Modified Mediterranean diet score and cardiovascular risk in a North American working population

The dietary inflammatory index and cardiometabolic parameters in US firefighters

Introduction

Dietary choices play a crucial role in influencing systemic inflammation and the eventual development of cardiovascular diseases (CVD). The Dietary Inflammatory Index (DII®) is a novel tool designed to assess the inflammatory potential of one's diet. Firefighting, which is characterized by high-stress environments and elevated CVD risk, represents an interesting context for exploring the dietary inflammatory-CVD connection.

Aim

This study aims to investigate the associations between Energy-adjusted Dietary Inflammatory Index (E-DII™) scores and cardiometabolic risk parameters among US firefighters.

Methods

The study analyzed 413 participants from the Indianapolis Fire Department who took part in a Federal Emergency Management Agency (FEMA)-sponsored Mediterranean diet intervention trial. Thorough medical evaluations, encompassing physical examinations, standard laboratory tests, resting electrocardiograms, and submaximal treadmill exercise testing, were carried out. Participants also completed a detailed food frequency questionnaire to evaluate dietary patterns, and E-DII scores were subsequently computed based on the gathered information.

Results

Participants had a mean body mass index (BMI) of 30.0 ± 4.5 kg/m2 and an average body fat percentage of 28.1 ± 6.6%. Regression analyses, adjusted for sex, BMI, maximal oxygen consumption (VO2 max), max metabolic equivalents (METS), age, and body fat percentage, revealed significant associations between high vs. low E-DII scores and total cholesterol (β = 10.37, p = 0.04). When comparing low Vs median E-DII scores there is an increase in glucose (β = 0.91, p = 0.72) and total cholesterol (β = 5.51, p = 0.26).

Conclusion

Our findings support an association between higher E-DII scores and increasing adiposity, as well as worse lipid profiles.

Nutritional Barriers to the Adherence to the Mediterranean Diet in Non-Mediterranean Populations

Adherence to the Mediterranean diet has been shown to lower the risk of developing chronic non-communicable diseases like cardiovascular and neurodegenerative diseases and cancer. Improvements in depression, participation in daily activities in older individuals, weight loss and a reduction in adverse pregnancy outcomes are associated with adherence to the Mediterranean diet. The number of studies that have evaluated barriers to adherence to the Mediterranean diet in the US and, in particular, in racial and ethnic minority populations within the US are few. Among Native American and Alaskan Native populations, studies evaluating traditional or alternative Mediterranean diet adherence for chronic non-infectious diseases is unavailable. Mediterranean diet scoring instruments used in studies in European and Mediterranean countries and among white participants in the US fail to capture the dietary patterns of racial and ethnic minority populations. In this narrative review, the food components of the traditional Mediterranean diet are discussed, adherence to the Mediterranean diet is examined in Mediterranean and non-Mediterranean countries and barriers preventing adherence to the Mediterranean diet in the US and among racial and ethnic minority populations is reviewed. Recommendations for improving nutrition education and intervention and for increasing adherence and cultural adaptions to the Mediterranean diet are provided.

Comment on Flatscher et al. Impact of Mediterranean Diet on Lipid Composition in the Colaus-PsyColaus Study. Nutrients 2023, 15, 4659

With great interest, we read the article by Flatscher et al [...].

Firefighter Health: A Narrative Review of Occupational Threats and Countermeasures

Structural firefighters are responsible for protecting properties and saving lives during emergency operations. Despite efforts to prepare firefighters for these hazardous occupational demands, the unfortunate reality is that the incidence of health morbidities is increasing within the fire service. Specifically, cardiovascular disease, cancer, and mental health disorders are among the most documented morbidities in firefighters. Pubmed and Google Scholar search engines were used to identify peer-reviewed English language manuscripts that evaluated firefighters' occupational health threats, allostatic factors associated with their occurrence, and evidence-based strategies to mitigate their impact. This narrative review provides fire departments, practitioners, and researchers with evidence-based practices to enhance firefighters' health.

Surviving & Thriving; a healthy lifestyle app for new US firefighters: usability and pilot study protocol

In the United States (US), new firefighters' fitness and health behaviors deteriorate rapidly after fire academy graduation. Over the long-term, this increases their risks for chronic diseases. This study protocol describes the proposed usability testing and pilot study of a newly designed and developed healthy lifestyle smartphone app, "Surviving & Thriving", tailored towards young US firefighters. "Surviving & Thriving" will provide interactive educational content on four lifestyle factors; nutrition, sleep, physical activity, and resilience, and include a personalized journey, habit tracker, and elements of gamification to promote engagement and long-term healthy behavior change. The first phase of the app development entails alpha testing by the research team and pre-beta testing by a fire service expert panel which will help refine the app into a pre-consumer version. Upon completion of the full app prototype, beta 'usability' testing will be conducted among new fire academy graduates from two New England fire academies to collect qualitative and quantitative feedback via focus groups and satisfaction surveys, respectively. A last phase of piloting the app will evaluate the app's efficacy at maintaining/improving healthy lifestyle behaviors, mental health metrics, and physical fitness metrics. We will also evaluate whether firefighters' perceived "health cultures" scores (ratings of each fire station's/fire department's environments as to encouraging/discouraging healthy behaviors) modify the changes in health metrics after utilizing the app for three to six months. This novel user-friendly app seeks to help new firefighters maintain/improve their health and fitness more effectively, reducing their risk of lifestyle-related chronic disease. Firefighters who can establish healthy habits early in their careers are more likely to sustain them throughout their lives.

The Prevalence of Metabolic Syndrome and Its Components in Firefighters: A Systematic Review and Meta-Analysis

Previous studies consistently report a high prevalence of cardiovascular disease (CVD) risk factors among firefighters. However, the clustering of CVD risk factors, defined as metabolic syndrome (MetSyn), has received little attention by comparison. Therefore, the aim of this study was to estimate the pooled prevalence of MetSyn among firefighters. Using combinations of free text for 'firefighter' and 'metabolic syndrome', databases were searched for eligible studies. Meta-analyses calculated weighted pooled prevalence estimates with 95% confidence intervals (CI) for MetSyn, its components and overweight/obesity. Univariate meta-regression was performed to explore sources of heterogeneity. Of 1440 articles screened, 25 studies were included in the final analysis. The pooled prevalence of MetSyn in 31,309 firefighters was 22.3% (95% CI: 17.7-27.0%). The prevalences of MetSyn components were hypertension: 39.1%; abdominal obesity: 37.9%; hypertriglyceridemia: 30.2%; dyslipidemia: 30.1%; and hyperglycemia: 21.1%. Overweight and obesity prevalence rates in firefighters were 44.1% and 35.6%, respectively. Meta-regression revealed that decreased risk of bias (RoB) score and increased body mass index (BMI) were positively associated with an increase in MetSyn prevalence. Since one in five firefighters may meet the criteria for MetSyn, novel interventions should be explored to both prevent MetSyn and reduce the onset of CVD risk factors.

