: 0.98 (0.98-0.99), P < 0.001]. Higher OBS quartiles were significantly correlated with a decreased CKD risk [Q4 vs. Q1: OR: 0.82 (0.68-0.98), P = 0.03; P for trend = 0.01]. The GAM and smoothed curve fit indicated a linear relationship between OBS and the risk of CKD. Stratified and sensitivity analyses further substantiated the inverse relationship between OBS and CKD prevalence.

Conclusions

Our findings from the NHANES data affirm a significant inverse association between OBS and CKD risk in the U.S. population, underscoring the role of optimizing dietary and lifestyle factors in managing CKD risk. These results advocate for incorporating OBS considerations into CKD prevention and treatment strategies.

Association between Dietary Patterns and All-Cause Mortality in the Chinese Old: Analysis of the Chinese Longitudinal Healthy Longevity Survey Cohort

Diet is one of the most important ways to intervene and promote the health of older adults and reduce all-cause mortality. This study aimed to investigate the association between dietary patterns and all-cause mortality in the Chinese old. This study involved 11,958 subjects aged 65-116 years in the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2008 to 2018. Dietary patterns were derived from principal component analysis (PCA) with varimax rotation. Four dietary patterns were derived: the 'milk-egg-sugar pattern', 'carnivorous pattern', 'healthy pattern', and 'northeastern pattern'. Cox proportional hazard models were built for males and females separately to estimate the relationship between different dietary patterns and all-cause mortality. After adjusting for all covariates, the milk-egg-sugar pattern played a reverse role in mortality risk in males and females in different quartiles. In the carnivorous pattern, only males in the fourth quartile were observed to have a significantly reduced mortality risk (HR = 0.84 (95% CI: 0.77-0.93)). Both genders benefited from the healthy pattern, which consistently lowered mortality risk across all quartiles (males: HR = 0.87 (95% CI: 0.84-0.89); females: HR = 0.95 (95% CI: 0.92-0.97)). The northeastern pattern also showed an inverse association with all-cause mortality in males (HR = 0.94 (95% CI: 0.92-0.97)) and females (HR = 0.96 (95% CI: 0.93-0.98)). This study showed the association between dietary patterns and all-cause mortality in the Chinese old, which is significant for further quantitative studies.

Adherence to a healthy lifestyle, genetic susceptibility to abdominal obesity, cardiometabolic risk markers, and risk of coronary heart disease

BACKGROUND

Little is known about whether the association between genetic susceptibility to high waist-to-hip ratio (WHR), a measure of abdominal obesity, and incident coronary heart disease (CHD) is modified by adherence to a healthy lifestyle.

OBJECTIVES

To explore the interplay of genetic susceptibility to high WHR and adherence to a healthy lifestyle on incident CHD.

METHODS

This study included 282,316 white British individuals from the UK Biobank study. Genetic risk for high WHR was estimated in the form of weighted polygenic risk scores (PRSs), calculated based on 156 single-nucleotide polymorphisms. Lifestyle scores were calculated based on 5 healthy lifestyle factors: regular physical activity, no current smoking, a healthy diet, <3 times/wk of alcohol consumption and 7-9 h/d of sleep. Incident CHD (n = 11,635) was accrued over a median 13.8 y of follow-up, and 12 individual cardiovascular disease risk markers assessed at baseline.

RESULTS

Adhering to a favorable lifestyle (4-5 healthy factors) was associated with a 25% (hazard ratio: 0.75, 95% confidence interval: 0.70, 0.81) lower hazard of CHD compared with an unfavorable lifestyle (0-1 factor), independent of PRS for high WHR. Estimated 12-y absolute risk of CHD was lower for a favorable lifestyle at high genetic risk (1.73%) and medium genetic risk (1.67%) than for an unfavorable lifestyle at low genetic risk (2.08%). Adhering to a favorable lifestyle was associated with healthier levels of cardiovascular disease risk markers (except random glucose and high-density lipoprotein), independent of PRS for high WHR.

CONCLUSIONS

Individuals who have high or medium genetic risk of abdominal obesity but adhere to a healthy lifestyle may have a lower risk of developing CHD, compared with those who have low genetic risk and an unhealthy lifestyle. Future clinical trials of lifestyle modification could be implemented for individuals at high genetic risk of abdominal obesity for the primary prevention of CHD events.

Associations between body mass index and all-cause mortality: A systematic review and meta-analysis

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. β coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted β -0.829 [95% CI -1.313, -0.345] and adjusted β -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted β -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted β -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted β -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2  ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

A nonlinear association between body roundness index and all-cause mortality and cardiovascular mortality in general population

OBJECTIVE

The aim of the study was to investigate the association between body roundness index (BRI) and all-cause mortality and cardiovascular mortality in general population.

DESIGN

A retrospective cohort study.

SETTING

The status of cardiovascular mortality and all-cause mortality of participants were followed through 31 December 2015. Multivariate adjusted Cox restricted cubic spline regression models and Kaplan-Meier survival curves were used to evaluate the relationship between BRI and cardiovascular mortality and all-cause mortality.

PARTICIPANTS

A sample of 47 356 participants from the National Health and Nutrition Examination Surveys 1999-2014 with aged ≥18 years.

RESULTS

Mean age was 47 years and female were 49·9 %. During a median follow-up of 92 months, 4715 participants died from any cause, with 985 died of CVD. In multivariate adjusted Cox regression, compared with the lowest quartile of Body roundness index (BRI), the hazard ratios (HR) for all-cause mortality from other quartiles were 0·83, 95 % CI (0·75, 0·92), 0·73, 95 % CI (0·65, 0·81) and 0·80, 95 % CI (0·72, 0·89), respectively (P_{for trend} < 0·05) and the HR for cardiovascular mortality from other quartiles were 0·79, 95 % CI (0·62, 1·00), 0·78, 95 % CI (0·62, 0·99) and 0·79, 95 % CI (0·62, 1·01), respectively (P for trend > 0·05). In the restricted cubic spline regression models, the relationship was showed U-shaped between BRI and all-cause mortality and cardiovascular mortality. In Kaplan-Meier survival curves, the lowest cumulative survival rate of cardiovascular mortality and all-cause mortality was recorded in the highest BRI quartile.

CONCLUSIONS

The U-shaped association between BRI and all-cause mortality and cardiovascular mortality in a large population-based cohort was observed.

Greater Adherence to Dietary Guidelines Associated with Reduced Risk of Cardiovascular Diseases in Chinese Patients with Type 2 Diabetes

The evidence regarding the impact of the scores on healthy eating indices on the risk of cardiovascular events among patients with type 2 diabetes (T2D) is limited. As such, in this study, we examined the associations of adherence to the Chinese and American dietary guidelines and the risk of cardiovascular disease (CVD) among Chinese individuals with T2D. We conducted a 1:1 age- and sex-matched case−control study based on a Chinese population. We used a structured questionnaire and a validated 79-item food-frequency questionnaire to collect general information and dietary intake information, and calculated the Chinese Healthy Eating Index (CHEI) and the Healthy Eating Index-2015 (HEI-2015). As participants, we enrolled a total of 419 pairs of hospital-based CVD cases and controls, all of whom had T2D. We found a significant inverse association between diet quality scores on the CHEI and HEI-2015 and the risk of CVD. The adjusted odds ratios (95% confidence interval) per five-score increment were 0.68 (0.61, 0.76) in the CHEI and 0.60 (0.52, 0.70) in the HEI-2015. In stratified analyses, the protective associations remained significant in the subgroups of sex, BMI, smoking status, tea-drinking, hypertension state, dyslipidemia state, T2D duration, and medical nutrition therapy knowledge (all p < 0.05). These findings suggest that a higher CHEI or HEI-2015 score, representing a higher-quality diet relative to the most recent Chinese or American dietary guidelines, was associated with a decreased risk of CVD among Chinese patients with T2D.

Associations of longitudinal trajectories in body roundness index with mortality and cardiovascular outcomes: a cohort study

BACKGROUND

The body roundness index (BRI) is a new anthropometric index that combines height and waist circumference to predict the percentages of total and regional fat. The longitudinal trajectories of BRI can reflect the long-term pattern of BRI changes; however, their effects on the incidence of cardiovascular disease (CVD) and mortality are poorly characterized.