The allostatic load model: a framework to understand the cumulative multi-system impact of work-related psychosocial stress exposure among firefighters

Firefighting is recognised as a profession where health and well-being can be affected by a variety of occupational factors, such as physical, thermal, and chemical stressors. Along with the risks intuitively associated with the fire service, however, psychosocial stress has begun to attract attention as another variable deserving of consideration. Indeed, long-term exposure to work-related psychosocial stress has been linked with poor health outcomes in many workers; however, despite this association, very little has been done to examine how such stressors become biologically embedded in firefighters. To help facilitate research into how psychosocial stress can affect health-related outcomes in the fire service, we propose a framework centered on the notion of allostatic load. First, we reviewed the occupational characteristics that may generate psychosocial stress within firefighters before introducing allostatic load (that is, dysregulation across various physiological systems caused by the need to manage ongoing stressors). Next, we provided a summary of how allostatic load can be measured and touched on the framework's utility for studying the cumulative effects of work-related stress on firefighter health. After this, factors that may influence the steps leading from stress exposure to health outcomes were discussed; in particular, we commented upon how research in this area should consider specific non-modifiable (age, sex, and ethnicity) and modifiable (psychosocial resources and behavioural habits) factors. Finally, we presented methodological barriers and opportunities that may arise when using the allostatic load framework with this professional group. By introducing the framework, we hope to provide a tool that may be used by those interested in stress-health research in firefighters to build the evidence needed to inform primary prevention measures.

Effect of a Nutrition Intervention on Mediterranean Diet Adherence Among Firefighters: A Cluster Randomized Clinical Trial

Importance

US firefighters are a working population at risk of chronic diseases, including obesity, cardiovascular disease, and cancer. This risk may be mitigated by a healthy diet.

Objective

To evaluate the effect of a Mediterranean nutrition intervention using a behavioral/environmental approach (firefighter/fire station/home) at the individual participant level.

Design, Setting, and Participants

This 12-month cluster randomized clinical trial included US career firefighters from fire stations and homes within 2 Indiana fire departments. Participants were randomized by fire station to either Mediterranean diet or control (usual care). The study was conducted from October 2016 to December 2019, and data were analyzed in November 2022.

Intervention

For the first 12 months of the study, firefighters located at fire stations randomized to the intervention group were provided with access to supermarket discounts and free samples of Mediterranean diet foods, online nutrition education platforms, email announcements and reminders, family and peer education and support, and chef demonstrations. Firefighters in fire stations allocated to the control group received no intervention and were instructed to follow their usual diet.

Main Outcomes and Measures

Change in dietary habits at 12 months as measured by a modified Mediterranean diet score (range, 0 to 51 points) at baseline and 6-month and 12-month follow-up. Cardiometabolic parameters were secondary outcomes.

Results

Of 485 included firefighters, 458 (94.4%) were male, and the mean (SD) age was 47 (7.5) years. A total of 241 firefighters (27 fire stations) were randomized to the Mediterranean nutrition intervention, and 244 (25 fire stations) were randomized to usual diet. Outcomes were analyzed using generalized linear mixed models for modified Mediterranean diet score at 6 months (n = 336) and 12 months (n = 260), adjusting for baseline age, sex, race and ethnicity, fire department, physical activity, and waist circumference. In the intervention group compared with the control group, the modified Mediterranean diet score significantly increased by 2.01 points (95% CI, 0.62-3.40; P = .005) at 6 months and by 2.67 points (95% CI, 1.14-4.20; P = .001) at 12 months. Among secondary outcomes, changes in cardiometabolic risk factors were not statistically significant at 1 year. Results from analyses with multilevel multiple imputation for missingness were similar.

Conclusions and Relevance

In this Mediterranean nutrition intervention of multicomponent behavioral/environmental changes, career firefighters had increased adherence to a Mediterranean diet.

Trial Registration

ClinicalTrials.gov Identifier: NCT02941757.

Comparison and convergent validity of five Mediterranean dietary indexes applied to Brazilian adults and older adults: data from a population-based study (2015 ISA-Nutrition)

Different dietary indexes are proposed to investigate adherence to the Mediterranean diet (MD). However, they are based on different methodologies, and limited research has compared them to each other, particularly in non-Mediterranean populations. We aimed to compare five indexes intended to measure adherence to the MD. The sample was composed of adults and older adults (n 1187) from 2015 ISA-Nutrition, a cross-sectional population-based study in São Paulo, SP, Brazil. Dietary data obtained through two 24-h dietary recalls (24HDR) from which the Mediterranean diet scale (MDS), Mediterranean diet Score (MedDietscore), Mediterranean dietary pattern (MDP), Mediterranean Adequacy Index (MAI) and Mediterranean-Style Dietary Pattern Score (MSDPS) were calculated. The correlations and agreements between them were analysed by Spearman's correlation and linearly weighted Cohen's Kappa coefficients, respectively. Confirmatory factor analyses (CFAs) were applied to investigate their convergent validity. The highest correlations were found between MDP and MAI (r = 0⋅76; 95% CI 0⋅74-0⋅79) and between MDP and MDS (r = 0⋅72; 95% CI 0⋅69-0⋅75). The greatest agreements observed were moderate, between MDP v. MAI (κ = 0⋅57, P < 0⋅001) and MDP v. MDS (κ = 0⋅48, P < 0⋅001). The goodness-of-fit of CFA for MedDietscore (RMSEA = 0⋅033, 90% CI 0⋅02-0⋅042; SRMR = 0⋅042) and MSDPS (RMSEA = 0⋅028, 90% CI 0⋅019-0⋅037; SRMR = 0⋅031) had acceptable values for absolute fit indices. Vegetables, olive oil, MUFA:SFA ratio and cereals with legumes were more relevant to characterise the MD (factor loadings ≥0⋅50). The MDS, MAI and MDP classified the population similarly, but the MedDietscore showed better performances in evaluating adherence to the MD. These results provided guidance for the most appropriate Mediterranean dietary index to be applied in non-Mediterranean populations.

Dietary Behavior and Diet Interventions among Structural Firefighters: A Narrative Review

Structural firefighters (SFFs) are exposed to multiple occupational hazards that affect dietary behavior and can contribute to increased risks of cancer and cardiovascular disease compared to the United States’ general population. Dietary behavior is a feasible modification for positive health outcomes. The objectives of this narrative review are to summarize the diet behavior of SFFs, review findings of diet interventions that positively modify diet behavior, identify research gaps, and suggest recommendations for addressing those gaps. PubMed, MEDLINE, Scopus, and CABI Web of Science were searched between February 2020 and June 2022 for peer-reviewed articles. The inclusion criteria were as follows: (1) study population must include SFFs; (2) investigate diet or diet intervention among SFFs; (3) report results specific to SFFs; and (4) be published in the English language. Thirty-four studies were included. Results indicate that SFFs recognize the importance of a healthy dietary pattern, but do not follow one, and that food choices are often influenced by colleagues. Diet interventions, such as the Mediterranean diet, were observed to have positive health improvements, such as improved lipid levels and lower CVD risk. Team counseling was found to be more effective for adopting healthier diets compared to one-on-one counseling; and general counseling was more effective than no counseling. A gap identified by this review is the lack of information concerning differences in dietary intake, diet quality, and dietary behaviors while on- and off-shift, and throughout the career. Diet is an important risk factor for occupational disease development; therefore, effective, consistent dietary interventions are necessary.

Application of Mediterranean Diet in Cardiovascular Diseases and Type 2 Diabetes Mellitus: Motivations and Challenges

Objective: Cardiovascular disease (CVD) is the leading cause of disability and death in many countries. Together with CVD, Type 2 diabetes mellitus (T2DM) accounts for more than 80% of all premature non-communicable disease deaths. The protective effect of the Mediterranean diet (MedDiet) on CVD and its risk factors, including T2DM, has been a constant topic of interest. Notwithstanding, despite the large body of evidence, scientists are concerned about the challenges and difficulties of the application of MedDiet. This review aims to explore the motivations and challenges for using MedDiet in patients with CVD and T2DM. Design: An electronic search was conducted for articles about MedDiet published in PubMed, ScienceDirect, Scopus, and Web of Science up to December 2021, particularly on CVD and T2DM patients. From a total of 1536 studies, the final eligible set of 108 studies was selected. Study selection involved three iterations of filtering. Results: Motivation to apply MedDiet was driven by the importance of studying the entire food pattern rather than just one nutrient, the health benefits, and the distinct characteristics of MedDiet. Challenges of the application of MedDiet include lacking universal definition and scoring of MedDiet. Influences of nutritional transition that promote shifting of traditional diets to Westernized diets further complicate the adherence of MedDiet. The challenges also cover the research aspects, including ambiguous and inconsistent findings, the inexistence of positive results, limited evidence, and generalization in previous studies. The review revealed that most of the studies recommended that future studies are needed in terms of health benefits, describing the potential benefits of MedDiet, identifying the barriers, and mainly discussing the effect of MedDiet in different populations. Conclusions: In general, there is consistent and strong evidence that MedDiet is associated inversely with CVD risk factors and directly with glycemic control. MedDiet is the subject of active and diverse research despite the existing challenges. This review informs the health benefits conferred by this centuries-old dietary pattern and highlights MedDiet could possibly be revolutionary, practical, and non-invasive approach for the prevention and treatment CVD and T2DM.

Eating Habits among US Firefighters and Association with Cardiometabolic Outcomes

Cardiovascular disease is the leading cause of on-duty mortality among firefighters, with obesity as an important risk factor. However, little is known regarding the dietary patterns which are characteristic in this population and how these patterns relate to cardiometabolic outcomes. The aim of this study was to identify the dietary patterns of US firefighters and examine their association with cardiometabolic outcomes. The participants (n = 413) were from the Indianapolis Fire Department, and were recruited for a Federal Emergency Management Agency (FEMA)-sponsored Mediterranean diet intervention study. All of the participants underwent physical and medical examinations, routine laboratory tests, resting electrocardiograms, and maximal treadmill exercise testing. A comprehensive food frequency questionnaire was administered, and dietary patterns were derived using principal component analysis. The mean body mass index (BMI) was 30.0 ± 4.5 kg/m2 and the percentage of body fat was 28.1 ± 6.6%. Using principal component analysis, two dietary patterns were identified, namely a Mediterranean diet and a Standard American diet. Following the adjustment for gender, BMI, maximal oxygen consumption (VO2 max), max metabolic equivalents (METS), age, and body fat percent, the Mediterranean diet was positively associated with high-density lipoprotein (HDL) cholesterol (β = 1.20, p = 0.036) in linear regression models. The Standard American diet was associated with an increase in low-density lipoprotein (LDL) cholesterol (β = −3.76, p = 0.022). In conclusion, the Mediterranean diet was associated with more favorable cardiometabolic profiles, whereas the Standard American diet had an inverse association. These findings could help in providing adequate nutrition recommendations for US firefighters to improve their health.

Effects of a healthy lifestyle intervention and COVID-19-adjusted training curriculum on firefighter recruits

There are knowledge gaps regarding healthy lifestyle (HLS) interventions in fire academy settings and also concerning the impacts of the pandemic on training. We enrolled fire recruits from two fire academies (A and B) in New England in early 2019 as the historical control group, and recruits from academies in New England (B) and Florida (C), respectively, during the pandemic as the intervention group. The three academies have similar training environments and curricula. The exposures of interest were a combination of (1) an HLS intervention and (2) impacts of the pandemic on training curricula and environs (i.e. social distancing, masking, reduced class size, etc.). We examined the health/fitness changes throughout training. The follow-up rate was 78%, leaving 92 recruits in the historical control group and 55 in the intervention group. The results show an HLS intervention improved the effects of fire academy training on recruits healthy behaviors (MEDI-lifestyle score, 0.5 ± 1.4 vs. − 0.3 ± 1.7), systolic blood pressure (− 7.2 ± 10.0 vs. 2.9 ± 12.9 mmHg), and mental health (Beck Depression score, − 0.45 ± 1.14 vs. − 0.01 ± 1.05) (all P < 0.05). The associations remained significant after multivariable adjustments. Moreover, a 1-point MEDI-lifestyle increment during academy training is associated with about 2% decrement in blood pressures over time, after multivariable adjustments (P < 0.05). Nonetheless, the impacts of pandemic restrictions on academy procedures compromised physical fitness training, namely in percent body fat, push-ups, and pull-ups.

The Relationship Between Dietary Intake and Dietary-Focused Lifestyle Interventions on Risk Factors Associated with Cardiovascular Disease in Firefighters

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death to on-duty firefighters and is a substantial health concern. Preventative measures, including dietary interventions, may improve CVD in firefighters. The purpose of this review is to examine the literature on the relationship between dietary intake, dietary lifestyle interventions, and risk of CVD in firefighters.

RECENT FINDINGS

Existing evidence, albeit limited, suggests that firefighters do not meet dietary guidelines. Lifestyle modifications featuring dietary interventions are effective in improving risk factors associated with CVD in firefighters. Unfortunately, no consistent nutrition-related trend was identified across the retrieved studies and only a limited number of randomized controlled trials have examined the efficacy of lifestyle intervention studies on CVD in firefighters. Although this review suggests dietary lifestyle interventions may facilitate decreases in risk factors associated with CVD in firefighters, current evidence is limited, and additional research is needed.

Dietary Approaches to Stop Hypertension (DASH) diet, Mediterranean diet and blood lipid profiles in less-developed ethnic minority regions

Different from developed countries, there is a paucity of research examining how the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets relate to lipids in less-developed ethnic minority regions (LEMR). A total of 83 081 participants from seven ethnic groups were retrieved from the baseline data of the China Multi-Ethnic Cohort study, which was conducted in less-developed Southwest China between May 2018 and September 2019. Multivariable linear regression models were then used to examine the associations of the DASH and alternative Mediterranean diet (AMED) scores, assessed by modified DASH score and AMED, as well as their components with total cholesterol (TC), LDL-cholesterol, HDL-cholesterol, TAG and TC/HDL-cholesterol. The DASH scores were negatively associated with TC, HDL-cholesterol and TAG. Comparing the highest quintiles with the lowest DASH scores, TC decreased 0·0708 (95 % CI -0·0923, -0·0493) mmol/l, HDL-cholesterol decreased 0·0380 (95 % CI -0·0462, -0·0299) mmol/l and TAG decreased 0·0668 (95 % CI -0·0994, -0·0341) mmol/l. The AMED scores were negatively associated with TC, LDL-cholesterol and HDL-cholesterol. Comparing the highest quintiles with the lowest AMED scores, TC decreased 0·0816 (95 % CI -0·1035, -0·0597) mmol/l, LDL-cholesterol decreased 0·0297 (95 % CI -0·0477, -0·0118) mmol/l and HDL-cholesterol decreased 0·0275 (95 % CI -0·0358, -0·0192) mmol/l. Although both the DASH diet and the Mediterranean diet were negatively associated with blood lipids, those associations showed different patterns in LEMR, particularly for TAG and HDL-cholesterol.

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.

A Mediterranean Lifestyle Is Associated With Lower Hypertension Prevalence and Better Aerobic Capacity Among New England Firefighter Recruits

OBJECTIVE

Examine the association between healthy Mediterranean lifestyle practices and cardiovascular disease (CVD) risk factors among New England firefighter recruits.

METHODS

A MEDI-Lifestyle score was used to measure adherence to a Mediterranean lifestyle (not smoking, increased physical activity, high adherence to Mediterranean diet, non-obese body mass index, decreased screen time, adequate nightly sleep, and napping) among the recruits. MEDI-Lifestyle scores were cross-sectionally analyzed with blood pressure, aerobic capacity, and other CVD risk factors.