OBJECTIVES

Our aim was to identify BRI trajectories and to estimate their associations with mortality and incident CVD events.

METHODS

This study included a total of 59,278 participants (mean age, 54.8 years) free of malignant tumors and CVD and with repeated measurements of BRI from 2006 to 2012. The BRI trajectories from 2006 to 2012 were identified using the latent mixture model. A Cox proportional hazards model was used to analyze the associations between BRI trajectories and the risk of CVD events and mortality.

RESULTS

We grouped the BRI trajectories into 4 distinct groups during 2006-2012: low-stable (mean BRI = 2.7), moderate-stable (mean BRI = 3.7), moderate-high-stable (mean BRI = 4.7), and high-stable (mean BRI = 5.8). We identified 1928 CVD events and 2928 deaths during the follow-up. After adjustment for potential confounders, compared with the low-stable group, the HRs of CVD were 1.37 (95% CI: 1.19-1.58) for the moderate-stable group, 1.64 (95% CI: 1.40-1.91) for the moderate-high-stable group, and 2.03 (95% CI: 1.64-2.52) for the high-stable group. We observed similar associations for myocardial infarction and ischemic stroke. The association between BRI trajectories and CVD was more prominent in subjects aged <55 years.

CONCLUSIONS

BRI trajectories were significantly associated with the risk of CVD, and the association was more evident in younger adults.

Milk and Fermented Milk Consumption and Risk of Stroke: Longitudinal Study

The role of milk and fermented milk consumption in stroke risk is unclear. We investigated associations of time-updated information on milk and fermented milk consumption (1997 and 2009) with total stroke, cerebral infarction, and hemorrhagic stroke risk among 79,618 Swedish women and men (mean age 61.3 years). During a mean follow-up of 17.7 years, we identified 9735 incident cases of total stroke, of which 7573 were cerebral infarctions, 1470 hemorrhagic strokes, and 692 unspecified strokes. Compared with an intake of 100 g/day of milk, the multivariable-adjusted hazard ratios (95% confidence interval) of cerebral infarction were 1.05 (1.02–1.08) for 0 g/day, 0.97 (0.95–0.99) for 200 g/day, 0.96 (0.92–1.00) for 400 g/day, 0.98 (0.94–1.03) for 600 g/day, and 1.01 (0.94–1.07) for 800 g/day. Corresponding estimates for hemorrhagic stroke were 0.98 (0.91–1.05) for 0 g/day, 1.02 (0.97–1.07) for 200 g/day, 1.07 (0.98–1.17) for 400 g/day, 1.13 (1.02–1.25) for 600 g/day, and 1.19 (1.03–1.36) for 800 g/day. No associations were observed between milk consumption and total stroke or for fermented milk consumption and any of the stroke outcomes. Higher long-term milk consumption based on repeated measures of intake was weakly and non-linearly associated with cerebral infarction, and was directly associated with hemorrhagic stroke.

Obesity, metabolic risk and adherence to healthy lifestyle behaviours: prospective cohort study in the UK Biobank

BACKGROUND

Contested evidence suggests that obesity confers no risk to health in people who have a healthy lifestyle, particularly if there are no metabolic complications of obesity. The aim was to examine the association between adherence to lifestyle recommendations and the absence of metabolic complications on the incident or fatal cardiovascular disease and all-cause mortality across different categories of body mass index (BMI).

METHODS

This contemporary prospective cohort study included 339,902 adults without cardiovascular disease at baseline, recruited between 2006 and 2010 from the UK Biobank and followed until 2018-2020. The main exposures were four healthy lifestyle behaviours: never smoker, alcohol intake ≤ 112g/ week, 150 min moderate physical activity or 75 min vigorous activity/week, ≥ 5 servings of fruit or vegetables/day, and we assessed these overall and across the BMI groups. Metabolic complications of excess adiposity were hypertension, diabetes and hyperlipidaemia, and we examined whether obesity was associated with increased risk in the absence of these complications. The outcomes were all-cause mortality, death from, and incident cardiovascular disease (CVD).