RESULTS

Among 92 recruits, high adherence to MEDI-Lifestyle was significantly associated with a decreased risk of prevalent hypertension (odds ratio [OR] = 0.14 [0.03-0.71]) and a greater probability of high aerobic capacity (OR = 5.80 [1.05-32.05]) as compared with low adherence in age- and sex-adjusted analyses.

CONCLUSIONS

Increased adherence to MEDI-Lifestyle is associated with a better CVD risk profile in firefighter recruits.

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.

Barriers to Weight Management Among Overweight and Obese Firefighters

OBJECTIVE

To examine barriers to weight management among firefighters.

METHODS

Health risk data collected on 2373 overweight firefighters were used for this cross-sectional study. Barriers to weight management were the dependent variables and demographic characteristics, readiness for change, and health risk factors were the correlates in the multivariate-adjusted logistic models.

RESULTS

Overweight firefighters who were ready to begin a weight management program were more likely to identify "lack of knowledge about weight management," "lack of access to exercise opportunities," and "eating helps me cope with stress" and report a greater number of barriers toward weight management. Older firefighters were less likely to identify or report one or more barriers to weight management.

CONCLUSION

Understanding barriers, readiness for change, and age may be useful in planning interventions to help firefighters better manage their weight.

The Effects of Fire Academy Training and Probationary Firefighter Status on Select Basic Health and Fitness Measurements

PURPOSE

This study aimed to investigate changes in firefighter recruits' select health and fitness measurements, from academy training to the early probationary firefighter period.

METHODS

Firefighter recruits from two New England fire academies were followed up prospectively from enrollment at the academy to graduation after 15- to 16-wk training programs, and then for an average of 8 months as probationary firefighters. The participants' demographic, lifestyle, and mental health information was collected using a questionnaire. Body mass index, percent body fat, blood pressure, and push-ups were also measured at each time point. Furthermore, the academies tested the recruits on selected fitness measures (push-ups, pull-ups, and 1.5-mile running time) at academy entry, midtraining, and at graduation.

RESULTS

Ninety-two recruits consented and were included in the analyses. The recruits' percent body fat significantly decreased (median, 21.0%-18.2%) from baseline to graduation, and push-up capacity significantly improved (median, 34-53 per minute) in the same period, along with pull-ups and 1.5-mile running time. However, the recruits' blood pressure, both systolic and diastolic, increased significantly by an average of 3 mm Hg during the training. Those completing probationary follow-up (45/92 recruits) showed that most health/fitness improvements declined after graduation. From academy graduation to probationary follow-up, recruits' physical activity decreased and TV screen time increased significantly, leading to a lower healthy lifestyle score (median, 4-3). After multivariate adjustments, the recruits' diastolic blood pressure increased by 2 mm Hg per measuring time throughout the study period.

CONCLUSIONS

Fire academy training improved recruits' select health and fitness measurements, but the benefits dissipated as probationary firefighters, and blood pressures increased throughout the study period. Further interventions regarding blood pressure and to maintain training benefits after joining fire departments are warranted.

Wildland firefighter exposure to smoke and COVID-19: A new risk on the fire line

Throughout the United States, wildland firefighters respond to wildfires, performing arduous work in remote locations. Wildfire incidents can be an ideal environment for the transmission of infectious diseases, particularly for wildland firefighters who congregate in work and living settings. In this review, we examine how exposure to wildfire smoke can contribute to an increased likelihood of SARS-CoV-2 infection and severity of coronavirus disease (COVID-19). Human exposure to particulate matter (PM), a component of wildfire smoke, has been associated with oxidative stress and inflammatory responses; increasing the likelihood for adverse respiratory symptomology and pathology. In multiple epidemiological studies, wildfire smoke exposure has been associated with acute lower respiratory infections, such as bronchitis and pneumonia. Co-occurrence of SARS-CoV-2 infection and wildfire smoke inhalation may present an increased risk for COVID-19 illness in wildland firefighters due to PM based transport of SARS CoV-2 virus and up-regulation of angiotensin-converting enzyme II (ACE-2) (i.e. ACE-2 functions as a trans-membrane receptor, allowing the SARS-CoV-2 virus to gain entry into the epithelial cell). Wildfire smoke exposure may also increase risk for more severe COVID-19 illness such as cytokine release syndrome, hypotension, and acute respiratory distress syndrome (ARDS). Current infection control measures, including social distancing, wearing cloth masks, frequent cleaning and disinfecting of surfaces, frequent hand washing, and daily screening for COVID-19 symptoms are very important measures to reduce infections and severe health outcomes. Exposure to wildfire smoke may introduce additive or even multiplicative risk for SARS-CoV-2 infection and severity of disease in wildland firefighters. Thus, additional mitigative measures may be needed to prevent the co-occurrence of wildfire smoke exposure and SARS-CoV-2 infection.

The Relationship Between the Healthy Diet Index, Chronic Diseases, Obesity and Lifestyle Risk Factors Among Adults in Kaunas City, Lithuania

A healthy and balanced diet is an important factor contributing to overall health and wellness. The aim of this study was to develop a Healthy Diet Index (HDI) score and assess its association with various chronic diseases and lifestyle risk factors. A cross-sectional survey included 1,111 adults aged 18 years and older. Information on dietary habits was collected using a questionnaire. Additional demographic, socioeconomic and lifestyle risk factors data were also collected. Sixteen food groups were used to develop the HDI score for the residents of Kaunas city, Lithuania based on the national recommendations, World Health Organization (WHO) and other guidance on a healthy diet. We used logistic regression models to assess the association of the HDI score with chronic diseases, obesity and lifestyle risk factors. We found that both males and females were lacking the optimal consumption of the base components of a healthy diet-fruits and vegetables, starchy carbohydrates, and proteins. We also observed significant associations between the HDI score and several outcomes such as hypertension, arrhythmia, physical activity, and obesity. The suggested HDI score could serve as a valuable tool in assessing and improving dietary habits beneficial for promoting health and preventing many diseases.

Adherence to the Mediterranean Diet and Healthy Aging: A Narrative Review over the Last Decade

Objective: Even though modern medicine has significantly contributed to the extension of human lifespan, it has failed to delay the upsurge of chronic diseases. Health benefits of the Mediterranean diet are well established. Thus, adherence to this diet pattern may be the key to healthy aging. Ôhe aim of this review is to investigate the potential benefits of the Mediterranean diet on healthy aging. Methods: A literature search of three databases (ScienceDirect, MEDLINE and The Cochrane Library) was conducted in order to trace all relevant studies published between January 1st 2010 and June 6th 2020 that focused on the impact of adherence to the Mediterranean diet on the physical and mental well-being of individuals aged 60 or older. Results:Twenty-two studies fulfilled the selection criteria and were classified into six groups, according to the main outcome of each study: mental health (eight studies), frailty (6), cardiovascular risk factors (3), plasma levels of uric acid (1), length of hospital stay (1), and aging mechanisms (3). Based on these studies, the protective role of Mediterranean diet on depression, cardiovascular and frailty risk was established. Moreover, adherence to the Mediterranean diet resulted in reduced plasma uric acid levels as well as decreased length of hospital stay and mortality risk among patients who were urgently admitted for any cause in a tertiary hospital. In contrast, results on the effect of Mediterranean diet on cognition were controversial, as studies presented positive or neutral correlations. Conclusions: This review provides evidence on the association between adherence to the Mediterranean diet and healthy aging and highlights the importance of conducting more studies among seniors in order to provide further insight into this matter.