RESULTS

Individuals who met four lifestyle recommendations but had excess weight had higher all-cause mortality; for BMI 30-34.9 kg/m², the hazard ratio (HR) was 1.42 (95% confidence interval 1.20 to 1.68), and for BMI ≥ 35 kg/m², HR was 2.17 (95% CI 1.71 to 2.76). The risk was lower, but still increased for people with no metabolic complications; for all-cause mortality, BMI 30-34.9 kg/m² had an HR of 1.09 (95% CI 0.99 to 1.21), and BMI ≥ 35 kg/m² had an HR of 1.44 (95% CI 1.19 to 1.74) for all-cause mortality. Similar patterns were found for incident and fatal CVD.

CONCLUSIONS

Meeting healthy lifestyle recommendations, or the absence of metabolic complications of obesity offsets some, but not all, of the risk of subsequent CVD, and premature mortality in people with overweight or obesity. Offering support to achieve and maintain a healthy weight and to adopt healthy behaviours are likely to be important components in effective preventative healthcare.

Feasibility of a high-PRotein Mediterranean-style diet and resistance Exercise in cardiac Rehabilitation patients with sarcopenic obesity (PRiMER): Study protocol for a randomised control trial

BACKGROUND

Cardiac rehabilitation (CR) is an essential component of long-term recovery following a cardiac event. Typical CR may not be optimal for patients presenting with sarcopenic obesity (SO) who present with reduced muscle mass and elevated adipose tissue, and may indicate greater cardiovascular disease (CVD) risk. Resistance exercise and high-protein diets are known to increase muscle mass, while Mediterranean-style diets have been shown to reduce CVD risk. A high-protein Mediterranean-style diet combined with resistance exercise intervention is yet to be trialled in cardiac rehabilitation populations.

OBJECTIVES

Primary outcome: to determine the feasibility of such an intervention by investigating the perceptions, acceptance and adherence to a resistance exercise protocol and high-protein Mediterranean style diet in a UK cardiac rehabilitation population with SO. Secondary outcome: to trial this protocol ahead of a fully powered clinical study.

METHODS

Eligible cardiac rehabilitation patients will be randomised to one of the following: 1) a control group (standard CR), 2) high-protein Mediterranean-style diet, 3) resistance exercise group, or 4) both high-protein Mediterranean-style diet and resistance exercise group. The pilot study will last 12 weeks. Measures of body composition (dual energy x-ray absorptiometry) grip strength, CVD risk (e.g., fasting triglycerides, glucose, cholesterol) and dietary adherence will be assessed at baseline and after 12 weeks. To compare groups, a mixed model ANOVA (time x intervention) will be performed. Patient participant involvement throughout the development of this project will be used to determine the feasibility of a future, fully powered, randomised control trial. A feasibility questionnaire will help establish the proportion of eligible participants, their willingness to be randomised, response rates, and ethical considerations. Furthermore, focus groups, food tasting and telephone interviews will be conducted to assess the acceptability of recipes and exercise protocols provided.

DISCUSSION

This pilot trial will determine whether a fully powered, multi-centred randomised control trial in CR patients with SO can be implemented. The information received from patient involvement will be invaluable for identifying possible barriers to participation and tailoring interventions to participant needs, helping to increase the likelihood of long-term compliance to health-promoting lifestyle changes.

REGISTRATION

This study is registered at clinicaltrials.gov (NCT04272073), registered on 17/02/2020, https://clinicaltrials.gov/ct2/show/NCT04272073.

DATE AND VERSION

28/12/20 version 3.0.

Serum 25-hydroxyvitamin D is associated with fracture risk only during periods of seasonally high levels in women with a high body mass index