Sleep and Association With Cardiovascular Risk Among Midwestern US Firefighters

INTRODUCTION

Cardiovascular disease is the leading cause of on-duty fatalities among U.S. firefighters. Research has demonstrated that many modifiable risk factors are contributors to the high prevalence of cardiometabolic risk factors. The current study aimed to assess whether sleep is associated with cardiometabolic risk factors among Indianapolis firefighters. The findings could support improving sleep hygiene in this population.

MATERIAL AND METHODS

This cross-sectional study was conducted from the baseline data of eligible firefighters enrolled in "Feeding America's Bravest", a Mediterranean diet lifestyle intervention within the Indiana Fire Departments. Participants' sleep quality was categorized as "good" (≤ 8 points) or "bad" (>8 points) by a sleep quality questionnaire based on some questions from Pittsburgh Sleep Quality Index. In addition, firefighters' sleep duration was stratified based on the number of hours slept per night (≤6 as "short sleep" or >6 hours as normal). Linear and logistic regression models were used to examine the association of sleep with cardiometabolic risk factors.

RESULTS

A total of 258 firefighters were included. Bad sleepers had higher weight, greater waist circumference, higher body mass index (BMI), and increased body fat (all p<0.01) compared to good sleepers. Similarly, participants with short sleep duration were heavier (p<0.02), had greater BMI (p<0.02) and increased body fat (p<0.04) compared with participants with normal sleep duration. Both bad and short sleepers had a higher prevalence of hypertension and obesity (p <0.05).

CONCLUSIONS

Our study supports that both sleep quality and quantity are associated with cardiometabolic risk among firefighters.

Association of the Modified Mediterranean Diet Score (mMDS) with Anthropometric and Biochemical Indices in US Career Firefighters

The Mediterranean diet is associated with multiple health benefits, and the modified Mediterranean Diet Score (mMDS) has been previously validated as a measure of Mediterranean diet adherence. The aim of this study was to examine associations between the mMDS and anthropometric indices, blood pressure, and biochemical parameters in a sample of career firefighters. The participants were from Indiana Fire Departments, taking part in the "Feeding America's Bravest" study, a cluster-randomized controlled trial that aimed to assess the efficacy of a Mediterranean diet intervention. We measured Mediterranean diet adherence using the mMDS. Anthropometric, blood pressure, and biochemical measurements were also collected. Univariate and multivariate linear regression models were used. In unadjusted analyses, many expected favorable associations between the mMDS and cardiovascular disease risk factors were found among the 460 firefighters. After adjustment for age, gender, ethnicity, physical activity, and smoking, a unitary increase in the mMDS remained associated with a decrease of the total cholesterol/HDL ratio (β-coefficient -0.028, p = 0.002) and an increase of HDL-cholesterol (β-coefficient 0.254, p = 0.004). In conclusion, greater adherence to the Mediterranean diet was associated with markers of decreased cardiometabolic risk. The mMDS score is a valid instrument for measuring adherence to the Mediterranean diet and may have additional utility in research and clinical practice.

The Effects of a Mediterranean Diet Intervention on Targeted Plasma Metabolic Biomarkers among US Firefighters: A Pilot Cluster-Randomized Trial

Metabolomics is improving the understanding of the mechanisms of the health effects of diet. Previous research has identified several metabolites associated with the Mediterranean Diet (MedDiet), but knowledge about longitudinal changes in metabolic biomarkers after a MedDiet intervention is scarce. A subsample of 48 firefighters from a cluster-randomized trial at Indianapolis fire stations was randomly selected for the metabolomics study at 12 months of follow up (time point 1), where Group 1 (n = 24) continued for another 6 months in a self-sustained MedDiet intervention, and Group 2 (n = 24), the control group at that time, started with an active MedDiet intervention for 6 months (time point 2). A total of 225 metabolites were assessed at the two time points by using a targeted NMR platform. The MedDiet score improved slightly but changes were non-significant (intervention: 24.2 vs. 26.0 points and control group: 26.1 vs. 26.5 points). The MedDiet intervention led to favorable changes in biomarkers related to lipid metabolism, including lower LDL-C, ApoB/ApoA1 ratio, remnant cholesterol, M-VLDL-CE; and higher HDL-C, and better lipoprotein composition. This MedDiet intervention induces only modest changes in adherence to the MedDiet and consequently in metabolic biomarkers. Further research should confirm these results based on larger study samples in workplace interventions with powerful study designs.

Adherence to a Mediterranean diet associated with lower blood pressure in a US sample: Findings from the Maine-Syracuse Longitudinal Study

Hypertension is a key modifiable risk factor for cardiovascular disease. The Mediterranean diet (MedDiet) may be associated with improvements in blood pressure. However, few studies have examined the association between MedDiet adherence and blood pressure in non-Mediterranean populations, and findings are mixed. We analyzed cross-sectional data (Wave 6) for 851 participants of the Maine-Syracuse Longitudinal Study. MedDiet adherence was calculated using food frequency questionnaire data and a literature-based MedDiet adherence score. Dependent variables included systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP). Separate linear robust regression analyses revealed significant associations between MedDiet adherence and for SBP (b = -0.69, 95% CI = [-1.25, -0.20]), DBP (b = -0.33, 95% CI = [-0.58, -0.04]), and MAP (b = -0.45, 95% CI = [-0.77, -0.11]), but not for PP. These findings indicate that the MedDiet is associated with some metrics of blood pressure in a large, community-based, non-Mediterranean sample.

Anthocyanin Intake and Physical Activity: Associations with the Lipid Profile of a US Working Population

While growing evidence exists on the independent associations between anthocyanins and physical activity on cardiovascular disease (CVD) risk determinants, the possible interaction between these exposures has not yet been studied. We aimed to study the potential synergism between anthocyanin intake and physical activity on lipid profile measures. This cross-sectional study was conducted among 249 US career firefighters participating in the Feeding America's Bravest trial. Anthocyanin intake was calculated using a validated food frequency questionnaire (FFQ) and physical activity level by a validated questionnaire. Multivariable linear regression models determined the extent to which anthocyanin intake and physical activity predicted lipid parameters. Generalized linear models were used for joint effect and interaction analyses on the multiplicative and additive scales. Both anthocyanins and physical activity were independently inversely associated with total cholesterol:high density lipoprotein (HDL) cholesterol. Only physical activity was inversely associated with triglycerides, low density lipoprotein (LDL) cholesterol:HDL, and triglycerides (TG):HDL. Although the combined exposure of low anthocyanin intake and low physical activity was associated with lower (RR = 2.83; 95% CI: 1.42 to 5.67) HDL cholesterol <40 mg/dL, neither multiplicative (p = 0.72) nor additive interactions were detected (relative excess risk due to interaction (RERI): 0.02; 95% CI: -1.63 to 1.66; p = 0.98). Our findings provide insight on the potential synergism between anthocyanin intake and physical activity on the lipid profile.

Development and Validation of the Short Healthy Eating Index Survey with a College Population to Assess Dietary Quality and Intake

Because diet quality (DQ) is associated with risk of chronic disease and is a common construct assessed in health-related research, validated tools to assess DQ are needed that have low respondent and researcher burden. Thus, content experts develop the Short Healthy Eating Index (sHEI) tool and an associated scoring system. The sHEI scoring system was then refined using a classification and regression tree (CRT) algorithm methodology with an iterative feedback process with expert review and input. The sHEI scoring system was then validated using a concurrent criterion validation process that included the sHEI DQ scores (calculated from responses from 50 participants) being compared to the participants' Healthy Eating Index scores derived from 24 h recalls. The total HEI score from the CRT algorithm highly correlated with the 24 h recall HEI score (0.79). For individual food group items, the correlation between the CRT algorithm scoring and the 24 h recall data scoring ranged from 0.44 for refined grains to 0.64 for whole fruits. The sHEI appears to be a valid tool for estimating overall dietary quality and individual items (with correlations > 0.49) for fruits, vegetables, dairy, added sugar, sugar from sugar-sweetened beverages, and calcium.

Comparison of Supervised and Telehealth Delivery of Worksite Exercise for Prevention of Low Back Pain in Firefighters: A Cluster Randomized Trial

OBJECTIVE

This study assessed worksite exercise delivered by on-site supervision (supervised) or telehealth to reduce lost work time (LWT) related to low back pain (LBP) in firefighters.

METHODS

A cluster randomized controlled trial assigned 264 career firefighters to supervised (n = 86) or telehealth (n = 95) back and core exercises 2×/week for 12 months, or control (n = 83).

RESULTS

58.0% (153/264) of participants reported LBP and 7.6% (20/264) reported LWT related to LBP (control n = 10, supervised n = 5, telehealth n = 5). Participants in the control group experienced 1.15 times as many hours of LWT as the supervised group, and 5.51 times as many hours of LWT as the telehealth group.

CONCLUSIONS

Worksite exercise, delivered by on-site supervision or telehealth, can reduce LWT related to LBP in career firefighters.

Dietary Pattern and Its Correlates among Lithuanian Young Adults: Mediterranean Diet Approach

A poor diet leads to serious health risks and accounts for a significant proportion of deaths. Young adults are the population whose health behaviors particularly need to be studied in terms of nutrition because they are in a period of life when the effects of nutrition accumulate to health outcomes that usually appear later in life in forms of disease or infirmity. The aim of this study is to examine the dietary pattern and its relationships with physical activity and covariates, such as body mass index, gender, age and education among Lithuanian young adults of 18-36 years old. A cross-sectional study was performed among Lithuanian young people aged 18-36 years. Snowball sampling-a non-probability, convenient sampling strategy-was used. In total, data were collected from 3031 study participants: 1723 (56.8%) were male and 1308 (43.2%) were female. The mean age was 23.72 ± 4.80 years. Adherence to a dietary pattern was evaluated using the Mediterranean Diet Adherence Screener (MEDAS). Physical activity, height, weight and education data were also gathered. About 7% of young people fully complied with the health-related Mediterranean diet, and one-third had poor compliance. Non-compliance is mostly related to the underconsumption of olive oil, nuts, fish, seafood, legumes and wine, as well as the overconsumption of red meat. The female gender (β = 0.26; p < 0.01), higher education (β = 0.30; p < 0.01) and a sufficient level of physical activity (β = 0.15; p < 0.01) predict a healthier diet. These study results should be considered by nutrition policymakers and public health authorities to improve policies and develop intervention plans for improving the nutrition habits of young adults in order to prevent health-damaging outcomes later in their life.

Assessing Validity of Self-Reported Dietary Intake within a Mediterranean Diet Cluster Randomized Controlled Trial among US Firefighters

Collecting dietary intake data is associated with challenges due to the subjective nature of self-administered instruments. Biomarkers may objectively estimate the consumption of specific dietary items or help assess compliance in dietary intervention studies. Our aim was to use a panel of plasma and urine biomarkers to assess the validity of self-reported dietary intake using a modified Mediterranean Diet Scale (mMDS) among firefighters participating in Feeding America's Bravest (FAB), an MD cluster-randomized controlled trial. In our nested biomarker pilot study, participants were randomly selected from both the MD intervention group (n = 24) and the control group (n = 24) after 12-months of dietary intervention. At baseline data collection for the pilot study (t = 12-months of FAB), participants in the control group crossed-over to receive the MD intervention (active intervention) for 6-months. Participants in the intervention group continued in a self-sustained continuation phase (SSP) of the intervention. Food frequency questionnaires (FFQ), 13-item-mMDS questionnaires, 40 plasma fatty acids, inflammatory biomarkers and urinary hydroxytyrosol and tyrosol were analyzed at both time points. Spearman's correlation, t-tests and linear regression coefficients were calculated using SAS software. Overall, the mMDS derived from the FFQ was highly correlated with the specific 13-domain-mMDS (r = 0.74). The concordance between the two questionnaires for low and high adherence to MD was high for all the participants in the parent trial (κ = 0.76). After 6 months of intervention in the pilot study, plasma saturated fatty acid decreased in both groups (active intervention: -1.3 ± 1.7; p = 0.002; SSP: -1.12 ± 1.90; p = 0.014) and oleic acid improved in the SSP (p = 0.013). Intake of olive oil was positively associated with plasma omega-3 (p = 0.004) and negatively with TNF-α (p < 0.001) at baseline. Choosing olive oil as a type of fat was also associated with higher levels of plasma omega-3 (p = 0.019) at baseline and lower TNF-α (p = 0.023) at follow up. Intake of red and processed meats were associated with lower serum omega-3 (p = 0.04) and fish consumption was associated with lower IL-6 at baseline (p = 0.022). The overall mMDS was associated with an increase in plasma omega-3 (p = 0.021). Good correlation was found between nutrient intake from the FFQ and the corresponding plasma biomarkers (omega-3, EPA and DHA). In this MD randomized controlled trial, some key plasma biomarkers were significantly associated with key MD diet components and the overall mMDS supporting the validity of the mMDS questionnaire as well as compliance with the intervention.

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?

Aspects of Dietary Diversity Differ in Their Association with Atherosclerotic Cardiovascular Risk in a Racially Diverse US Adult Population

The study objectives were to measure dietary diversity (DD) of an urban US population and to determine if associations of 10 year atherosclerotic cardiovascular (ASCVD) risk with DD were independent of dietary quality. Participants were drawn from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, wave 4 (n = 2066, 1259 African Americans (AA), 807 Whites (W). Three DD measures were derived from 2 days of 24 h recall data collected with the USDA automated-multiple-pass-method. Count was based on consumption of at least half an equivalent of food from 21 subgroups. Evenness was calculated using Berry Index (BI) and BI-adjusted by food health values. Dissimilarity was calculated by Mahalanobis Distance. Diet quality was assessed by Mean Nutrient Adequacy (MAR) and DASH scores. Associations of DD and quality with ASCVD risk, calculated using 2013 American College of Cardiology and American Heart Association guidelines, were assessed with multivariable regression. Covariates included income, education, food security, and energy/kg weight. Count and MAR were positively associated whereas dissimilarity was negatively associated with ASCVD risk. There was no evidence that evenness contributed to cardiovascular health. The findings suggest more diversity in food attributes and diets rich in micronutrients rather than increased count support cardiovascular health.

Association Between Push-up Exercise Capacity and Future Cardiovascular Events Among Active Adult Men

IMPORTANCE

Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity; however, few have studied simple, low-cost measures of functional status.

OBJECTIVE

To evaluate the association between push-up capacity and subsequent CVD event incidence in a cohort of active adult men.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective longitudinal cohort study conducted between January 1, 2000, and December 31, 2010, in 1 outpatient clinics in Indiana of male firefighters aged 18 years or older. Baseline and periodic physical examinations, including tests of push-up capacity and exercise tolerance, were performed between February 2, 2000, and November 12, 2007. Participants were stratified into 5 groups based on number of push-ups completed and were followed up for 10 years. Final statistical analyses were completed on August 11, 2018.