Serum 25-hydroxyvitamin D (S-25OHD) is used to assess vitamin D status and is known to be affected by season and fat mass. Because these factors are often ignored when interpreting S-25OHD, assessment of vitamin D associations with disease outcomes may be distorted. We aimed to investigate the impact of season of blood draw and fat mass on the association of S25OHD with fracture risk. We enrolled 5000 women, mean ± SD age 68 ± 7 years, with dual-energy x-ray absorptiometry (DXA) scans and blood collection in a population-based cohort. Proportional hazards regression, stratified by season and fat mass, was used to determine hazard ratios (HRs) of fracture according to categories of S-25OHD. Our secondary exposures were serum 1,25-dihydroxycholecalciferol (1,25-(OH)₂ D₃ ), the most active vitamin D metabolite and plasma parathyroid hormone (P-PTH). During an average of 9.2 years of follow-up, 1080 women had a fracture. Women with S-25OHD <30 nmol/L drawn during sunny months (May-October) had a multivariable-adjusted fracture HR of 2.06 (95% CI, 1.27-3.35) compared with those with S-25OHD >60 nmol/L; those with S-25OHD 30-40 nmol/L had an HR of 1.59 (95% CI, 1.12-2.26). In contrast, S-25OHD drawn during November through April was unrelated to fracture risk. The increased risk with low sunny season S-25OHD was seen only among women with body mass index (BMI) ≥25 kg/m² or fat mass index (FMI) ≥9.8 kg/m² . High fat mass and low S-25OHD were independently related to lower S-1,25-dihydroxycholecalciferol, which itself predicted fracture risk with samples collected during the sunny season. Irrespective of season, P-PTH was unrelated to fracture risk. We conclude that S-25OHD is associated with fracture risk only if drawn during periods of seasonally high levels in women with a high BMI. These results have implications for the evaluation of vitamin D status and can explain the lack of effect seen with vitamin D supplementation in many fracture trials. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Nutrition to Optimise Human Health-How to Obtain Physiological Substantiation?

Demonstrating in an unambiguous manner that a diet, let alone a single product, 'optimizes' health, presents an enormous challenge. The least complicated is when the starting situation is clearly suboptimal, like with nutritional deficiencies, malnutrition, unfavourable lifestyle, or due to disease or ageing. Here, desired improvements and intervention strategies may to some extent be clear. However, even then situations require approaches that take into account interactions between nutrients and other factors, complex dose-effect relationships etc. More challenging is to substantiate that a diet or a specific product optimizes health in the general population, which comes down to achieve perceived, 'non-medical' or future health benefits in predominantly healthy persons. Presumed underlying mechanisms involve effects of non-nutritional components with subtle and slowly occurring physiological effects that may be difficult to translate into measurable outcomes. Most promising strategies combine classical physiological concepts with those of 'multi-omics' and systems biology. Resilience-the ability to maintain or regain homeostasis in response to stressors-is often used as proxy for a particular health domain. Next to this, quantifying health requires personalized strategies, measurements preferably carried out remotely, real-time and in a normal living environment, and experimental designs other than randomized controlled trials (RCTs), for example N-of-1 trials.

Association between the Mediterranean lifestyle, metabolic syndrome and mortality: a whole-country cohort in Spain

Background

Evidence is limited about the joint health effects of the Mediterranean lifestyle on cardiometabolic health and mortality. The aim of this study was to evaluate the association of the Mediterranean lifestyle with the frequency of the metabolic syndrome (MS) and the risk of all-cause and cardiovascular mortality in Spain.

Methods

Data were taken from ENRICA study, a prospective cohort of 11,090 individuals aged 18+ years, representative of the population of Spain, who were free of cardiovascular disease (CVD) and diabetes at 2008–2010 and were followed-up to 2017. The Mediterranean lifestyle was assessed at baseline with the 27-item MEDLIFE index (with higher score representing better adherence).

Results

Compared to participants in the lowest quartile of MEDLIFE, those in the highest quartile had a multivariable-adjusted odds ratio 0.73 (95% confidence interval (CI) 0.5, 0.93) for MS, 0.63. (0.51, 0.80) for abdominal obesity, and 0.76 (0.63, 0.90) for low HDL-cholesterol. Similarly, a higher MELDIFE score was associated with lower HOMA-IR and highly-sensitivity C-reactive protein (P-trend < 0.001). During a mean follow-up of 8.7 years, 330 total deaths (74 CVD deaths) were ascertained. When comparing those in highest vs. lowest quartile of MEDLIFE, the multivariable-adjusted hazard ratio (95% CI) was 0.58 (0.37, 0.90) for total mortality and 0.33 (0.11, 1.02) for cardiovascular mortality.

Conclusions

The Mediterranean lifestyle was associated with lower frequency of MS and reduced all-cause mortality in Spain. Future studies should determine if this also applies to other Mediterranean countries, and also improve cardiovascular health outside the Mediterranean basin.