MAIN OUTCOMES AND MEASURES

Cardiovascular disease-related outcomes through 2010 included incident diagnoses of coronary artery disease and other major CVD events. Incidence rate ratios (IRRs) were computed, and logistic regression models were used to model the time to each outcome from baseline, adjusting for age and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared). Kaplan-Meier estimates for cumulative risk were computed for the push-up categories.

RESULTS

A total of 1562 participants underwent baseline examination, and 1104 with available push-up data were included in the final analyses. Mean (SD) age of the cohort at baseline was 39.6 (9.2) years, and mean (SD) BMI was 28.7 (4.3). During the 10-year follow up, 37 CVD-related outcomes (8601 person-years) were reported in participants with available push-up data. Significant negative associations were found between increasing push-up capacity and CVD events. Participants able to complete more than 40 push-ups were associated with a significantly lower risk of incident CVD event risk compared with those completing fewer than 10 push-ups (IRR, 0.04; 95% CI, 0.01-0.36).

CONCLUSIONS AND RELEVANCE

The findings suggest that higher baseline push-up capacity is associated with a lower incidence of CVD events. Although larger studies in more diverse cohorts are needed, push-up capacity may be a simple, no-cost measure to estimate functional status.

Mediterranean diet pattern and sleep duration and insomnia symptoms in the Multi-Ethnic Study of Atherosclerosis

Sleep duration and sleep quality are important predictors of risk for cardiovascular disease (CVD). One potential link between sleep health and CVD is through lifestyle factors such as diet. To clarify the association between diet and sleep, we assessed the associations of sleep duration and insomnia symptoms with current Mediterranean-style diet (aMed) and with historical changes in aMed score. Actigraphy-measured sleep duration and self-reported insomnia symptoms categorized as insomnia with short sleep (<6 hr/night), insomnia without short sleep, no insomnia with short sleep, and no insomnia or short sleep were obtained from 2068 individuals who also had dietary intake data. A 10-point aMed score, derived from a self-report food frequency questionnaire, was collected concurrently with the sleep assessment and 10 years before. Compared with individuals who currently reported a low aMed score, those with a moderate-high aMed score were more likely to sleep 6-7 vs. <6 hr/night (p < 0.01) and less likely to report insomnia symptoms occurring with short sleep (vs. no insomnia or short sleep alone; p < 0.05). An increase in aMed score over the preceding 10 years was not associated with sleep duration or insomnia symptoms. However, compared with those with decreasing aMed score, individuals with an unchanging score reported fewer insomnia symptoms (p ≤ 0.01). These results suggest that a Mediterranean-style diet is associated with adequate sleep duration, less insomnia symptoms, and less likely to have insomnia accompanied by short sleep. Further research should identify possible mediators through which diet may promote adequate sleep duration and reduce the risk of insomnia.

High adherence to Mediterranean diet, but not individual foods or nutrients, is associated with lower likelihood of being obese in a Mediterranean cohort

PURPOSE

The aim of the present study was to evaluate the association between the Mediterranean diet and obesity in a Mediterranean cohort.

METHODS

The study population of MEAL (Mediterranean Healthy Eating, Ageing, and Lifestyle) study comprised 1814 men and women (18 + years) recruited in the city of Catania, southern Italy. Food intake was evaluated through a validated food frequency questionnaire and the Mediterranean diet adherence was assessed through the MEDI-LITE score.

RESULTS

Individuals highly adherent to the Mediterranean diet (highest quartile of the score) were less likely to be obese (OR 0.53, 95% CI 0.32, 0.89) despite there was no significant associations when considering men and women separately. The dietary profile of obese and non-obese individuals did not significantly differ, except for vitamin E, processed meat, and alcohol more consumed among non-obese ones. Among the food groups characterizing this dietary pattern, only satisfaction of the criterion for dairy products (< 1 serving/day) was significantly associated with lower odds of being obese. Among other covariates, current smoking was associated with obesity, while high physical activity and regular alcohol drinking were inversely associated. Some differences between men and women in the highest category of occupational status occurred, as the former were less likely, while the latter were more likely to be obese.

CONCLUSIONS

Higher adherence to the Mediterranean diet as a whole dietary pattern, rather than its individual components, is associated with less likelihood of being obese.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Review of a priori dietary quality indices in relation to their construction criteria

A multitude of indices measure the healthiness of dietary patterns. Because validation results with respect to health outcomes do not sufficiently facilitate the choice of a specific dietary quality index, the decision of which index to use for a particular research objective should be based on other criteria. This review aims to provide guidance on which criteria to focus upon when choosing a dietary index for a specific research question. A review of 57 existing specifications of dietary quality indices was conducted, taking explicitly into account relevant construction criteria explicated in the Organisation for Economic Co-operation and Development handbook on constructing composite indicators. Index construction choices regarding the following criteria were extracted: theoretical framework, indicator selection, normalization and valuation functions, and aggregation methods. Preferable features of dietary indices are discussed, and a summarizing toolbox is provided to help identify indices with the most appropriate construction features for the respective study aim and target region and with regard to the available database. Directions for future efforts in the specification of new diet quality indices are given.

The Influence of Habitual Protein Intake on Body Composition and Muscular Strength in Career Firefighters

OBJECTIVE

The aim of this research was to determine the relationship among protein (PRO) intake, body composition, and muscle strength in overweight and obese firefighters. A secondary objective was to evaluate differences in body composition and muscle strength among overweight and obese firefighters with low (L; < 0.8 g·kg-1), moderate (M; 0.8-1.0 g·kg-1), and high (H; > 1.0 g·kg-1) PRO intake.

METHODS

Relative PRO intake [r_PRO] was evaluated from 3-day dietary logs, self-reported by 43 overweight and obese male career firefighters (mean ± standard deviation; age = 37.3 ± 7.2 years; body mass index = 33.2 ± 5.0 kg·m-2; percent body fat [%BF] = 28.9 ± 4.0%). Body composition (fat mass [FM], %BF, lean mass [LM], percent LM [%LM]) and muscle strength (peak torque [PT], relative peak torque [r_PT] of the leg extensors) were measured using dual-energy x-ray absorptiometry and isokinetic dynamometry, respectively.

RESULTS

Greater r_PRO was associated with less FM, %BF, LM (r = -0.498 to -0.363) and greater %LM (r = 0.363), but not muscle strength (p > 0.05). Fat mass (r = -0.373) and %BF (r = -0.369) were associated with lower r_PT; %LM was associated with greater r_PT (r = 0.373). Individuals with L r_PRO had greater FM (mean difference ± standard error: L-H = 10.08 ± 3.18 kg), %BF (L-H = 3.8% ± 1.4%) and lower %LM (L-H = -3.7% ± 1.3%) than those with H r_PRO (p < 0.05) but no significant differences in muscle strength (p > 0.05).

CONCLUSIONS

Protein intake > 0.8 g·kg-1 was associated with more favorable body composition in male career firefighters.

Gut microbial diversity in HIV infection post combined antiretroviral therapy: a key target for prevention of cardiovascular disease

PURPOSE OF REVIEW

Although the HIV-infected population is living longer and getting older under current treatment regimens, significant challenges arise for health management as the infection is associated with various premature aging phenotypes, particularly increased incidence of cardiovascular diseases (CVDs). Here we review the current understanding of HIV-related gut dysbiosis in association with CVD and advances in clinical trials aiming to restore gut microbial diversity.

RECENT FINDING

Identification of a unique signature for gut dysbiosis in HIV infection between different cohorts remains challenging. However, low diversity of microbiota combined with the outgrowth of pathogenic bacterial species together with dysregulated metabolic pathways have been linked to compromised gut immunity, bacterial translocation and systemic inflammation, hence higher CVD risk among different cohorts. Data from recent clinical trials aiming to evaluate the tolerability and efficacy of probiotics in treated HIV+ patients are promising and support a significant increase in microbiota diversity and reduction of systemic inflammation. However, the impact of these microbial and immunological corrections on the prevalence of CVD in HIV+ patients remains unclear.

SUMMARY

Positive immunological outcomes following enrichment of the gut microbial diversity have been documented, and further trials are in progress to evaluate the range of patients, with different immunological backgrounds, who might benefit from these treatments.

Current evidence on the association of the metabolic syndrome and dietary patterns in a global perspective

The metabolic syndrome (MetS) is a key indicator of two main causes of death worldwide: CVD and diabetes. The present paper aimed to perform a review of the population-based research on the association of dietary patterns and the MetS in terms of methodology and findings. For the purpose of the present study, a scoping literature review was conducted using MEDLINE and EMBASE databases and hand searching in Google Scholar. Thirty-nine population-based studies were selected. Most of these studies used the factor analysis method and the a priori dietary approach, which had been initially extracted via a posteriori methods such as using the Mediterranean dietary pattern. The main finding was that following the Mediterranean or similar 'healthy' pattern reduced risk of the MetS, while following a 'Western' pattern increased risk of the MetS. The methodological approach in determining the dietary pattern of a population, whether a priori or a posteriori, should be chosen based on the purpose of the research. Overall, evidence suggests a diet based on the components of the Mediterranean diet and the avoidance of the 'Western' diet can aid in preventing the MetS.

A modified Mediterranean diet score is inversely associated with metabolic syndrome in Korean adults

BACKGROUND/OBJECTIVES

Findings from studies in Western countries showed that Mediterranean diet is inversely associated with metabolic syndrome, but little is known about this association in Asian countries. To evaluate the association between Mediterranean diet and metabolic syndrome in Korean population, this study was conducted.

SUBJECTS/METHODS

A total of 8387 adults 19-64 years of age from the Korea National Health and Nutrition Examination Survey 2012-2015 were assessed. A 112-item dish-based semiquantitative food frequency questionnaire was used to assess dietary intakes. Mediterranean diet was assessed by a modified Mediterranean diet score, which was based on the alternate Mediterranean diet score of Fung et al. Multivariable logistic regression models were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) adjusted for other dietary and lifestyle variables.

RESULTS

Participants with 5-6 and 7 or higher modified Mediterranean diet scores had a lower prevalence of metabolic syndrome by 27% (OR = 0.73, 95% CI: 0.56-0.96) and 36% (OR = 0.64, 95% CI: 0.46-0.89; P-trend = 0.0031), compared with those with 2 or lower modified Mediterranean diet scores, respectively. Higher modified Mediterranean diet scores were associated with a lower prevalence of abdominal obesity and hypertriglyceridemia, which are components of metabolic syndrome CONCLUSIONS: Our findings suggest that diet rich in fruit, vegetables, whole grains, legumes, peanuts and fish is associated with a lower prevalence of metabolic syndrome in Korean adults.

A comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: Are individual components equal?

Many studies have reported that higher adherence to Mediterranean diet may decrease cardiovascular disease (CVD) incidence and mortality. We performed a meta-analysis to explore the association in prospective studies and randomized control trials (RCTs) between Mediterranean diet adherence and CVD incidence and mortality. The PubMed database was searched up to June 2014. A total of 17 studies were extracted and 11 qualified for the quantitative analysis. Individuals in the highest quantile of adherence to the diet had lower incidence [relative risk (RR): 0.76, 95% confidence intervals (CI): 0.68, 0.83] and mortality (RR: 0.76, 95% CI: 0.68, 0.83) from CVD compared to those least adherent. A significant reduction of risk was found also for coronary heart disease (CHD) (RR: 0.72, 95% CI: 0.60, 0.86), myocardial infarction (MI) (RR: 0.67; 95% CI: 0.54, 0.83), and stroke (RR: 0.76; 95% CI: 0.60, 0.96) incidence. Pooled analyses of individual components of the diet revealed that the protective effects of the diet appear to be most attributable to olive oil, fruits, vegetables, and legumes. An average reduced risk of 40% for the aforementioned outcomes has been retrieved when pooling results of RCTs. A Mediterranean dietary pattern is associated with lower risks of CVD incidence and mortality, including CHD and MI. The relative effects of specific food groups should be further investigated.

Survival Mediterranean Style: Lifestyle Changes to Improve the Health of the US Fire Service

Cardiovascular disease (CVD) causes almost half of all on-duty deaths in US firefighters and is an important and costly cause of morbidity. In addition, cancer is a growing health concern in this population. Obesity and obesity-associated, cardiometabolic risk clustering are major, modifiable risk factors for fire service CVD and cancer risk. The Mediterranean diet (MedDiet) is proven effective in primary and secondary CVD prevention. It is also associated with a decreased risk of cancer and other chronic diseases. Moreover, it can be adapted into successful workplace interventions. Emerging data from our group regarding the US Fire Service show that greater compliance with the MedDiet is associated with improved CVD risk profiles and less weight gain among career firefighters. Moreover, the fact that career firefighters take a considerable number of meals communally on the job also represents an excellent opportunity for a workplace Mediterranean Diet Nutritional Intervention (MDNI). The devastating effects of obesity, CVD, and cancer on the US fire service are recognized, but currently few effective preventive programs exist. The consistently positive health benefits from following a MedDiet and promising preliminary data in the fire service justify translational research to determine the most effective means of delivering MDNIs to US firefighters. Therefore, a high priority should be assigned to efforts, which can help further disseminate and implement our program of novel behavior change strategies, "Survival Mediterranean Style," throughout the US fire service and eventually to other occupations.

Does a Mediterranean-type dietary pattern exert a cardio-protective effect outside the Mediterranean region? A review of current evidence

Current evidence suggests a beneficial effect of the Mediterranean diet (MD) on human health. This has led to a rise in studies investigating the role of the MD in cardiovascular disease (CVD) prevention outside the region of its origin. We aimed to outline the evolving understanding of the MD and to provide an overview of adherence to MD in non-Mediterranean countries and the modulatory effects of MD on CVD biomarkers. Evidence suggest that MD may exert a protective effect on CVD via ameliorating blood lipid profile and blood pressure. A protective effect of MD was found with regard to left ventricular mass but data on carotid intima media thickness and pulse wave velocity are lacking. The paucity of data does not give a clear picture of the health effects of the MD in non-Mediterranean countries, thus larger and well-designed studies on MD outside the Mediterranean countries are warranted.

Association between Mediterranean diet adherence and dyslipidaemia in a cohort of adults living in the Mediterranean area

The aim of the present study was to determine the association between Mediterranean diet adherence and dyslipidaemia in a cohort of adults living in the Mediterranean area. The cross-sectional study comprised a total sample of 2044 men and women, aged >18 years old from southern Italy. The Mediterranean diet adherence was assessed using a validated score (MEDI-LITE score). Clinical data were investigated and anthropometric examinations were collected using standardised methods. Among included individuals, 18.4% had dyslipidaemia. The percentage of females with dyslipidaemia was higher than males (21.2% vs. 14.6%). Higher adherence to Mediterranean diet was inversely associated with dyslipidaemia (OR: 0.56, 95% Cl: 0.36, 0.86). Similar association was observed in men, but not in women. On the contrary, a positive association was found between dyslipidaemia and current smoking and higher occupational status. Our results support the potential effectiveness of this diet in the prevention of dyslipidaemia and justify future intervention studies.